Within this technical package, some approaches do not yet have research evidence demonstrating impact on rates of suicide but instead are supported by evidence indicating impacts on risk or protective factors for suicide help? seeking, stigma reduction, depression, connectedness). In terms ofthe strength ofthe evidence, programs that have demonstrated effects on suicidal behavior reductions in deaths, attempts) provide a higher-level of evidence, but the evidence base is not that strong in all areas. For instance, there has been less evaluation of community engagement and family programs on suicidal behavior. Thus, approaches in this package that have effects on risk or protective factors re?ect the developing nature of the evidence base and the use of the best available evidence at a given time. It is also important to note that there is often signi?cant heterogeneity among the programs, policies, or practices that fall within one approach or strategy in terms of the nature and quality of the available evidence. Not all programs, poli- cies, or practices that utilize the same approach are equally effective, and even those that are effective may not work across all populations.Tailoring programs and conducting more evaluations may be necessary to address different population groups. The evidence-based programs, practices, or policies included in the package are not intended to be a comprehensive list for each approach, but rather to serve as examples that have been shown to impact suicide or have bene?cial effects on risk or protective factors for suicide. Contextual and Cross-Cutting Themes One important feature ofthe package is the complementary and potentially synergistic impact ofthe strategies and approaches. The strategies and approaches included in this technical package represent different levels of the social ecology, with efforts intended to impact community and societal levels, as well individual and relationship levels. The strategies and approaches are intended to work in combination and reinforce each other to prevent suicide (see box on page 12). The strategies are arranged in order such that those strategies hypothesized to have the greatest potential for broad public health impact on suicide are included ?rst, followed by those that might impact subsets of the population persons who have already made a suicide attempt]. "to . like most public health . problems, suicide is preventable. Preventing Suicide: ll Technical Package of Policy, Programs, and Practices 1 Strategy Preventing Suicide Approach Strengthen economic supports Strengthen household ?nancial security - Housing stabilization policies Strengthen access and delivery of suicide care Coverage of mental health conditions in health insurance policies Reduce provider shortages in underserved areas Safer suicide care through systems change Create protective environments - Reduce access to lethal means among persons at risk of suicide Organizational policies and culture Community-based policies to reduce excessive alcohol use Promote connectedness Peer norm programs Community engagement activities Teach coping and problem-solving skills Social-emotional learning programs Parenting skill and family relationship programs Identify and support people at risk Gatekeeper training Crisis intervention Treatment for people at risk of suicide Treatment to prevent re-attempts Lessen harms and prevent future risk Postvention Safe reporting and messaging about suicide It is important to note that these strategies are not mutually exclusive but each has an immediate focus. For instance, social?emotional learning programs, an approach under the Teach Coping and Problem-Solving Skills strategy, sometimes include components to change peer norms and the broader environment. The primary focus of these programs, however, is to provide children and youth with skills to resolve problems in relationships, school, and with peers, and to help youth address other negative in?uences substance use) associated with suicide. Preventing Suicide: ATechnical Package of Policy, Programs, and Practices The goal of this package is to stress the importance of comprehensive prevention efforts and to provide examples of effective programs addressing each level of the social ecology, with the knowledge that some programs, practices, and policies may impact multiple levels. Further, those that involve multiple sectors and that impact multiple levels of the social ecology are more likely to have a greater impact on the overall burden ofsuicide. Suicide ideation, thoughts, attempts. and deaths vary by gender, racefethnicity, age. occupation, and other important population characteristic591?:l Further, certain transition periods are also associated with higher rates ofsuicide transition from working into retirement, transition from active duty military status to civilian In fact, suicide risk can change along with dynamic risk factors. For example, individuals? coping skills may change during periods of crisis and heightened stress, limiting their normal ability to effectively solve problems and cope. Research indicates that suicide risk changes as a result of the number and intensity of key risk and protective factors experienced.52 Ideally, the availability of multiple strategies and approaches tailored to the social, economic, cultural, and environmental context of individuals and communities are desirable as they may increase the likelihood of removing barriers to supportive and effective care and provide opportunities to develop individual and community resilience.? identifying programs, practices, and policies with evidence of impact on suicide, suicide attempts, or bene?cial effects on risk or protective factors for suicide is only the ?rst step. In practice, the effectiveness of the programs, policies and practices identi?ed in this package will be strongly dependent on how well they are implemented, as well as the partners and communities in which they are implemented. Practitioners in the ?eld may be in the best position to assess the needs and of their communities and work with community members to make decisions about the combination of approaches included here that are best suited to their context. Data-driven strategic planning processes can help communities with this work.53'55 These planning processes engage and guide community stakeholders through a prevention planning process designed to address a community?s pro?le of risk and protective factors with evidence?based programs, practices, and policies. These processes can also be used to monitor implementation, track outcomes, and make adjustments as indicated by the data. The readiness of the program for broad dissemination and implementation availability of program materials, training and technical assistance) can also in?uence program effects. Implementation guidance to assist practitioners, organizations and communities will be developed separately. This package includes strategies where public health agencies are well positioned to bring leadership and resources to implementation efforts. it also includes strategies where public health can serve as an important collaborator strategies addressing community and societal level risks}, but where leadership and commitment from other sectors such as business, labor or health care is critical to implement a particular policy or program workplace policies; treatment to prevent re?attemptsi.The role of various sectors in the implementation of a strategy or approach in preventing suicide is described further in the section on Sectorinvolvement. In the sections that follow, the strategies and approaches with the best available evidence for preventing suicide are described. Wanting Suicide: Tedmlcal Package We. 1? Strengthen Economic Supports Rationale Studies from the US. examining historical trends indicate that suicide rates increase during economic recessions marked by high unemployment rates, job losses, and economic instability and decrease during economic expansions and periods marked by low unemployment rates, particularly for working-age individuals 25 to 64 years Economic and ?nancial strain, such asjob loss, long periods of unemployment, reduced income, dif?culty covering medical, food, and housing expenses, and even the anticipation of such ?nancial stress may increase an individual?s risk for suicide or may indirectly increase risk by exacerbating related physical and mental health problems.55 Buffering these risks can, therefore, potentially protect against suicide. For example, strengthening economic support systems can help people stay in their homes or obtain affordable housing while also paying for necessities such as food and medical care, job training, child care, among other expenses required for daily living. In providing this support, stress and anxiety and the potential for a crisis situation may be reduced, thereby preventing suicide. Although more research is needed to understand how economic factors interact with other factors to increase suicide risk, the available evidence suggests that strengthening economic supports may be one opportunity to buffer suicide risk. Approaches Economic supports for individuals and families can be strengthened by targeting household ?nancial security and ensuring stability in housing during periods of economic stress. Strengthening household ?nancial security can potentially buffer the risk ofsuicide by providing individuals with the ?nancial means to lessen the stress and hardship associated with a job loss or other unanticipated ?nancial problems.The provision of unemployment bene?ts and other forms of temporary assistance, livable wages, medical bene?ts, and retirement and disability insurance to help cover the cost of necessities or to offset costs in the event of disability, are examples of ways to strengthen household ?nancial security. Housing stabilization policies aim to keep people in their homes and provide housing options for those in need during times of?nancial insecurity. This may occur through programs that provide affordable housing such as through government subsidies or through other options available to potential homebuyers such as loan modi?cation programs, move-out planning, or ?nancial counseling services that help minimize the risk or impact of foreclosures and eviction. Potential Outcomes - Reductions in foreclosure rates . Reductions in eviction rates - Reductions in emotional distress - Reductions in rates of suicide Preventing Suicide: A Technical Package of Policy, Programs, and Fractious Evidence There is evidence suggesting that strengthening household ?nancial security and stabilizing housing can reduce suicide risk. Strengthen household ?nancial security. The Federal- Stote Unemployment insurance Program allows states to de?ne the maximum amount and duration of unemployment bene?ts that workers are entitled to receive after a job loss.59 An examination of variations in unemployment bene?t programs across states demonstrated that the impact of unemployment on rates of suicide was offset in those states that provided greater than average unemployment bene?ts {mean level: $7,990 per person in U.S. constant dollars}.The effects of unemployment bene?t programs were also consistent by sex and age group.59 Another U.S. study examining the link between unemployment and suicide rates using suicide data, length of unemployment (less than 5 weeks, 5-14 weeks, 15-26 weeks, and greater than 26 weeks), and job losses found that the duration of unemployment, as opposed to just the loss of a job, predicted suicide risk.m Together, these results suggest that not only should state unemployment bene?t programs be generous in their ?nancial allocations, but also in their duration. Other measures to strengthen household ?nancial security transfer payments related to retirement and disability insurance, unemployment insurance compensation, medical bene?ts, and other forms of family assistance) have also shown an impact on rates of suicide. A study by Flavin and Radcliff?? examined the impact of statesF per capita spending on transfer payments, medical bene?ts, and family assistance (Temporary Assistance to Needy and total state spending on suicide rates between 1990- 2000, controlling for a number of suicide risk factors residential mobility, divorce rate, unemployment rate) at the state level. As per capita spending on total transfer payments, medical bene?ts, and family assistance increased there was an associated decrease in state suicide rates. In terms of lives saved, Flavin and Radclif?f calculated the cost of reducing a state's suicide rate by a full point for the years studied.? At the national level, they estimated 3,000 fewer suicides would occur per year nationwide if every state increased its per capita spending on these types of Preventing'Suicirle: ATechni-i Package of Policy, Programs, amt Practices i Evidence suggest-5 that stre Marking . Smog/arm ?blitzing? housing can reduce suicide risk. assistance by $45 per year?" Although this was a correlational study, the results demonstrate the potential bene?ts of policies that reach particularly vulnerable individuals during periods of great need. More evaluation studies are needed to further understand the outcomes impacted by programs such as these. Housing stabilization policies. The Neighborhood was designed to help neighborhoods suffering from high rates of foreclosure and abandonment by slowing the deterioration of the neighborhoods and providing affordable housing options for low, moderate, and middle-income homebuyers. This program also offers ?nancial assistance to eligible individuals for the purchase of a new home. Although this program has not been rigorously evaluated for its impact on suicide outcomes, it addresses foreclosure and eviction, which are risk factors for suicide. A longitudinal analysis of annual data on suicides and foreclosures demonstrated that as the proportion of foreclosed properties increased in U.S. states, so did the state suicide rate, particularly among working-aged adults.?53 Another study of data from 16 US. states participating in the Notionoi Vioient Death Reporting System found that suicides precipitated by home foreclosures and evictions increased more than 100% from 2005 (before the housing crisis began] to 2010 [after it had peaked)? Most of these suicides occurred prior to the actual loss of the decedent's home. These ?ndings suggest that integrating suicide prevention resources, messaging, and referrals into ?nancial, foreclosure, and move-out planning and counseling services may help to prevent suicide. Preventing Suicide: ll Technical Package of Policy, Programs, and Practices 3? m, 'm I, Strengthen Access and Delivery of Suicide (are Rationale While most people with mental health problems do not attempt or die by suicide?19 and the level of risk conferred by different types of mental illness previous research indicates that mental illness is an important risk factor for suicide?? State-level suicide rates have also been found to be correlated with general mental health measures such as Findings from the National Comorbidity Survey indicate that relatively few people in the US with mental health disorders receive treatment for those conditions.m Lack of access to mental health care is one of the contributing factors related to the underuse of mental health services?1 Identifying ways to improve access to timely, affordable, and quality mental health and suicide care for people in need is a critical component to prevention.S Additionally, research suggests that services provided are maximized when health and behavioral health care systems are set up to effectively and ef?ciently deliver such care."2 Apart from treatment bene?ts, these approaches can also normalize help?seeking behavior and increase the use of such services. Approaches There are a number of approaches that can be used to strengthen access and delivery of suicide care, including: Coverage of mental health conditions in health insurance policies. Federal and state laws include provisions for equal coverage of mental health services in health insurance plans that is on par with coverage for other health concerns mental health parity)? Bene?ts and services covered include such things as the number of visits, co- pays, deductibles, inpatienthutpatient services, prescription drugs, and hospitalizations. Ifa state has a stronger mental health parity law than the federal parity law, then insurance plans regulated by the state must follow the state parity law. lfa state has a weaker parity law than the federal parity law le.g., includes coverage for some mental health conditions but not others}, then the federal parity law will replace the state law. Equal coverage does not necessarily imply good coverage as health insurance plans vary in the extent to which bene?ts and services are offered to address various health conditions. Rather it helps to ensure that mental health services are covered on par with other health concerns. Reduce provider shortages in underserved areas. Access to effective and state-of?the-art mental health care is largely dependent upon the training and the size ofthe mental health care workforce. Over 85 million Americans live in areas with an insuf?cient number of mental health providers; this shortage is particularly severe among low- income urban and rural communities.M There are various ways to increase the number and distribution of practicing mental health providers in underserved areas including offering ?nancial incentives through existing state and federal programs loan repayment programs] and expanding the reach of health services through telephone, video and web?based technologies. Such approaches can increase the likelihood that those in need will be able to access affordable, quality care for mental health problems, which can reduce risk for suicide. Preventing Suicide: ll Technical Package of Policy. ngrarns. and Practice i, at a Safer suicide care through systems change. Access to health and behavioral health care services is critical for people at risk of suicide; however this isjust one piece of the puzzle. Care should also be delivered ef?ciently and effectively. More speci?cally, care should take place within a system that supports suicide prevention and patient safety through strong leadership, workforce training, systematic identi?cation and assessment of suicide risk, implementation of evidence-based treatments (see identify and Support People at Risk}, continuity of care, and continuous quality improvement. Care that is patient-centered and promotes equity for all patients is also of critical importance.? Potential Outcomes - Increased use of mental health services - Lower rates of treatment attrition . Reductions in depressive - Reductions in rates of suicide attempts - Reductions in rates of suicide Evidence There is evidence suggesting that coverage of mental health conditions in health insurance policies and improving access and the delivery of care can reduce risk factors associated with suicide and may directly impact suicide rates. Coverage of mental health conditions in health insurance policies. The National Survey on Drug Use and Health is a nationally representative survey of the US. population that provides data on substance use, mental health conditions, and service utilization?? Using data from this survey, Harris, Carpenter, and Bao? found that 12 months after states enacted mental health parity laws, self-reported use of mental healthcare services signi?cantly increased. Moreover, subsequent research by Lang"3 examined state mental health laws and suicide rates between 1990 and 2004 and found that mental health parity laws, speci?cally, were associated with an approximate 5% reduction in suicide rates.This reduction, in the 29 states with parity laws, equated to the prevention of 592 suicides per year.59 Reduce provider shortages in underserved areas. One example ofa program to improve access to mental health care providers is the National Health Service Corps which offers ?nancial incentives to attract mental/behavioral health clinicians to underserved areas.? Programs such as NHSC encourage individuals to work in the mental health profession in locations designated as Health Professional Shortage Areas in exchange for student loan debt repayment. A 2012 retention survey conducted by the Health Resources and Services Administration (HRSA), found that 61% of mental and behavioral health care providers continued to practice in designated mental health shortage areas after their four year commitment to the Although this program has not been evaluated for impact on suicide, it addresses access to care, which is a critical component to suicide prevention. Telemental Health (TMH) services refer to the use of telephone, video and web-based technologies for providing or care at a distance.? TMH can be used in a variety of settings outpatient clinics, hospitals, military treatment facilities] to treat a wide range of mental health conditions. It can also improve access to care for patients in isolated areas, as well as reduce travel time and expenses, reduce delays in receiving care, and improve satisfaction interacting with the mental health care system. A systematic review of TMH services found that services rated as high or good quality were effective in treating mental health conditions such as depression, schizophrenia, substance - 20 Preventing Suidrle: ?technical Package of Policy, Programs, and Practices Access to health and behavioral health care services is critical for people afsaicideabuse, and suicidal ideation and suicidef?g Further, Mohr and colleagues? conducted a meta?analysis examining the effect of delivered speci?cally via telephone and found that it signi?cantly reduced depressive in comparison to face-to-face also found that treatment attrition rates were signi?cantly lower among patients receiving telephone-administered compared to patients receiving face-to-face therapy?? Thus, TMH may not only offer improved access to mental health care, but it may also ensure continuity of care, and thereby further reduce the risk for suicide. Safer suicide care through systems change. Henry Ford Health System, which is a large health maintenance organization (HMO) in the state of Michigan, pioneered PerfectDepression Cares" the pro-cursor to what is now called Zero Suicide. The overall goal of Perfect Depression Care was to eliminate suicide among HMO members. More broadly, the goal of the program was to redesign delivery of depression care to achieve ?breakthrough improvement? in quality and safety by focusing on effectiveness, safety, patient centeredness, timeliness, ef?ciency, and equity among patients. The program screened and assessed each patient for suicide risk and implemented coordinated continuous follow-up care system wide.?51 An examination of the impact of the program found that there was a dramatic and statistically signi?cant decrease in the rate of suicide between the baseline years, 1999 and 2000, and the intervention years, 2002-2009. During this time period, the suicide rate fell by Further, among HMO members who received mental health specialty services, the suicide rate signi?cantly decreased over time from 1999 to 2010 (110.3 to 47.6 per 100,000 population; p<.04) with a mean of 36.2 per 100,000 over the period.33 Additionally, for those HMO members who accessed only general medical services as opposed to specialty mental health services, the suicide rate increased from 2.7 to 5.6 per 100,000 Similarly, in the state of Michigan, rates of suicide in the general population increased over the period from 9.8 to 12.5 per Preventing Suicide: A Technical Package of Policy, Frog ram, and Practices 3? Create Protective Environments Rationale Prevention efforts that focus not only on individual behavior change help-seeking, treatment interventions) but on changes to the environment can increase the likelihood of positive behavioral and health outcomes.Em Creating environments that address risk and protective factors where individuals live, work, and play can help prevent suicide."17 For example, rates of suicide are high among middle-aged adults who comprise 42.6% ofthe workforce55; among certain occupational groupsm'?; and among people in detention facilities jail, prisonlfl?a to name a few. Thus, settings where these populations work and reside are ideal for implementing programs, practices and policies to buffer against suicide. Changes to organizational culture through the implementation of supportive policies, for instance, can change social norms, encourage help-seeking, and demonstrate that good health and mental health are valued and that stigma and other risk factors for suicide are notam Similarly, modifying the characteristics ofthe physical environment to prevent harmful behavior such as access to lethal means can reduce suicide rates, particularly in times of crisis or transition.39?94 Approaches The current evidence suggests three potential approaches for creating environments that protect against suicide. Reduce access to lethal means among persons at risk of suicide. Means of suicide such as ?rearms, hangingr? suffocation, orjumping from heights provide little opportunity for rescue and, as such, have high case fatality rates about 85% of people who use a ?rearm in a suicide attempt die from their Research also indicates that: 1) the interval between deciding to act and attempting suicide can be as short as 5 or 10 and 2) people tend not to substitute a different method when a highly lethal method is unavailable or dif?cult to accessf?ir?i9 Therefore, increasing the time interval between deciding to act and the suicide attempt, for example, by making it more dif?cult to access lethal means, can be lifesaving. The following are examples of approaches reducing access to lethal means for persons at risk of suicide: - intervening otSuicr'de Hotspots. Suicide hotspots, or places where suicides may take place relatively easily, include tall structures bridges, cliffs, balconies, and rooftops), railway tracks, and isolated locations such as parks. Efforts to prevent suicide at these locations include erecting barriers or limiting access to prevent jumping, and installing signs and telephones to encourage individuals who are considering suicide, to seek help.? - Safe Storage Practices. Safe storage of medications, ?rearms, and other household products can reduce the risk for suicide by separating vulnerable individuals from easy access to lethal means. Such practices may include education and counseling around storing ?rearms locked in a secure place leg, in a gun safe or lock box), unloaded and separate from the ammunition; and keeping medicines in a locked cabinet or other secure location away from people who may be at risk or who have made prior Organizational policies and culture that promote protective environments may be implemented in places of employment, detention facilities, and other secured environments residential settings). Such policies and cultural values encourage leadership from the top down and may promote prosocial behavior asking for help), skill building, positive social norms, assessment, referral and access to helping services mental health, substance abuse treatment, ?nancial counseling), and development of crisis response plans, postvention and other measures to foster a safe physical environment. Such policies and cultural shifts can positively impact organizational climate and morale and help prevent suicide and its related risk factors depression, social isolationiFfrmi Community-based policies to reduce excessive alcohol use. Research studies in the United States have found that greater alcohol availability is positively associated with alcohol?involved suicidesm'm Policies to reduce excessive alcohol use broadly include zoning to limit the location and density of alcohol outlets, taxes on alcohol, and bans on the sale of alcohol for individuals under the legal drinking age.?35 These policies are important because acute alcohol use has been found to be associated with more than one-third of suicides and approximately 40% of suicide attempts.?5 Potential Outcomes - Increases in safe storage of lethal means - Reductions in rates of suicide - Reductions in suicide attempts - Increases in help-seeking . Reductions in alcohol-related suicide deaths Evidence The evidence suggests that creating protective environments can reduce suicide and suicide attempts and increase protective behaviors. Reduce access to lethal means among persons at risk of suicide. A meta-analysis examining the impact of suicide hotspot interventions implemented in combination or in isolation, both in the U5. and abroad, found associated reduced rates of For example, after erecting a barrier on the Jacques?Cartier bridge in Canada, the suicide rate from jumping from the bridge decreased from about 10 suicide deaths per year to about 3 deaths per year.?is Moreover, the reduction in suicides byjumping was sustained even when all bridges and nearbyjumping sites were considered, suggesting little to no displacement of suicides to otherjumping sites.mg Further evidence for the effectiveness of bridge barriers was demonstrated by a study examining the impact of the removal of safety barriers from the Grafton Bridge in Auckland, New Zealand. After removal of the barrier, both the number and rate of suicide increased ?vefold-??11?? Another form of means reduction involves implementation of safe storage practices. In a case-control study of ?rearm-related events identi?ed from 37 counties in Washington, Oregon, and Missouri, and from 5 trauma centers, researchers found that storing ?rearms unloaded, separate from ammunition, in a locked place or secured with a safety device was protective of suicide attempts among adolescents!? Further, a recent systematic review of clinic and community-based education and counseling interventions suggested that the provision of safety devices signi?cantly increased safe ?rearm storage practices compared to counseling alone or compared to the provision of economic incentives to acquire safety devices on one's own.101 Preventing Suicide: A Technical Package of Policy, Program, and Practices 0 Another program, the Emergency Department Counseling on Access to Lethal Means (ED trained emergency clinicians in a large children?s hospital to provide lethal means counseling and safe storage boxes to parents of patients under age 13 receiving care for suicidal behavior. In a pre-post quality improvement project, Runyan et al39 found that at post-test 76% (of the 55% of parents followed up, n:114} reported that all medications in the home were locked up as compared to fewer than 10% at the time of the initial emergency department visit. Among parents who indicated the presence of guns in the home at pre-test all (100%) reported guns were currently locked up at post-test.Bg Organiaational policies and culture. Together for Life is a workplace program of the Montreal Police Force implemented to address suicide among of?cers. Policy and program components were designed to foster an organizational culture that promoted mutual support and solidarity among all members of the Force. The program included training of supervisors, managers and all units to improve competencies in identifying suicidal risk and to improve use and awareness of existing resources. The program also included an education campaign to improve awareness and help-seeking.? Police suicides were tracked over 12 years and compared to rates in the control city of Quebec.The suicide rate in the intervention group decreased signi?cantly by to a rate of 6.4 suicides per 100,000 population per year compared to an 11% increase in the control city {29.0 per Another example of this approach is the United States Air Force Suicide Prevention Program. The program included 1 1 policy and education initiatives and was designed to change the culture of the Air Force surrounding suicide.The program uses leaders as role models and agents of change, establishes expectations for behavior related to awareness of suicide risk, develops population skills and knowledge education and training], and investigates every suicide outcomes measurement]. The program represents a fundamental shift from viewing suicide and mental illness solely as medical problems and instead sees them as larger service?wide problems impacting the whole community.? Using a time?series design to examine the impact of the program on various violence?related outcomes, researchers found that the program was associated with a 33% relative risk reduction in suicide.? The program was also associated with relative risk reductions in related outcomes including moderate and severe family violence (30% and 54%. respectively}, homicide and accidental death A longitudinal assessment of the program over the period 1981 to 2008 (16 years before the 1997 launch of the program and 11 years post-launch] found signi?cantly lower rates ofsuicicle after the program was launched than before.? These effects were sustained over time, except in 2004, which the authors found was associated with less rigorous implementation of program components in that year than in the other years.? Finally, while the evidence is still being built for suicide prevention in correctional facilities, preliminary evidence suggests organizational policies and practices that include routine suicide prevention training for all staff; standardized intake screening and risk assessment; provision of shared information between staff members (especially in transitioning or transferring of inmates); varying levels of observation; safe physical environment; emergency response protocols; noti?cation of suicidal behavior/suicide through the chain of command; and critical incident stress debrie?ng and death review can potentially reduce suicide)? When these policies and practices were implemented across 1 1 state prisons in Louisiana, suicide rates dropped 46%, from a rate of 23.1 per 100,000 before the intervention to 12.4 per 100,000 the following year.?3 Similar programs have seen declines in suicide both in the United States and in other countries.? Community-based policies to reduce excessive alcohol use. While multiple policies to limit excessive use ofalcohol exist, several studies on alcohol outlet density and risk factors for suicide, such as interpersonal violence and social connectedness,?5??1 suggest that measures to reduce alcohol outlet density can potentially reduce alcohol-involved suicides. Additionally, a longitudinal analysis of alcohol outlet density, suicide mortality, and hospitalizations for suicide attempts over 6 years in 581 California zip codes, indicated that greater density of bars, speci?cally, was related to greater suicide and suicide attempts, particularly in rural areas.119 PmmtingSuldde: Package . ?it '1 3 Promote Connectedness Rationale Sociologist, Emile Durkheim theorized in 189? that weak social bonds, lack of connectedness, were among the chief causes of suicidalitme Connectedness is the degree to which an individual or group of individuals are socially close, interrelated, or share resources with others.?21 Social connections can be formed within and between multiple levels of the social ecology,? for instance between individuals peers, neighbors, co-workers}, families, schools, neighborhoods, workplaces, faith communities, cultural groups, and society as a whole. Related to connectedness, social capital refers to a sense of trust in one?s community and neighborhood, social integration, and also the availability and participation in social organizations?;123 Many ecological cross-sectional and longitudinal studies have examined the impact of aspects of social capital on depression depressive disorder, mental health more generally, and suicide. While the evidence is limited, existing studies suggest a positive association between social capital (as measured by social trust and community/neighborhood engagement], and improved mental Connectedness and social capital together may protect against suicidal behaviors by decreasing isolation, encouraging adaptive coping behaviors, and by increasing belongingness, personal value, and worth, to help build resilience in the face of adversity. Connectedness can also provide individuals with better access to formal supports and resources, mobilize communities to meet the needs ofits members and provide collective primary prevention activities to the community as a whole.121 Approaches Promoting connectedness among individuals and within communities through modeling peer norms and enhancing community engagement may protect against suicide. Peer narm programs seek to normalize protective factors for suicide such as help-seeking, reaching out and talking to trusted adults, and promote peer connectedness. By leveraging the leadership qualities and social in?uence of peers, these approaches can be used to shift group-level beliefs and promote positive social and behavioral change. These approaches typically target youth and are delivered in school settings but can also be implemented in community settings)? Community engagement activities Community engagement is an aspect of social capital? Community engagement approaches may involve residents participating in a range of activities, including religious activities, community clean-up and greening activities, and group physical exerciseThese activities provide opportunities for residents to become more involved in the community and to connect with other community members, organizations, and resources, resulting in enhanced overall physical health, reduced stress, and decreased depressive thereby reducing risk of suicide. . Preventing Suicide: A Technical Package of Policy. Program. am! Prank: 3F 0 Potential Outcomes Increases in healthy coping attitudes and behaviors Increases in referrals for youth in distress Increases in help?seeking behaviors Increases in positive perceptions of adult support Promoting connectedness among individuals and within -. communities may protect against suicide. 4?3- .- . - 28 Preventing Suicide: ATechnical Package of Policy, Programs, and Practices -r - .- Evidence Current evidence suggests a number of positive bene?ts of peer norm and community engagement activities, although more evaluation research is needed to examine whether these improvements in factors that protect against suicidal behavior translate into reduced suicide attempts and deaths. Peer norm programs. Evaluations show that programs such as Sources of Strength can improve school norms and beliefs about suicide that are created and disseminated by student peers. In a randomized controlled trial of Sources of Strength conducted with 18 high? schools (6 metropolitan, 12 rural], researchers found that the program improved adaptive norms regarding suicide, connectedness to adults, and school engagement.? Peer leaders were also more likely than controls to refer a suicidal friend to an adult. For students, the program resulted in increased perceptions of adult support for suicidal youths, particularly among those with a history of suicidal ideation, and the acceptability of help?seeking behaviors. Finally, trained peer leaders also reported a greater decrease in maladaptive coping attitudes compared with untrained leaders.?a Community engagement activities. A vacant lot greening initiative was undertaken in Philadelphia between 1999 and 2008. Local residents and community members worked together to green 4,436 lots (or 7.8 million square feet) in four areas of the city. Researchers found signi?cant reductions in community residents? self-reported level of stress, a risk factor for suicide, and engagement in more physical exercise, a protective factor for suicide, than residents in control vacant lot areas. There is some evidence for other cross-cutting bene?ts, including reductions in ?rearm assaults and Preventing Suicide: A Technical Package of Policy, Program. and Practices 3? Teach Coping and Problem-Solving Skills Rationale Building life skills prepares individuals to successfully tackle every day challenges and adapt to stress and adversity. Life skills encompasses many concepts, but most often include coping and problem-solving skills, emotional regulation, con?ict resolution, and critical thinking. Life skills are important in protecting individuals from suicidal behaviorsu?i? Suicide prevention programs that focus on life and social skills training are drawn from social cognitive theories,13g surmising that suicidal behavior is attributed to either direct learning and modeling or environmental and individual hopelessness) characteristics. The inability to employ adequate strategies to cope with immediate stressors or identify and ?nd solutions for problems has been characterized among suicide attempters?l Teaching and providing youth with the skills to tackle every day challenges and stressors is, therefore, an important developmental component to suicide prevention. Approaches Social-emotional learning programs and parenting skill and family relationship programs are two approaches for teaching coping and problem-solving skills. Socialremotional learning programs focus on developing and strengthening communication and problem?solving skills, emotional regulation, con?ict resolution, help seeking and coping skills.These approaches address a range of risk and protective factors for suicidal behavior. They provide children and youth with skills to resolve problems in relationships, school, and with peers, and help youth address other negative in?uences substance use) associated with suicide.I26 These approaches are typically delivered to all students in a particular grade or school, although some programs also focus on groups of students considered to be at high risk for suicide. Opportunities to practice and reinforce skills are an important part of programs that work.?32 Parenting skill and family relationship programs provide caregivers with support and are designed to strengthen parenting skills, enhance positive parent-child interactions, and improve children's behavioral and emotional skills and abilities.132 Programs are typically designed for parents or caregivers with children in a speci?c age range and can be self?directed or delivered to individual families or groups offamilies. Some programs have sessions primarily with parents or caregivers while others include sessions for parents or caregivers, youth, and the family. Speci?c program content typically varies by the age of the child but often has consistent themes of child development, parent?child communication and relationships, and youth?s interpersonal and problem-solving skills. Preventing Suicide: I. Technical Package of Policy, Programs, and Fraction 39F 3 Potential Outcomes - Reductions in suicide ideation - Reductions in suicide attempts - Reductions in suicide risk behaviors depression. anxiety, conduct problems, substance abuse] - Improvements in help-seeking behavior - Improvements in social competence and emotional regulation skills - Improvements in problem-solving and con?ict management skills Evidence Several social?emotional learning and parenting and family relationship programs have been shown in rigorous evaluations to improve resilience and reduce problem behavior and risk factors for various behaviors, including ones closely related to suicide, such as depression, internalizing behaviors, and substance abuse.133 Social-emotional learning programs. The Youth Aware ofMental Health Program (YAM) is a program developed for teenagers aged 14?16 that uses interactive dialogue and role-playing to teach adolescents about the risk and protective factors associated with suicide (including knowledge about depression and anxiety) and enhances their problem?solving skills for dealing with adverse life events, stress, school and other problems.134 In a cluster- randomized controlled trial conducted across 10 European Union countries and 168 schools, students in schools randomized to YAM were signi?cantly less likely to attempt suicide and have severe suicidal ideation at the 12+month follow?up compared to students in control schools which received educational materials and care as usual. Overall, the relative risk of youth suicide attempts among the YAM group was reduced by over 50% demonstrating that out of 1000 students, ?ve attempted suicide in the YAM group compared to in the control group. Additionally, related to severe suicide ideation, in the YAM group, relative risk fell by Another example is the Good Behavior Game which is a classroom-based program for elementary school children aged 6?10.The program uses a team-based behavior management strategy that promotes good behavior by setting clear expectations for good behavior and consequences for maladaptive behavior. The goal of the (336 program is to create an integrated classroom social system that is supportive of all children being able to learn with little aggressive or disruptive behavior.?35Two cohorts of youths participated in the program in 1985-86 and 198687 school years when they were in the ?rst and second grades. A number of proximal and distal outcomes were assessed among the two cohorts over time. With respect to distal suicide?related outcomes, an outcome evaluation of the 686 indicated that individuals in the ?rst cohort, who were assigned to participate in 636 when they were in the ?rst grade, reported half the adjusted odds of suicidal ideation and suicide attempts when assessed approximately 15 years later, between the ages of 19 to 21, compared to peers who had been in a standard classroom setting.The bene?cial effect of the program was consistent for suicidal ideation regardless ofwhether baseline covariates were included.?35The GBG effect on attempts was less robust in some adjusted models including caregiver mental health. In the second cohort of 686 students, neither suicidal ideation nor suicide attempts were signi?cantly different between 686 and the control interventions.?35The researchers believed this may have been due to a lack of implementation ?delity, including less mentoring and monitoring of teachers. 636 was also found to be associated with reduced risk of later substance abuse and other suicide risk factors among the ?rst cohort of students. Results for the second cohort were generally smaller but in the desired Preventing Suicide: ?technical Package Policy. Program. ml Pmtim 6 Parenting skill and family relationship programs. Parenting and family skills training approaches have shown promising impacts in preventing key risk factors associated with suicide. For example, the incredible Years (W) is a comprehensive group training program for parents, teachers and children designed to reduce conduct and substance abuse problems {two important suicide risk factors in youth} by improving protective factors such as responsive and positive parent-teacher?child interactions and relationships, emotional self-regulation and social competence {all protective factors for The program includes 9-20 sessions offered in community-based settings religious, recreation centers, mental health treatment centers, and hospitals). Several studies have demonstrated the effect of the program on reducing internalizing such as anxiety and depression, and child conduct problems.131133 The program is also associated with improved problem-solving and conflict management; these skills were maintained at 1~year Additionally, the program demonstrated greater bene?ts in mother?rated child internalizing compared to the waitlisted control group, when parent, child, and teacher components were included.132 Additionally, Strengthening Families i0? i4 is a program that involves sessions for parents, youth, and families with the goal of improving parents? skills for disciplining, managing emotions and con?ict, and communicating with their children; promoting youths?interpersonal and problem-solving skills; and creating family activities to build cohesion and positive parent-child interactions. The premise of the program is that developing these skills for both parents and children will reduce internalizing behavior and adolescent substance abuse, two important risk factors for suicide.142 Strengthening Families has been shown to signi?cantly decrease externalizing behaviors, such as aggression, alcohol use, and drug use among youth participants, as well as reduce depression, alcohol use, and drug use among participating families.?42 Parenting and a family skills training approaches have shown promising impacts in preventing key risk factors associated with suicide. it- Preventing Suicide: ll Tech nkal Package of Policy, Programs, and Practices 3? . ll Identify and Support People at Risk Rationale In order to decrease suicide, care of, and attention to, vulnerable populations is necessary, as these groups tend to experience suicidal behavior at higher than average rates. Such vulnerable populations include, but are not limited to, individuals with lower socio-economic status or who are living with a mental health problem; people who have previously attempted suicide; Veterans and active duty military personnel; individuals who are institutionalized, have been victims of violence, or are homeless; individuals of sexual minority status; and members of certain racial and ethnic minority Supporting people at risk requires proactive case ?nding and effective response. crisis intervention, and evidence-based treatment. Finding optimal ways of identifying at risk individuals, customizing services to make them more accessible Internet?based services when appropriate] and engaging people in evidence? based care through such measures as collaborative treatment}, remain key Simply improving or expanding services does not guarantee that those services will be used by people most in need, nor will it necessarily increase the number of people who follow recommended referrals or treatment. For example, some people living in disadvantaged communities may face social and economic issues that can adversely affect their ability to access supportive services.m Approaches The following approaches focus on identifying and supporting people at increased risk of suicide. Gatekeeper training is designed to train teachers, coaches, clergy, emergency responders, primary and urgent care providers, and others in the community to identify people who may be at risk of suicide and to respond effectively, including facilitating treatment seeking and support services. Gatekeeper training may be implemented in a variety of settings to identify and support people at risk.?15 Crisis intervention These approaches provide support and referral services, typically by connecting a person in crisis {or a friend or family member of someone at risk) to trained volunteers or professional staff via telephone hotline, online chat, text messaging, or in-person. Crisis intervention approaches are intended to impact key risk factors for suicide, including feelings of depression, hopelessness, and subsequent mental health care utilization.m Similar to means reduction, crisis interventions can put space or time between an individual who may be considering suicide and harmful behavior. Treatment for peOple at risk of suicide can include various forms of delivered by licensed providers to help individuals with mental health problems and other suicide risk factors with problem?solving and emotional regulation. Treatment usually takes place in a one-on-one or group format between patients and clinicians and can vary in duration from several weeks to ongoing therapy, as needed.Treatment that employs collaborative between patient and therapist or care manager) and/or integrated care linkage between primary care and behavioral health care) can help engage and motivate patients, thereby increasing retention in therapy and decreasing suicide Parenting Suicide: A Technical Package of Policy. Programs. and Fraction Treatment to prevent reattempts. These approaches typically include follow?up contact and use diverse modalities ie.g., home visits, mail, telephone, e?mail) to engage recent suicide attempt survivors in continued treatment to prevent Treatment may focus on improved coping skills, mindfulness, and other emotional regulation skills, and may include case management home visits to increase adherence to treatment and continuity of care; and one-on-one interpersonal therapy andior group therapy. Approaches that engage and connect people who have attempted to peers and providers are especially important because many attem pters do not present to aftercare; 12%?25% re?attempt within a year, and 396?996 of attempt survivors die by suicide within I to 5 years of their initial attemptm Potential Outcomes - Reductions in suicidal ideation - Reductions in suicide attempts - Reductions in suicide rates - Reductions in depression and feelings of hopelessness - Reductions in re?attempts - Improvements in coping skills . Increases in treatment engagement and compliance with medications Evidence The current evidence suggests that identifying people at risk of suicide and the continued provision oftreatment and support for these individuals can positively impact suicide and its associated risk factors. {jatekeeraer training Applied Suicide intervention Training is a widely implemented training program that helps hotline counselors, emergency workers, and other gatekeepers to identify and connect with suicidal individuals, understand their reasoning for living and dying, and assist with safely connecting those in need to available resources. In a study employing a randomized controlled trial, Gould, Cross, Pisani, Munfakh, 8: Kleinman?? evaluated the training across the NotionaiSuicide Prevention tifeiine network of hotlines over the period 2008-2009. Using data from 1,41 0 suicidal individuals who called 17 Lifeline centers, the researchers found that callers who spoke with ASiST?trained - 7m WNW 0 counselors were signi?cantly more likely to feel less depressed, less suicidal, less overwhelmed, and more hopeful by the end oftheir call, compared to callers who spoke to non~ASiSTtrained counselors. Counselors trained in were also more skilled at keeping callers on the phone longer and establishing a connection with them. However, training in ASiSTdid not result in more comprehensive suicide risk assessments than usual care training?: Gatekeeper training has also been a primary component of the Garret Lee Smith (GL5) Suicide Prevention Program, which has been implemented in 50 states and 50 tribes. A multi-site evaluation assessed the impact of community gatekeeper training on suicide attempts and deaths by comparing the change in suicide rates and nonfatal suicidal behavior among young people aged 10?24 in counties implementing GL5 trainings, with the trajectory observed in similar counties that did not implement these trainings. Counties that implemented GL5 trainings had signi?cantly lower youth suicide rates one year following the training implementation.i53This ?nding equates to a decrease of 1 suicide death per 100,000 youth ages 10 to 24, or the prevention of approximately 237 deaths in the age group, between 2007 and 2010. Counties implementing GL5 program activities also had signi?cantly lower suicide attempt rates among youth ages 16 to 23 in the year following implementation of the GL5 program than did similar counties that did not implement GL5 activities (4.9 fewer attempts per 1000 More than 29,000 suicide attempts may have been prevented during the period examined. Crisis intervention. Suicide prevention hotlines are one way to provide crisis intervention. In an evaluation of the effectiveness of the Nationai Suicide Prevention Lifeiine to prevent suicide, 1,085 suicidal individuals who called the hotline completed a standard risk assessment for suicide, and 380 of those completed a follow-up assessment between 1 and 52 days (mean=13.5 days) after the initial assessment. Researchers found that over half ofthe initial sample were seriously considering suicide when they called, and they had a plan for their suicide. Researchers also found that among follow-up participants, there was a signi?cant decrease in pain, hopelessness, and intent to die between initiation of the call [time 1) to follow?up (time 3i).155 Between time 2 {end ofthe call] to time 3, the effect remained for pain and hopelessness, but was not signi?cant for intent to die, suggesting that greater effort at outreach during and following the call is needed for callers with high levels of suicide intent.155 Treatment for people at risk of suicideThe improving Mood?Promoting Access to Collaborative Treatment UMPACT) program aims to prevent suicide among older primary care patients by reducing suicide ideation and depression. lMPACTfacilitates the development of a therapeutic alliance, a personalized treatment plan that includes patient preferences, as well as proactive follow-up {biweekly during an acute phase and during continuation phase) by a depression care manager.156 The program has been shown to signi?cantly improve quality of life, and to reduce functional impairment, depression and suicidal ideation over 24-months of relative to patients who received care as usual. Coilaborative Assessment and Management of Suicidaiity (CAMS), is a therapeutic approach for suicide-speci?c assessment and treatment.The program?s flexible approach can be used across treatment settings and clinician theoretical orientations and involves the clinician and patient working together in an interactive assessment process to develop patient-speci?c treatment plans. Sessions are collaborative and involve constant patient input about what is and is not working with the ultimate goal of enhancing the therapeutic alliance and increasing treatment motivation in the suicidal patient. CAMS has been tested and supported in 6 correlational studies,?? in a variety of inpatient and outpatient settings, and in one RCT with several additional RCTs under way. A feasibility trial with a community-based sample of suicidal outpatients randomly assigned to CAMS or enhanced care as usual (intake with a or nurse practitioner followed by 1-11 visits with a case manager and medication as needed] found better treatment retention among the CAMS group and signi?cant improvements in suicidal ideation, overall distress, and feelings of hopelessness at the 12 month follow-up.155 Preventing Suicide: A Technical Package of Fancy. Fmgrammnd We. 3? Other examples include Dialectical Behavioral Therapy and Attachment?Based Family Therapy a multicomponent therapy for individuals at high risk for suicide and who may struggle with impulsivity and emotional regulation issues.The components of DBT include individual therapy, group skills training, between?session telephone coaching and a therapist consultation team. In a randomized controlled trial of women with recent suicidal or self- injurious behavior, those receiving DBTwere half as likely to make a suicide attempt at the two-year follow-up than women receiving community treatment (23% vs required less hospitalization for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined?? ABFT is a program for adolescents aged 12?1 8 and is designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety.?5? A randomized controlled trial ofABFTfound that suicidal adolescents assigned to experienced signi?cantly greater improvement in suicidal ideation over 24 weeks of follow-up than did adolescents assigned to enhanced usual care. Additionally, a signi?cantly higher percentage of ABFT participants reported no suicidal ideation in the week prior to assessment at 12 weeks than did adolescents receiving enhanced usual care (69.2% vs. 34.6%} and at 24 weeks [82.1% vs. The Veterans Affairs Translating initiatives for Depression into Effective Solutions project uses a depression care liaison to link primary care and mental health services.The depression care liaison assesses and educates patients and follows-up with both patients and providers between primary care visits to optimize treatment. This collaborative care increases the ef?ciency of providing mental health services by bringing mental health care to the primary care setting, where most patients are ?rst detected and subsequently treated for many mental health conditions. An evaluation of 17055 found signi?cant decreases in depression severity scores among 20% of primary care patients."5 7105? patients also demonstrated 85% and 95% compliance with medication and follow?up visits, respectively.1m Treatment to prevent re attempts. Several strategies that aim to prevent re?attempts have demonstrated impact on reducing suicide deaths. For example, Emergency Department Brief intervention with Follow?up Visits is a program that involves a one?hour discharge information session that addresses suicidal ideation and attempts, distress, risk and protective factors, alternatives to self-harm, and referral options, combined with nine follow?up contacts over 18 months (at 1, 2, 4, 7, 11 weeks and 4, 6, 12, 13 months). Follow-up contacts are either conducted by phone or through home visits according to a speci?c timeline for up to 18 months. A randomized controlled trial that enrolled suicide attempters from eight hospital emergency departments in ?ve countries (Brazil, India, Sri Lanka, lran, and China) found that a brief intervention combined with nine follow-up visits over 18 months was associated with signi?cantly fewer deaths from suicide relative to a treatment-as-usual group versus respectively).162 Another example of treatment to prevent re-attempts involves active follow-up contact approaches such as postcards, letters, and telephone calls intended to increase a patient?s sense of connectedness with health care providers and decrease isolation.151 These approaches include expression of care and support and typically invite patients to reconnect with their provider. Contacts are made periodically or every few months in the ?rst 12 months post?discharge with some programs continuing contact for two or more years}. In a meta?analysis conducted by Inagaki et al?51 interventions to prevent repeat suicide attempts in patients admitted to an emergency department for suicide attempt were found to reduce re-attempts by approximately 12% for up to 12 months post-discharge; however, the effects ofthese approaches beyond 12 months on re-attempts has not yet been demonstrated.151 Also, because the number oftrials and associated sample sizes included in this meta-analysis were small, it was not possible to determine the effect of active contact and follow-up approaches on suicide. 92mm Sul?de: Mahala! mirage of Polity, Preamp. and Practices 6 In a randomized controlled trial of the post?crisis suicide prevention long?term follow?up contact approach, Motto and Eiostrom'f'3 found that patients who refused ongoing care but who were randomized to be contacted by letter four times per year had a lower rate of suicide over two years of follow?up than did patients in the control group who received no further contact. Other studies have also shown post-crisis letters and coping cards to be protective against suicide ideation and Finally, Cognitive Behavior Therapy for Suicide Prevention (CST-SP) is an example of a therapeutic approach to prevent re-attempts. It uses a risk-reduction, relapse prevention approach that includes an analysis of proximal risk factors and stressors relationship problems, school or work-related dif?culties} leading up to and following the suicide attempt; safety plan development; skill building; and CBTASP also has family skill modules focused on family support and communication patterns as well as improving the family?s problem-solving skills. A randomized controlled trial of found that outpatient cognitive therapy designed to prevent repeat suicide attempts resulted in a 50% reduction in the likelihood of a suicide re?atternpt among adults who had been admitted to an emergency department for a suicide attempt relative to treatment as usual.?6 Several strategies that aim to prevent re-attempts have demonstrated impact on reducing suicide deaths. 4 Preventing Suicide: it Technical Package of Policy, Program, and Practices 39 ?7 Lessen Harms and Prevent Future Risk Rationale Millions of people are bereaved by suicide every year in the United States and throughout the world.5 Risk of suicide and suicide risk factors has been shown to increase among people who have lost a friend/peer, family member, co-worker, or other close contact to suicide?? Care and attention to the bereaved is therefore of high importance. Despite often good intentions, media and others responding to suicide may add to this risk. For example, research suggests that exposure to sensationalized or otherwise uninformed reporting on suicide may heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to what is known as suicide contagion??mg Approaches Some approaches that can be used to lessen harms and reduce future risk of suicide include postvention and safe reporting and messaging following a suicide. Postvention approaches are implemented after a suicide has taken place and may include debrie?ng sessions, counseling, and/or bereavement support groups for surviving friends, family members, or other close contacts.These programs have not typically been evaluated for their impact on suicide, attempts, or ideation, but they may reduce survivors'guilt, feelings of depression, and complicated grief.1m Safe reporting and messaging about suicide.The manner in which information on a recent suicide is communicated to the public school assemblies, mass media, social media} can heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion. Reports that are inclusive of suicide prevention messages, stories of hope and resilience, risk and protective factors, and links to helping resources hotline], and that avoid sensationalizing events or reducing suicide to one cause, can help reduce the likelihood of suicide contagion.?1 Potential Outcomes - Reductions in suicidal ideation - Reductions in suicide attempts - Reductions in rates of suicide - Reductions in distress - Improvements in reporting following suicide - Reductions in contagion effects related to suicide Preventing Suicide: A. Technical Package of Policy, Programs, and Practices 0 Evidence Current evidence suggests that postvention and safe reporting and messaging can impact risk and protective factors for suicide. Postvenliion. One example of a postvention program with evidence of impact on risk and protective factors for suicide is the StondBy Response Service {StondBy}. StondBy provides clients with face-to-face outreach and telephone support through a professional crisis response team. Site coordinators develop customized case management plans, referring clients to other existing community services matched to their needs.?2 In a study by Visser, Comans, and Scufl?ham,?2 StondBy clients were signi?cantly less likely to be at high risk for suicidality (suicide ideation and attempts} and had less distress than a suicide bereaved comparison group who had not had contact with the StondBy program {48% and 64% respectively]. Additionally, research suggests that active postvention approaches in which outreach to suicide survivors occurs at the scene of a suicide is associated with intake into treatment sooner, greater attendance at support group meetings, and attendance at more meetings compared to passive postvention approaches where survivors self-refer for Safe reparting and messaging about suicide- One way to ensure safe reporting and messaging about suicide is to encourage news media to adhere to Recommendations for Reporting on Suicide org). The most compelling evidence supporting these recommendations for reporting comes from Austria. After a sharp increase in suicides on the Viennese subway, media guidelines were introduced and an interrupted time?series design was used to evaluate the national impact of the guidelines on subsequent suicides. Changes in the quality and quantity ofmedia reporting resulted in a nationwide signi?cant reduction of81 suicides annually":19 Finally, research suggests that not only does reporting on suicide in a negative way reporting on suicide and repetition) have harmful effects on suicide, but reporting on positive coping skills in the face of adversity can also demonstrate protective effects against suicide.?4 Reports of individual suicidal ideation (not accompanied by reports of suicide or suicide attempts) along with reports describing a "mastery" of a crisis situation where adversities were overcome was associated with signi?cant decreases in suicide rates in the time period immediately following such reports.?4 Pastven tion and safe reporting and messaging can impact risk and protective factors for suicide. a ltedmiral Padraig? "afPallcy, Mauls-amt Indians 0 Sector Involvement Public health can play an important and unique role in addressing suicide. Public health agencies, which typically place prevention at the forefront of efforts and work to create broad population-level impact, can bring critical leadership and resources to bear on this problem. For example, these agencies can serve as a convener, bringing together partners and stakeholders to plan, prioritize, and coordinate suicide prevention efforts. Public health agencies are also well positioned to collect and disseminate data, implement preventive measures, evaluate programs, and track progress. Although public health can play a leadership role in preventing suicide, the strategies and approaches outlined in this technical package cannot be accomplished by the public health sector alone. As noted in the National Strategy for Suicide Prevention,? the integration and coordination of prevention activities across sectors and settings is critical for expanding the reach and impact of suicide prevention efforts. Other sectors vital to implementing this package include, but are not limited to, education, government (local, state, and federal), social services, health services, business, Iabor,justice, housing, media, and organizations that comprise the civil society sector such as faith-based organizations, youth-serving organizations, foundations, and other non-governmental organizations. Collectively, these sectors can make a difference in preventing suicide by impacting the various contexts and underlying risks that contribute to suicide. The strategies and approaches described in this technical package are summarized in the Appendix along with the relevant sectors that are well positioned to lead implementation efforts. For example, business and labor, the health sector {including insurers, providers, and health systems}, and government entities are in the best position to implement programs and policies that Strengthen Economic Supports and Strengthen Access and Delivery of Suicide Core. These types of supports go beyond individual behavior change and require commitment and support from those sectors that can directly address some of the underlying risks and the environmental contexts that increase the risk for suicide. Public health entities can play an important role by gathering and information to inform policy, raise awareness, and evaluate the effectiveness of various policies. Moreover, partnerships with non-governmental and community organizations can be instrumental in increasing awareness ofand garnering support for policies affecting individuals and families. The public health sector has been at the forefront of many community-based prevention efforts, working collaboratively with schools and community-based organizations, to change social norms and positively impact health behavior. Public health is well suited to take on a similar leadership role in Promoting Connectedness through peer norm and community engagement activities and supporting the development, evaluation, and adoption of effective programs that Teoch Coping and Problem?Solving to prevent the risk of suicide in the ?rst place.These programs are often delivered in school and community settings, making education and non?governmental organizations vital partners in prevention. Businesses, workplaces, and local and state government entities, on the other hand, are in the best position to establish policies and support practices that Create Protective Environments where people live, work, and play. Public health entities can serve in an important role by gathering and information, working with other governmental agencies criminal justice, defense) and agencies within the executive branch of their state or local government in support of policy and other approaches, and evaluating the effectiveness of measures taken. In a similar fashion, public health entities can partner with schools, workplaces, and community organizations to implement and evaluate prevention programs, policies and practices geared toward creating safe, healthy, and supportive environments. Preventing Suicide: A Technical Package of Fancy. Fmgrammnd hitting: 3 Finally, this technical package includes a number of interventions delivered in hospital, primary care, behavioral health care, and community settings designed to identity and SupportPeopie at Risk. The intensity and activities for many of these interventions require the expertise of professionals who are licensed and trained to deliver critical intervention support. The health, social services, and justice sectors can work collaboratively to support individuals at high-risk for suicide and their families. These activities also require coordination of supports across various service providers and community organizations. Regardless of strategy, action by many sectors will be necessary for the successful implementation ofthis package. In this regard, all sectors can play an important and in?uential role in preventing the risk ofsuicide in the ?rst place and lessening the immediate and long?term harms of suicidal behavior by helping those in times ofcrisis get the services and support they need. All sectors can play an important and in?uential role in preventing suicide. Monitoring and Evaluation Monitoring and evaluation are necessary components of the public health approach to prevention. It is important to have timely and reliable data to monitor the extent ofthe problem and to evaluate the impact of prevention efforts. Data are also necessary for prevention planning and implementation. Gathering ongoing and systematic data is important for prevention efforts. However, it is also important to gather data that are uniform and consistent across systems. Consistent I data allow public health and other entities to better gauge the scope of the problem, identify high?risk groups, and monitor the effects of prevention programs and policies. Currently, it is common for different sectors, agencies, and organizations to employ varying de?nitions of suicidal ideation, behavior, and death that can make it dif?cult to consistently monitor speci?c outcomes across sectors and over time. For example, the manner in which deaths are classi?ed can change from one jurisdiction to another, and can change based on local medical and/or medico-Iegal standards.4 CDC's uniform de?nitions and recommended data elements for self-directed violence provide a useful framework to help ensure that data are collected in a consistent manner across surveillance systems.4 Surveillance systems exist at the federal, state, and local levels. It is important to assess the availability of surveillance data and data systems across these levels to identify and address gaps in the systems. CDC's National Vital Statistics System and the National Violent Death Reporting System are examples of surveillance systems that provide data on deaths from suicide. NVSS is a nationwide surveillance system that collects demographic, geographic, and cause-of- death data from death certi?cates? is a state-based surveillance system [currently in 40 states, the District of Columbia, and Puerto Rico) that combines data from death certi?cates, law enforcement reports, and coroner or medical examiner reports to provide detailed information on the circumstances of violent deaths, including suicide, which can assist communities in guiding prevention approaches.?S Data from state and local Child Death Review teams?? and Suicide Death Review Teams (which are in a few states) offer another source to identify deaths and obtain insight into the gaps in services, systems, and modi?able risk factors for suicide. Preventing Suicide: ll Technical Package of Policy, Programs, and Practices 1? 0 The National Electronic injury Surveillance System?All injury Program provides nationally representative data about all types and causes of nonfatal injuries treated in US. hospital emergency departments, and can be used to assess national rates of, and trends in, self?harm injuries by cause falls, poisoning, etc.), age, racei ethnicity, sex, disposition (where the injured person goes when released from the emergency department)!5 In addition to information on deaths and nonfatal injuries, there are also surveillance systems that provide national, state, and some local estimates of suicidal behavior. The Youth Risk Behavior Surveillance System collects information from a nationally representative sample of 9?1 2 grade students and is a key resource in monitoring health-risk behaviors among youth, including whether youth have seriously considered attempting suicide, attempted suicide, made a plan, or required treatment by a doctor or nurse for a suicide attempt that resulted in an injury, poisoning, or overdoseWThe data are obtained from a national schoolebased survey conducted by CDC as well as from state, territorial, tribal, and large urban school district surveys conducted by education and health agencies.W The National Survey on Drug Use and Health is an annual survey ofthe civilian, non? institutionalized population aged 12 years and older. NSDUH provides both national and state?level estimates of substance use (alcohol, tobacco, illicit drugs, and non?medical use of prescription drugs); mental health (past year mental illness, co-occurring illnesses); and service utilization, along with suicide ideation, suicide plans, and suicide attempts. NSDUH is a key resource to track trends in suicide-related risk factors in the population and to help identify groups at increased risk?" It is also important at all levels (local, state, and federal} to address gaps in responses, track progress of prevention efforts and evaluate the impact ofthose efforts, including the impact of this technical package. Evaluation data, produced through program implementation and monitoring, is essential to provide information on what does and does not work to reduce rates ofsuicide and its associated risk and protective factors. Theories of change and logic models that identify short, intermediate, and long?term outcomes are an important part of program evaluation. The evidence?base for suicide prevention has advanced greatly over the last few decades. However, additional research is needed to understand the impact of programs, policies, and practices on suicide (and suicide attempts, at a minimum), as opposed to merely examining their effectiveness on risk factors. More research is also needed to examine the effectiveness of primary prevention strategies {before risk occurs) and community-level strategies to prevent suicide at the population level. It will be important for researchers to test the effectiveness of combinations ofthe strategies and approaches included in this package. Most existing evaluations focus on approaches implemented in isolation, but there is potential to understand the synergistic effects within a comprehensive prevention approach. Lastly, there are also many potential opportunities to build and strengthen partnerships across program areas leg, violence prevention, substance abuse prevention) to evaluate the impact of different approaches on multiple outcomes. Preventing Sul?de: Mahala! Package of Policy, Programs, and Practices 0 Conclusion Suicide is a serious public health problem. Rates of suicide have been on the rise for more than a decade and the costs stretch well into the billions of dollars each year. While suicide is a rare outcome statistically, its human impact has a ripple effect that is far-reaching. Each of us likely interacts with suicide survivors, those with lived experience, and those with thoughts of suicide on a daily basis?at home, at work, and in our communities. Suicide and suicide attempts are public health issues of societal concern.There are a number of barriers that have impeded progress, including, for example, stigma related to help?seeking, mental illness, being a survivor and fear related to asking someone about suicidal thoughts. Fortunately, like many public health problems, suicide is and more is being done to prevent suicide than ever before, as evidenced by the work ofthe National Action Alliance for Suicide the release of the ?rst world report on suicide,5 and more timely surveillance data, to namejust a few examples. In an effort to continue pushing the ?eld and society further towards prevention, this technical package includes strategies and approaches that ideally would be used in a comprehensive, multi-level and multi~sectoral way. It includes strategies and approaches to prevent the risk of suicide in the ?rst place, as well as strategies focused on lessening the immediate and long-term harms of suicidal behavior. It includes strategies that range from a focus on the whole population regardless of risk to strategies designed to support people at highest risk. lmportantly, this technical package extends the bounds ofthe typical prevention strategies to consider approaches that go beyond individual behavior change to better address risk factors impacting communities and populations more broadly economic policies to strengthen housing and ?nancial security}. While the evidence base continues to emerge, the collection of programs, policies, and practices laid out here are available for implementation now. In keeping with good public health practice, the intent is that monitoring and evaluation will play a key role in that implementation. Moreover, as new evidence becomes available, this technical package can be re?ned to re?ect the current state of the science. In closing, and in keeping with a message of resilience as spoken by those with lived experience, ?hope, help, and healing is possible." ?Hope, help, and healing is possible.? References 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. U.S. Of?ce of the Surgeon General, National Action Alliance for Suicide Prevention. 2012 Nationaistrategy forsuicide prevention: goals and objectives for action. Washington, DC: 2012. National Action Alliance for Suicide Prevention. Action Alliance priorities. 201?; http:/i Frieden TH. Six components necessary for effective public health program implementation. Am Public Health. 2014;1 041110242. Crosby AE, Ortega L, Melanson C. Sel?directed violence surveillance: uniform de?nitions and recommended data elements, version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for injury Prevention and Control; 2011. World Health Organization. Suicide prevention: a global imperative. Geneva, Switzerland: WHO Press; 2014. 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Pragmatism-aim Appendix: Summary of Strategies and Approaches to Prevent Suicide Best Available Evidence Strategy Practice or Policy Suicide Suicide Attempts or ldeation Other Risk! Protective Factors for Suicide Lead Sectors? Strengthening household ?nancial security Government Strengthen a (local, state, economic hemp oyment ene tprogranis Federal] supports ?3th inmme SUPPOTFS ?l Businessl La bor Housing stabilization policies Gwemmem . (local, state, Nerghborhood Stabilization Program 1/ Federal} Coverage of mental health conditions in health insurance policies Mental Health Parity La ws Government Strengthen Reduce provider shortages in underserved areas (local, state, Federal and National Health Service Corps delivery {If Telemental Health (TMl-li of Healthcare surcide care Safer suicide care through systems change Social Services Henry Ford Perfect Depression Care v" (Pre-cursor to Zero Suicide) Reduce access to lethal means among persons at risk Government intervening at suicide hot spots (local, state) Safe storage practices 1/ Public Health Emergency Department Counseling on Access to lethal Means (so CALM) Healthcare Create Organizational policies and culture Busmessl labor protective Togethe, for We Justice US Air Force Suicide Prevention Program Government . . . . 1/ (local, state, Correctional saicicle prevention Federal) Community-based policies to reduce excessive alcohol use Government (local, state) Alcohol outlet density .f ii" Business/labor Peer norm programs Public Health Promote Sources of Strength Education connectedness Community engagement activities Public Health . Government Greening vacant urban spaces (local) l*This column refers to the lead sectors well positioned to bring leadership and resources to implementation efforts. For each strategy, there are many other sectors such as non-governmental organizations that are instrumental to prevention planning and implementing speci?c activities. Preventing Suicide: ATechnical Package of Policy, Program. and Practices Best Available Evidence . . her Risk! n1, Suicide 0t . 1 Strategy Practice or Policy Attempts or Protective Lead Sectors . Factors for Ideatrnn . . Surcrde Social?emotional learning programs Youth Aware ofivlental Health Teach coping :eaEhBPLogramG Education and 00 dirt-or time solving skills Parenting skill and family relationship approaches Public Health The incredible Years Strengthening Families 30? Education Gatekeeper training Applied Suicide intervention Public Health Skills Training Garret Lee Smith Suicide v, Health Care Prevention Program Crisis intervention Public Health National Suicide v? Prevention Lifeline 50'3?! Services Treatment for people at risk of suicide improving Mood Promoting Access v, Identify and to Collaborative Treatment sup port people Collaborative Assessment and Healthcare at risk Management ofSurcrdalrty (CAMS) Social Services Dialectical Behavioral Therapy (DST) v? A ttachment-Based Family Therapy 1/ (A EFT) Translating initiatives for Depression into Effective Solutions project Treatment to prevent re-attempts ED Brief in tervention with v? alth care Follow?up Visrts Active follow?up contact approaches v? Social Services EST for Suicide Prevention Postvention ea care Lessen harms StandBy Response Service and prevent fe . 'd . future risk a reporting an message a out surcr public Health Media Guidelines s/ Media i*This column refers to the lead sectors well positioned to bring leadership and resources to implementation efforts. For each strategy: there are many other sectors such as non-governmental organizations that are instrumental to prevention planning and implementing speci?c activities. Preventing Suicide: A Technical Padrage of Policy, Programs. and "will For more information To learn more about preventing child abuse and neglect, call 1-800-CDC-INFO or visit violence prevention pages at NatiOnal Center for Injury Prevention and Control Division of Violence Prevention 3' DRAFT NARRATIVE FOR CDC CLEARANCE The information in this narrative has not been cleared for dissemination. Please do not cite, copy or disseminate Preventing Suicide: A Technical Package of Policy, Programs, and Practices Prepared by: Deb Stone, MSW, MPH Kristin Holland, MPH Brad Bartholow, Alex Crosby, MD, MPH Shane Davis, Natalie Wilkins, Division of Violence Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention 2017 Preventing Suicide: A Technical Package of Policies, Programs, and Practices is a publication of the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention. Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director National Center for Injury Prevention and Control Debra E. Houry, MD, MPH, Director Division of Violence Prevention James A. Mercy, Director Suggested Citation: Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, 5., and Wilkins, N. Preventing Suicide: A Technical Package of Policies, Programs, and Practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2017. Contents Acknowledgements 4 External Reviewers 5 Overview of Technical Package 6 Strengthen Economic Strengthen Access to Mental Health Care 16 Create Protective Environments 18 Promote Connectedness 22 Teach Coping and Problem-Solving Skills 24 Identify and Support People At-Risk 28 Intervene to Lessen Harms and Prevent Future Risk 32 Sector involvement 37 Monitoring and Evaluation 39 Conclusion 40 References 42 Appendix A 49 Acknowledgments [to be inserted'later] ?3 External. Reviewers [to be inserted'later] ?3 Overview This technical package represents a select group of strategies based on the best available evidence to help communities and states sharpen their focus on prevention activities with the greatest potential to prevent suicide. These strategies include: strengthening economic supports; strengthening access to mental health care; creating protective environments; promoting connectedness; teaching coping and problem-solving skills; identifying and supporting people at-risk; and intervening to lessen harms and prevent future risk. The strategies represented in this package include those with a focus on preventing suicide from happening in the first place as well as approaches to lessen the immediate and long-term harms of suicidal behavior for individuals, families, communities, and society. The strategies in the technical package support the goals and objectives of the National Strategy for Suicide Prevention and the National Action Alliance for Suicide Prevention?s priority to strengthen community-based prevention. Commitment, cooperation, and leadership from numerous sectors, including public health, education, justice, health care, social services, business, labor, and government can bring about the successful implementation of this package. What is a Technical Package? A technical package is a compilation of a core set of strategies to achieve and sustain substantial reductions in a specific risk factor or outcome {Friedem 2014). Technical packages help communities and states prioritize prevention activities based on the best available evidence. This technical package has three components. The first component is the strategy or the preventive direction or actions to achieve the goal of preventing suicide. The second component is the approach. The approach includes the specific ways to advance the strategy. This can be accomplished through programs, policies, and practices. The approaches included come primarily from studies based in the United States. The evidence for each of the approaches in preventing suicide or its associated risk factors is included as the third component. This package is intended as a resource to guide and inform prevention decision-making in communities and states. Preventing Suicide is a Priority Suicide, as defined by the Centers for Disease Control and Prevention (CDC), is part of a broader class of behavior called self-directed violence. Self-directed violence refers to behavior directed at oneself that deliberately results in injury or the potentiai for injury (A.E. Crosby, Ortega, Melanson, 2011). Self- directed violence may be suicide! or non-suicidal in nature. For the purposes of this document, we refer only to behavior where suicide is intended: - Suicide is a death caused by self-directed injurious behavior with any intent to die as a result of the behavior. Ir Suicide attempt is defined as a non?fate! self?directed and potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury. Suicide is highly prevalent. Suicide presents a major challenge to public health in the United States and worldwide. it contributes to premature death, morbidity, lost productivity, and health care costs (US ,l Office of the Surgeon General at National Action Alliance for Suicide Prevention, 2012,- World Health Organization, 2014). in 2014 {the most recent year of available death data}, suicide was responsible for 42,223 deaths in the U.S., which is approximately one suicide every 12 minutes (Centers for Disease ,l Control and Prevention, 2016]. In 2014, suicide ranked as the 10th leading cause of death and has been among the top 12 leading causes of death since 1975 in the 0.5 [Centers for Disease Control and Prevention, 2016}. lOverall suicide rates increased 24% from 1999 to 201:! lCurtin, Warner, 81 Hedegaard, 2016]. Suicide is a problem throughout the life span; it is the second leading cause ofdeath among those aged 10?34 years; it is the fourth leading cause among persons in their 405 and seventh among persons in their 505. Suicide rates vary by race/ethnicity, age, and other population characteristics, with the highest rates across the lifespan occurring among non?Hispanic American lndiaanlaska Native and none HiSpanic White population groups. In 2014, the rates for these groups were 17.3 and 16.4 per 100,000 population, respectively (Centers for Disease Control and Prevention, 2016c}. Other population groupg disproportionately impacted by suicide include middle-aged adults (whose rates increased 43% from 1999 to 2014, with steep increases seen among both males and females aged 45?64 years; Curtin et al., 2016]; Veterans and other military personnel, whose suicide rate nearly doubled from 2003 to 2008, surpassing the rate of suicide among civilians for the first time in decades et al., 2012; Lineberry 8L O'Connor); and workers in certain occupational groups protective service occupations; workers in farming, fishing, and forestry; McIntosh et al., 2016]. Suicides reflect only a portion of the problem Crosby, Han, Ortega, Parks, 8i. Gfroerer, 2011). Substantially more people are hospitalized as a result of nonfatal suicidal behavior li.e. suicide attempts} than are fatally injured, and an even greater number are either treated in ambulatory settings leg, emergency departments} or not treated at all Crosby, Han, et al., 2011}. For example, during 201d, among adults aged 18 years and older, for every one suicide there were 9 adults treated in hospital emergency departments for self-harm injuries, 27 who reported making a suicide attempt, and over 227 who reported seriously considering suicide li.e. ideationl lFerdon et al., In press]. Suicide is associated with several risk and protective factors. Suicide, like other human behaviors, has no single determining cause. Instead, suicide occurs in response to multiple biological, interpersonal, environmental and societal influences that interact with one another, often over time. The social?ecological model - encompassing multiple levels of focus from the individual, relationship, community, and societal is a useful framework for viewing and understanding suicide risk factors Comment IAI: Add another sentence about youth? identified in the literature [Dahlberg 8c Krug, 2002]. Risk and protective factors for suicide exist at each level. For example, risk factors include: Individual level: History of depression and other mental illnesses, hopelessness, substance no abuse, certain health conditions, previous suicide attempt, violence victimization and perpetration, and genetic and biological determinants Relationship level: High conflict or violent relationships, sense of isolation and lack of social support, familvfloved one?s history of suicide, financial and work stress Community level: inadequate community connectedness, barriers to health care leg, lack of access to providers and medications) Societal level: Availability of lethal means of suicide, unsafe media portrayals of suicide, stigma associated with help?seeking and mental illness (U.5. Office of the Surgeon General 8: National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014}. It is important to recognize that the vast majority of individuals who are depressed, attempt suicide, or who have other risk factors noted, do not die by suicide, Furthermore, the relevance of each risk factor can vary by age, race, gender, sexual orientation, residential geography, and socio?cultural and economic status (US. Office of the Surgeon General 81 National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). Protective factors, or those influences that buffer against the risk for suicide, can also be found across the different levels of the social-ecological model. Protective factors identified in the literature include: effective coping and problem solving skills, moral objections to suicide, strong and supportive relationships with partners, friends, and family; connectedness to school, community, and other social institutions; of quality and ongoing physical and mental health care, and reduced access to lethal means (LLB. Office ofthe Surgeon General St National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). These protective factors can either counter a specific risk factor or buffer against a number of risks associated with suicideSuicide is ?we? *0 M's" forms 0* bullying, peer violence, dating violence, sexual violence, and intimate partner violence] increases the risk of depression, post?traumatic stress disorder anxiety, suicide, and suicide attempts lBossarte, Simon Swahn, 2008; Chapman et al., 2004; Dube et al., 2001; Felitti et al., 1993; Klomek, Sourander, 8i Gould, 2010; Leeb, Lewis, Zolotor, 2011,- WHO, 2013}. Women exposed to partner violence are nearly 5 times more likely to attempt suicide as Women not exposed to partner violence (WHO, 2013). Exposure to adverse experiences in childhood, such as physical, sexual, emotional abuse and neglect, and living in homes with violence, mental health, substance abuse problems and other instability, increases the risk for suicide and suicide attempts several fold [Bellis et al., 2014,- Dube et al., 2001}. The Comment IAI: Beilis, M. A., Hughes, IL, 1 Leckenby, N., Jones, L., Baban, A., Kachaeva, M., Povilaitis, R., Pudule, Qirjako, G., Ulukol, 0., Raleva, M., En Terzic, N. (2014}. Adverse childhood experiences and associations with health? harming behaviors in young adults: surveys in the European Region. Bulletin of the World Health Organization, 92, Bossarte RM, Simon TR, Swahn MH. Clustering of adolescent dating violence, peer violence, and suicidal behavior. Journal of interpersonal Behavior, 2008; 23:815-833. Dube SR, Anda RF, Felitti VJ, Chapman 0, Williamson 0F, Giles WH. Childhood abuse, household dysfunction and the risk of attempted suicide throughout the life span: Findings from Adverse Childhood Experiences Study. JAMA. Chapman DP, Anda RF, Felitti Dube SR, Edwards VJ, Whitfield CL. Adverse childhood experiences and the risk of depressive disorders in adulthood. Affect Disord. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults - the adverse childhood experiences study. American Journal of Preventive Medicine, Klomek, A. 0., Sourander, A., El Gould, M. {2010}.The association of suicide and bullying in childhood to young adulthood: A review of cross-sectional and longitudinal research findings. Canadian Journal of 55(5), 282-283. Leeb TR, Lewis T, Zolotor A review of physical and mental health consequences of child abuse and neglect and implications fOr practice. American Journal of Lifestyle Medicine, 2011: effects of violence in childhood and adolescence can be observed decades later, including severe problems with finances, family, jobs, and stress factors that increase the risk for suicide. Suicide 3 git-11354453. and other forms of violence often share the same individual, relationship, community, and societal risk factors suggesting that efforts to prevent interpersonal violence may also prove bene?cial in preventing suicide {add [:itation%. Further, just as risk factors may be shared across suicide and violence, so too may protective factors overlap. For example, connectedness to one?s community [Kleiman, Riskind, Schaefer, 8t Weingarden, 2012i, school (Carter, McGee, Taylor, 81 Williams, 2002], family (Maimon. Browning, E: Brooks-Gum, 2010}, caring adults lCapaldi, Knoble, Shortt, Kim, 2012; Losel St Farrington, 2012}, and provsocial peers [Wyman et al., 2010} enhances resilience to suicide and other forms of violence. The health and economic consequences of suicide are substantial. Suicide and suicide attempts have far reaching consequences for individuals, families, and communities (Dunne, McIntosh, 34. Dunne- Maxim, 198?; Mishara, 1995; National Action Alliance for Suicide Prevention: Suicide Attempt Survivors Task Force, 2014,- National Action Alliance for Suicide Prevention: Survivors of Suicide Loss Task Force, 2015}. in an early study, Crosby and Sacks {2002} estimated that 7% of the U.5. adult population, or 13.2 million adults, knew someone in the prior 12 months who had died by suicide. They also estimated that for each suicide, 425 adults were exposed, or knew about the death. In a more recent study, in one state, Cerel et al {2016} found that 48% of the population knew at least one person who died by suicide in their lifetime. Research indicates that the impact of knowing someone who died by suicide and/or having lived experience lie, personally have attempted suicide, have had suicidal thoughts, or have been impacted by suicidal loss} is much more extensive than injury and death. People with lived experience may suffer long?term health and mental health consequences ranging from anger, guilt, and physical impairment, depending on the means and severity of the attempt {Chapman 8t Dixon-Gordon, 2007]. Similarly, survivors ofa loved one?s suicide may experience ongoing pain and suffering including complicated grief {MitchelL Kim, Prigerson, E: Mortimer-Stephens, 2004}, stigma, depression, anxiety, post-traumatic stress disorder, and increased risk of suicidal ideation and suicide [Julie Cerel, Neimeyer, Maple, 8; Marshall, 2014,- Sudak, Maxim, 8t Carpenter, 2003}. Less discussed but no less important, are the financial and occupational effects for those left behind (Florence, Simon, Haegerich, Luo, 8; Zhou, 2015). The economic toll of suicide is immense as well. According to conservative estimates, in 2013, suicide cost $50.8 billion in estimated lifetime medical and work-loss costs alone [Florence et al., 2015). Adjusting for potential under?reporting of suicide and drawing upon health expenditures per capita, GDP per ca pita, and variability among states in per capita health care expenditures and income, another study estimated the total lifetime costs associated with nonfatal injuries and deaths caused by selfvdirected violence to be approximately $93.5 billion in 2013 (Shepard, Gurewich, Lwin, Reed, 3: Silverman, 2015). The overwhelming burden of these costs were from lost productivity over the life course, with the average cost per suicide being over $1.3 million {Shepard et al., 2016}. The true economic costs are likely higher as neither study included monetary figures related to other societal costs such as those associated with the pain and suffering of family members or other impacts. I Comment IAI: Wilkins N, Tsao B, Hertz M, Davis R, Klevens 1. Connecting the dots: an overview ofthe links among multiple forms of violence. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (Atlanta, GM and Prevention institute. Oakland CA. 2014. Haegerich TM. Dahlberg LL. Violence as a public health risk. American Journal of Lifestyle Medicine, 2011; 5:51:392-406. Hamby S, J. The web of violence: exploring connections among different forms of interpersonal violence and ab05e. New York, NY: Springer Briefs in LSociology, 2013. 1 Suicide can be prevented. Like most public health problems, suicide is preventable (US. Public Health Service, 1999). While progress will continue to be made into the future, evidence for numerous programs, practices, and policies currently exists, and many programs are ready to be implemented now. Just as suicide is not caused by a single factor, research suggests that reductions in suicide will not be prevented by any single strategy or approach (Silverman 8L Maris, 1995; US. Office of the Surgeon General 8; National Action Alliance for Suicide Prevention, 2012}. Rather, suicide prevention is best achieved by a focus across the individual, relationship, family, community, and societal-levels and across all sectors, private and public business, public health, physical and behavioral healthcare, justice, education, and labor] (National Action Alliance for Suicide Prevention, 2014; World Health Organization, 2014). Assessing the Evidence This technical package includes programs, practices, and policies with evidence of impact on suicide or risk or protective factors for suicide. To be considered for inclusion in the technical package, the program, practice, or policy selected had to meet at least one of these criteria: a} meta-analyses or systematic reviews showing impact on suicide; b) evidence from at least one rigorous randomized controlled trial or quasi-experimental design) evaluation study that found significant preventive effects on suicide; cl meta-analyses or systematic reviews showing impact on risk or protective factors for suicide, or d) evidence from at least one rigorous RCT or quasi-experimental design) evaluation study that found significant impacts on risk or protective factors for suicide. Finally, consideration was also given to the likelihood of achieving beneficial effects on multiple forms of violence; no evidence of harmful effects on specific outcomes or with particular subgroups; and feasibility of implementation in a U.S. context if the program, policy, or practice has been evaluated in another country. Within this technical package, some approaches do not yet have research evidence demonstrating impact on rates of suicide but instead are supported by evidence indicating impacts on risk or protective factors for suicide help-seeking, stigma reduction, depression, connectedness). In terms of the strength of the evidence, programs that have demonstrated effects on suicidal behavior reductions in deaths, attempts} provide a higher-level of evidence, but the evidence base is not that strong in all areas. For instance, there has been less evaluation of community engagement and family programs on suicidal behavior. Thus, approaches in this package that have effects on risk or protective factors reflect the developing nature of the evidence base and the use of the best available evidence at a given time. it is also important to note that there is often significant heterogeneity among the programs, policies, or practices that fall within one approach or strategy area in terms of the nature and quality ofthe available evidence. Not all programs, policies, or practices that utilize the same approach are equally effective, and even those that are effective may not work across all populations. Tailoring programs and more evaluation may be necessary to address different population groups. The evidence-based programs, 10 practices, or policies included in the package are not intended to be a comprehensive list for each approach, but rather to serve as examples that have been shown to impact suicide or have beneficial effects on risk or protective factors for suicide. Context and Cross-Cutting [Theme% One important feature of the package is the complementary, but potentially synergistic impact of the strategies and approachES. The strategies and approaches that have been included in this technical package represent different levels of the social ecology, with efforts intended to impact the community and societal levels, as well individual and relationship levels. The strategies and approaches are intended to work in combination and reinforce each other to prevent suicide [see box below). The strategies are arranged in order such that those strategies hypothesized to have the greatest potential for broad public health impact on suicide are included first; followed by those that might impact more select populations persons who have already made a suicide attempt]. Preventing Suicide Strategy Approach Strengthen economic supports I Strengthen household financial security I Housing stabilization policies Strengthen access to mental health care a Coverage of mental health conditions in health insurance policies Create protective environments I Reducing access to lethal means among persons at-risk of suicide I Organizational policies and culture I Commanity?based policies to reduce excessive alcohol use Promote connectedness - Peer norm approaches 0 Community engagement activities Teach coping and problem~solving skills I Social-emotional learning programs I Parenting skill and family relationship approaches Identify and support people at risk - Gatekeeper training I Screening combined with care management I Crisis intervention Intervene to lessen harms and prevent I Treatment for people atvrisk of suicide future risk I Treatment to prevent rte-attempts I Postvention I Safe reporting following a suicide It is important to note that examples listed under one strategy may also be relevant to another strategy. For instance, some forms of crisis intervention, an approach under identify and Support People Atvliislr, 11 Comment IAI: A few other things that could be mentioned: The S?li package included the following paragraph: "The strategies and approaches delineate prevention efforts that impact various 5V related outcomes. The strategies are not mutually exclusive categories. but each has an immediate focus. The strategy Create Protective Environments! for example, may ultimately impact 51! social norms, but the immediate focus of this strategy is to change school, workplace and comm unity environmental factors. Similarly, the approaches within any one strategy sometimes have components that cross other strategies. For example, Mobilizing Men and Boys as Allies, an approach in the Promote Social Norms that Protect against Violence strategy, includes fostering healthy dating relationships which is also found in some of the approaches under the Teach Skills to Prevent 5V strategy. may also be considered under intervene to Lassen Harms and Prevent Future Risk. Social emotional learning programs, an approach under the Teocn Coping and Problem-Solving Skills strategy, sometimes inciude components to change peer norms and the broader environment. The goal of this package is to stress the importance of comprehensive prevention efforts and to provide examples of effective programs addressing each level of the social ecology, with the knowledge that some programs, practices, and policies may impact multiple levels. Further, those that involve multiple sectors and impact multiple Comment Edwards, R. W., Jumper- 1 Thurman, P., Plested, 3., Getting, E. FL, Swanson, L. [2000}. Community readiness: research to practice. Journal of Community 233}, 291-301 Plested, B. A., Edwards, R. W., 3: Jumper- Thurman, P. {2006}. Community Readiness: A Handbook for Successful Change. Fort Collins. C0: Tri~Ethnic Center levels of the social ecology are more likely to have a greater impact on the overall burden of suicide. Suicide ideation, thoughts, attempts, and deaths vary by gender, racefethnicity, age, occupation, and other important population characteristics. Further, certain transition periods are also associated with higher rates of suicide leg, transition from working into retirement, transition from active duty military status to civilian status). In fact, suicide risk can change along with dynamic risk factors. For example, individuals' coping skills may change during periods of crisis and heightened stress, limiting their normal ability to effectively solve problems and cope. Research indicates that suicide risk changes as a result of the number and intensity of key risk and protective factors experienced lTurecki, 2014). ldeally, the availability of multiple strategies and approaches tailored to the social, economic, cultural, and environmental context of individuals and communities are desirable as they may increase the likelihood of removing barriers to supportive and effective care and provide opportunities to develop individual and community resilience. Identifying programs, practices, and policies with evidence of impact on suicide, suicide attempts, or beneficial effects on risk or protective factors for suicide is only the first step. In practice, the effectiveness ofthe programs, policies and practices identi?ed in this package will be strongly dependent on how well programs are implemented as well as the partners and communities in which they are implemented. Practitioners in the field may be in the best position to assess the needs and of their communities and work with community members to make decisions about the combination of approaches included here that are best suited to their context. ll Data-driven strategic planning processes can help communities with this work see Hawkinsi Catalano, Ea Kuklinski, 2014;Fdw'ards et al., 2000; Plested, Edwards, 3L Jumper?Thurman, 20063._T_hes_e_l planning processes engage and guide community stakeholders through a prevention planning process designed to address a community?s profile of risk and protective factors with evidence?based programs, practices, and policies. These processes can also be used to monitor implementation, track outcomes, and make adjustments as indicated by the data. The readiness of the program for broad dissemination and implementation (eg, availability of program materials, training and technical assistance) can also influence program effects. Implementation guidance to assist practitioners, organizations and communities will be developed separately. This package includes strategies where public health agencies are well positioned to bring leadership and resources to implementation efforts. It also includes strategies where public health can serve as an 12 Lfor Prevention Research. important collaborator strategies addressing communitv and societal level risks), but where leadership and commitment from other sectors such as business, labor or health care is critical to implement a particular policyr or program workplace policies; screening combined with care management). The role of various sectors in the implementation of a strategy or approach in preventing suicide is described further in the section on Sector involvement. In the sections that follow, the strategies and approaches with the best available evidence for preventing suicide are described. 13 Strengthen Economic Supports Rationale Studies from the U.S. examining historical trends indicate that suicide rates increase during economic recessions marked by high unemployment rates, job losses, and economic instability and decrease during economic expansions and periods marked by low unemployment rates, particularly for working- age individuals 25 to 64 years old {Luo et al., 2011; Fowler et al., 2015). Economic and financial strain, such as job loss, long periods of unemployment, reduced income, difficulty covering medical, food, and housing expenses, and even the anticipation of such financial stress may increase an individual?s risk for suicide or may indirectly increase risk by exacerbating related physical and mental health problems; buffering these risks can therefore, potentially protect against suicide (Stack 8: Wasserman, 2007). For example, strengthening economic support systems can help people stay in their homes or obtain affordable housing while also paying for necessities such as food and medical care, job training, child care, among other expenses required for daily living. In providing this support, stress and anxiety and the potential for a crisis situation may be reduced, thereby preventing suicide. Although more research is needed to understand how economic factors interact with other factors to increase suicide risk, the available evidence suggests that strengthening economic supports may be one opportunity to buffer suicide risk. Approaches Economic supports for individuals and families can be strengthened by targeting household financial security and ensuring stability in housing during periods of economic stress. 0 Strengthening household financial security can potentially buffer the risk ofsuicide by providing individuals with the financial means to lessen the stress and hardship associated with a job loss or other unanticipated financial problems. The provision of unemployment benefits and other forms of temporary assistance, livable wages, medical benefits, and retirement and disability insurance to help cover the cost of necessities or to offset costs in the event of disability, are examples of ways to strengthen household financial security. 0 Housing stabilization policies aim to keep people in their homes and provide housing options for those in need during times of financial insecurity. This may occur through programs that provide affordable housing such as through government subsidies or through other options available to potential homebuyers such as loan modification programs, move-out planning, or financial counseling services that help minimize the risk or impact of foreclosures and eviction. Potential Outcomes Reductions in suicide rates 14 Reductions in foreclosure rates I Reductions in eviction rates I Reductions in emotional distress Evidence There is evidence suggesting that strengthening household financial security and stabilizing housing can reduce suicide risk. Strengthen household ?nancial security. The Federal-State Unemployment insurance Program allows states to define the maximum amount and duration of unemployment benefits that workers are entitled to receive after a job loss {Cylus, Glymour, 8: Avendano, 2014). An examination of variations in unemployment benefit programs across states demonstrated that the impact of unemployment on rates of suicide was offset in those states that provided greater than average unemployment benefits (mean level: $1990 per person in U.S. constant dollars;(Cylus, Glymou r, 8: Avenda no, 2014}. The effects of unemployment benefit programs were also consistent by sex and age group. Another US. study examining the link between unemployment and suicide rates using suicide data, length of unemployment (less than 5 weeks, 5-14 weeks, 15-26 weeks, and greater than 26 weeks}, and job losses found that the duration of unemployment, as opposed to just the loss ofjob, predicted suicide risk (Classen 8; Dunn, 2012}. Together, these results suggest that not only should state unemployment benefit programs be generous in their financial allocations, but also in their duration. Other measures to strengthen household financial security transfer payments related to retirement and disability insurance, unemployment insurance compensation, medical benefits, and other forms of family assistance} have also shown an impact on rates of suicide. A study by Flavin and Radcliff (2009} examined the impact of states? per capita spending on transfer payments, medical benefits, and family assistance (Temporary Assistance to Needy Families - TAN F) and total state spending on suicide rates between 1990-2000, controlling for a number of suicide risk factors residential mobility, divorce rate, unemployment rate) at the state level. As per capita spending on total transfer payments, medical benefits, and family assistance increased there was an associated decrease in state suicide rates. Moreover, it wasn?t spending in general that was associated with the reduction but spending on these types of assistance. In terms of lives saved, Flavin El. Radcliff calculated the cost of reducing a state?s suicide rate by a full point for the years studied. At the national level, they estimated that 3,000 fewer suicides would occur per year nationwide if every state increased its per capita spending on these types of assistance by $45 per year {Flavin 8L Radcliff, 2009]. Although this was a correlational study, the results demonstrate the potential benefits of policies that reach particularly vulnerable 15 Individuals during periods of great need and increased risk for suicide. More evaluation studies are needed to further understand the outcomes impacted by programs such as these. Housing stabilization Emlicleq. The National Neighborhood Stabilization Program was designed to . help neighborhoods suffering from high rates of foreclosure and abandonment bv slowing the deterioration ofthe neighborhoods and providing affordable housing options for low, moderate, and middle?income homebuvers. This program also offers financial assistance to eligible individuals for the purchase of a new home. Although this program has not been rigorously evaluated for its impact on suicide outcomes, it addresses foreclosure and eviction. which are risk factors for suicide. A longitudinal analysis of annual data on suicides and foreclosures demonstrated that as the proportion of foreclosed properties increased in U.5. states, so did the state suicide rate, particularlvr among working-aged adults [Houle El Light, 2014). Another study of data from 16 U5. states participating in the National Violent Death Reporting System found that suicides precipitated by home foreclosures and evictions increased more than 100% from 2005 {before the housing crisis began} to 2010 {after it had peaked; Fowler, Gladden, ?v?agi, Barnes, and Frazier {2015? Most of these suicides occurred prior to the actual loss of the decedent?s home. These findings suggest that integrating suicide prevention resources, messaging, and referrals into ?nancial, foreclosure, and move~out planning and counseling services may help to prevent suicide. 15 a i I I Comment IAI: Per Richard Mckeon's comment, looking into whether there's any info on the effectiveness of housing for those with mental Comment IAI: This word sticks out to Strengthen Access to Mental Health Care me. Could delete in order to avoid questions about what contemporary care means?unless we know and Want to state but guessing we don?t. Or maybe Rationale say ?state?of?the?art?? While most people with mental health problems do not attempt or die by suicide (Olfson, Gerhard, Huang, 8r. Stroup, 2015; Owens, 2002), and the level of risk conferred by different types of mental illness varies {Arsenault?Lapierre, Kim, El Turecki, 2004; E. C. Harris 81 Barraclough, 199?; Tyrer, Reed, 8: Crawford, 2015}, previous research indicates that mental illness is an important risk factor for suicide (E. C. Harris 81 Barraclough, 1998; World Health Organization, 2014). State?level suicide rates have also been found to be correlated with general mental health measures such as depression (Lang, 2013; Mark, Shem, Bagalman, Si. Can, 200?}. Findings from the National Comorbidity Survey indicate that relatively few people in the U5. with mental health disorders receive treatment for those conditions (Kessler et al., 2005}. Lack of access to mental health care is one of the contributing factors related to the underuse of mental health services (Cunningham, 2009). Identifying ways to improve access to timely, affordable, and quality mental health care for people in need is a critical component to suicide prevention [World Health Organization, 2014]. Apart from the treatment bene?ts. it can also serve to normalize help- seeking behavior and increase the use of such services. i i i i Approaches i. One approach to strengthening access to mental health care is through the provision of mental health coverage in health insurance policies. Attending to training and provider shortages is another approach. .5 i i 1 Coverage of mental health conditions in health insurance policies. Federal and state laws include provisions for equal coverage of mental health services in health insurance plans that is on par with coverage for other health concerns mental health parity}. Benefits and services covered include such things as the number of visits, co?pays, deductibles, inpatientfoutpatient serviCES, prescription drugs, and hospitalizations. If a state has a stronger mental health parity law than the federal parity law, then insurance plans regulated by the state must follow the state parity law. If a state has a weaker parity law than the federal parity law includes coverage for some mental health conditions but not others), then the federal parity law will replace the state law. Equal coverage does not necessarily imply good coverage as health insurance plans vary in the extent to which benefits and services are offered to address various health conditions. Rather it helps to ensure that mental health services are covered on par with other health concerns. Improve training and access to mental healthcare providers. Access to effective and Ezontempor-arylnental health-carats largely dependent upon the size ofthe mental health tare workforce available td- provide duality price. ever- as million Americans live in areas With an insuf?cient number of'mental health providers; this shortage is particularly severe amonglow?income urban and rural communities ?Departrnent of Health and 1? Potential Outcomes - Increases in utilization of mental health services I Reductions in of mental illnesses I Reductions in rates of suicide attempts I RedUCtions in rates of suicide Evidence There is evidence suggesting that coverage of mental health conditions in health insurance policies can reduce risk factors associated with suicide and may directly impact suicide rates. Coverage of mental health conditions in health insurance policies. The National Survey of Drug Use and Health is, a nationally representative survey of the U.S. population that provides data on substance use, mental health conditions, and services utilization. Using data from this survey, K. M. Harri5,.Carpenter, and Bao {2006] found that 12 months after states enacted mental heoith parity lows, Self-reported use of mental healthcare services significantly increased. Moreover, subsequent research by Lang (2013] examined state mental health laws and suicide rates between 1990 and 2004 and found that mental health parity laws, specifically, were associated with an approximate 5% reduction in suicide rates. This reduction, in the 29 states with parity laws. equated to the prevention of 592 suicides per year (Lang, 2013). 13 Comment Love this paragraph. My only comment {exoept for the one above Is that the approach says "Improve but the text is fucu?ed exclusively on access- Might want to insert another mention of ?training? (explicitly). could insert after federal migrants and tralning for providers.? Comment A t Can WE take this anti-1?? ,5 Comment ithink 1111515 7 grammatically car'rect buti'd recommend .I, shortenin [11:15 this right? just tacked I ?hi. that on Malta sure this is. what you 1" intentied I [Cumm?nt i may have changed this! IS this correct? CI Comment IAI: Not sure whether to keep 3 or drop the clause about the as of the workforce. It comes from the following 3' link and is the combined percentage for Create Protective Environments those aged 35-54. Rationale Prevention efforts that focus not only on individual behavior change help?seeking, treatment interventions) but on changes to the environment can increase the likelihood of positive behavioral and table 30?" health outcomes {Haddon, 1980}. Creating environments that address risk and protective factors where individuals live, work, and play, can help prevent suicide {Dahlberg 8; Krug, 2002; 0.5. Office of the Surgeon General 8: National Action Alliance for Suicide Prevention, 2012}. For example, rates of suicide . are high among middle-aged adults {who comprise 42.5% of the certain occupational groups farming, fishing, forestry, and construction; Han et al., 2016; McIntosh et al., 2016). Thus, workplaces may serva as an ideal setting for reaching certain high-risk groups and implementing programs, practices and policies to buffer against suicide. Changes to organizational culture through the implementation of supportive policies, for instance, can change social norms, encourage help?seeking, and demonstrate that good health and mental health are valued and that stigma and other risk factors for suicide are not (Knox et al., 2010; National Action Alliance for Suicide Prevention Workplace Task Force, 2015}. Similarly, modifying the characteristics of the environment to prevent harmful behavior such as access to lethal means can reduce suicide rates, particularly in times ofcrisis (Beautrais, Gibb, Fergusson, Horwood, 8: Larkin, 2009; A.E. Crosby, Espitia?Hardeman, Ortega, E: Lozano, 2013; Kaplan et al., 2013; Miller, Warren, Hemenway, Azrael, 2015; Runyan et al., 2015Approaches The current evidence suggests three potential approaches for creating environments that protect against suicide. . Reducing access to lethal means among persons at-risk of suicide. Means of suicide such as firearms, hanginglsuffocation, or jumping from heights provide little opportunity for rescue and, as such, have high case fatality rates about 85% of people who use a firearm in a suicide attempt will die from the injury}. Research also indicates that 1] the interval between deciding to act and attempting suicide can be as short as 5 or 10 minutes (Deisenhammer et al., 2009; Simon et al., 2001) and 2) that people tend not to substitute a different method when a highly lethal method is unavailable or dif?cult to access {Hawton, 2002,- Yip et al., 2012). Therefore, increasing the time interval between deciding to act and the suicide attempt, for example, by making it more difficult to access lethal means, can be lifesaving. The following are examples of approaches reducing access to lethal means for persons at?risk of suicide: intervening otSuicio?e Hotspots. Suicide hotspots, or places where suicides may take place C- relatively easily, include tall structures leg, bridges, cliffs, balconies, and rooftops), 21 railway tracks, and isolated locations such as parks. Efforts to prevent suicide at these locations include erecting barriers or limiting access to prevent jumping and installing signs and telephones to encourage individuals who are considering suicide, to seek help (Cox et al., 2013). Safe Storage Practices. Safe storage of medications, firearms, and other household products can reduce the risk for suicide by separating vulnerable individuals from easy access to lethal means. Such practices may include education and counseling around storing in a secure place in a gun safe or lock box), unloaded and separate from the ammunition--and keeping medicines in a locked cabinet or other secure location away from people who may be at risk or who have made prior attempts (Rowhani-Rahbar, Simonetti, 3L Rivara, 2016; Runyan et al., 2016). I Organizational policies and culture that promote protective environments may be implemented in places of employment. Such policies and cultural values may promote prosocial behavior asking for help}, skill building, changing social norms, referral and access to helping services mental health, substance abuse treatment, financial counseling), and encourage leadership support from the top down. Such policies and cultural shifts can positively impact organizational climate and morale and help prevent suicide and its related risk factors depression, social isolation) {National Action Alliance for Suicide Prevention Workplace Task Force, 2015}. - Community-based policies to reduce excessive alcohol use. Research studies in the United States have found that greater alcohol availability is positively associated with alcohol-involved suicides (Escobedo 8: Ortiz, 2002; Giesbrecht et al., 2015}. Policies to reduce excessive alcohol use broadly include zoning to limit alcohol outlet locations and density, taxes on alcohol, and bans on the sale of alcohol for individuals under the legal drinking age. These policies are important because acute alcohol use has been found to be associated with more than one-third of suicides and approximately 40% of suicide attempts {CherpiteL Borges, EL Wilcox, 2004). Potential Outcomes I Increases in safe storage of means - Reductions in suicide attempts - Reductions in suicide deaths - Increases in help-seeking I Reductions in alcohol-related suicide deaths 22 Evidence The evidence suggests that creating protective environments can reduce suicide and suicide attempts and increase protective behaviors. Reducing access to lethal means among persons at-risk of suicide. A meta-analysis examining the impact of suicide hotspot interventions implemented in combination or in isolation, both in the U5. and abroad, found associated reduced rates of suicide (Cox et al., 2013; Pirkis et al., 2015). For example, after erecting a barrier on the Jacques-Cartier bridge in Canada, the suicide rate from jumping from the bridge decreased from about 10 suicide deaths per year to about 3 deaths per year (Perron, Burrows, Fournier, Perron, 8i Ouellet, 2013). Moreover, the reduction in suicides by jumping was sustained even when all bridges and nearby jumping sites were considered, suggesting little to no displacement of suicides to otherjumping sites (Perron et al., 2013). Further evidence for the effectiveness of bridge barriers was demonstrated by a study examining the impact of the removal of safety barriers from the Grafton Bridge in Auckland, New Zealand. After removal of the barrier, both the number and rate of suicide increased fivefold lBeautrais, 2001; Beautrais et al., 2009}. Another form of means reduction involves implementation of safe storage practices. in a case- control study of firearm-related events identified from 37 counties in Washington, Oregon, and Missouri, and from 5 trauma centers, Grossman et al. (2005] found that storing firearms unloaded, separate from ammunition, in a locked place or secured with a safety device was protective of suicide attempts among adolescents. Further, a recent systematic review of clinic and community-based education and counseling interventions suggested that the provision of safety devices significantly increased safe firearm storage practices compared to counseling alone or compared to the provision of economic incentives to acquire safety devices on one?s own (Rowhani-Rahbar et al., 2016). Another program, The Emergency Department Counseiing on Access to Lethal Means (ED CALM), trained emergency clinicians in a large children?s hospital to provide lethal means counseling and safe storage boxes to parents of patients under age 18 receiving care for suicidal behavior. In a pre-post quality improvement project, Runyan et al (2016} found that at post-test 76% (of the 55% of parents followed up, n=114) reported that all medications in the home were locked up as compared to fewer than 10% at the time of the initial emergency department visit. Among parents who indicated the presence of guns in the home at pre-test (Le. all (100%) reported guns were currently locked up at post-test {Runyan et al., 2016}. Organizational policies and culture. Togetherfor Life is a workplace program of the Montreal Police Force implemented to address suicide among officers. Policy and program components 23 were designed to foster an organizational culture that promoted mutual support and solidarity among all members of the Force. The program included training of supervisors, managers and all units to improve competencies in identifying suicidal risk and to improve use and awareness of existing resources. The program also included an education campaign to improve awareness and help-seeking (Mishara 8: Martin, 2012). Police suicides were tracked over 12 years and compared to rates in the control city of Quebec. The suicide rate in the intervention group decreased significantly by 78.9% to a rate of 6.4 suicides per 100,000 population per year compared to an 11% increase in the control city (29.0 per 100,000) (Mishara 8: Martin, 2012). Another example of this approach is the United States Air Force Suicide Prevention Program. The program included 11 policy and education initiatives and was designed to change the culture of the Air Force surrounding suicide. The program uses leaders as role models and agents of change, establishes expectations for behavior related to awareness of suicide risk, develops population skills and knowledge education and training), and investigates every suicide outcomes measurement). The program represents a fundamental shift from viewing suicide and mental illness solely as medical problem and instead sees them as larger service- wide problems impacting the whole community (Knox, Litts, Talcott, Feig, Caine, 2003). Using a time-series design to examine the impact of the program on various violence-related outcomes, researchers found that the program was associated with a 33% relative risk reduction in suicide (Knox et al., 2003).The program was also associated with relative risk reductions in related outcomes including moderate and severe family violence (30% and 54%, respectively), homicide and accidental death {Knox et al., 2003). A longitudinal assessment ofthe program over the period 1981 to 2008 (16 years before the 1997 launch of the program and 11 years post-launch) found significantly lower rates of suicide after the program was launched than before (Knox et al., 2010). These effects were sustained over time, except in 2004, which the authors found was associated with less rigorous implementation in that year than in the other years (Knox et al., 2010). Community-based policies to reduce excessive alcohol use. While multiple policies to limit excessive use of alcohol exist, several studies on alcohol outlet density, specifically, suggest that measures to reduce alcohol outlet density can potentially reduce alcohol-involved suicides. Additionally, a longitudinal analysis of alcohol outlet density, suicide mortality, and hospitalizations for suicide attempts over 6 years in 581 California zip codes indicated that the density of bars, specifically, is related to suicide and suicide attempts, particularly in rural areas (Johnson, Gruenewald, 8: Remer, 2009). 24 Promote Connectedness Rationale Sociologist, Emile Durkheim theorized in 1897 that weak social bonds, i.e. lack of connectedness, are among the chief causes for suicidality (Durkheim, 1897/1951}. Connectedness is the degree to which an individual or group of individuals are socially close, interrelated, or share resources with others (Centers for Disease Control and Prevention, 2009). Social connections can be formed within and between multiple levels ofthe social ecology {Dahlberg 8; Krug, 2002}, for instance between individuals peers, neighbors, co-workers), families, schools, neighborhoods, workplace, faith communities, cultural groups, and society as a whole. Related to connectedness, social capitol refers to a sense of trust in one?s community and neighborhood, social integration, and also the availability and participation in social organizations (Beyer, Layde, Hamberger, 8: Laud, 2015; Muennig, Cohen, Palmer, 8L Zhu, 2013]. Many ecological cross-sectional and longitudinal studies have examined the impact of aspects of social capital on depression depressive disorder, mental health more generally, and suicide. While the evidence is limited, existing studies suggest the pattern is towards a positive association between social capital measured by social trust, community/neighborhood engagement, and improved mental health. Connectedness and social capital together can serve to protect against suicidal behaviors by decreasing isolation, encouraging adaptive coping behaviors, increasing belongingness, personal value and worth all of which helps individuals to build resilience in the face of adversity. Connectedness can also provide individuals with better access to formal supports and resources, mobilize communities to meet the needs of its members and provide collective primary prevention activities to the community as a whole {Centers for Disease Control and Prevention, 2009). Approaches Promoting connectedness among individuals and within communities through modeling peer norms and enhancing community engagement may protect against suicide. Peer norm approaches seek to normalize protective factors for suicide such as help-seeking, reaching out and talking to trusted adults, and promote peer connectedness. By leveraging the leadership qualities and social influence of peers, these approaches can be used to shift group- level beliefs and promote positive social and behavioral change. These approaches typically target youth and are delivered in school settings but can also be implemented in community settings. I Community engagement activities. Community engagement is an aspect of social capital. Community engagement approaches may involve residents participating in a range of activities, including religious activities, community clean-up and greening activities, and physical exercise. These activities provide opportunities for residents to become more involved in the community and to connect with other community members, organizations, and resources, resulting in 25 enhanced overall physical health, reduced stress, and decreased depressive thereby reducing risk of suicide. Potential Outcomes I Reductions in maladaptive coping attitudes and behaviors I Increases in healthy coping attitudes and behaviors - Increases in referrals for youth in distressed Increases help-seeking behaviors I Increases in positive perceptions of adult support Evidence Current evidence suggests a number of positive benefits of peer norm and community engagement activities, although more evaluation research is needed to examine whether these improvements in factors that protect against suicidal behavior translate into reduced suicide attempts and deaths. Peer norm approaches. Evaluations show that programs such as Sources of Strength can improve school norms and beliefs about suicide that are created and disseminated by student peers. In a randomized controlled trial of Sources ofStrength conducted with 18 high-schools (E metropolitan, 12 rural), Wyman et al. (2010) found that the program improved adaptive norms regarding suicide among peer leaders, connectedness to adults, and school engagement. Peer leaders were also more likely than controls to refer a suicidal friend to an adult. For students, the program resulted in increased perceptions of adult support for suicidal youths, particularly among those with a history of suicidal ideation, and the acceptability of help-seeking behaviors. Finally, trained peer leaders also reported a greater decrease in maladaptive coping attitudes compared with untrained leaders {Wyman et al., 2010}. Community engagement activities. A vacant lot greening initiative was undertaken in Philadelphia between 1999 and 2008. Local residents and community members worked together to green 4,436 lots (or 7.8 million square feet) in 4 areas ofthe city. Researchers found significant reductions in community residents? self-reported level of stress, which is a risk factor for suicide, and engagement in more physical exercise, a protective factor for suicide, than residents in control vacant lot areas. Other benefits included reductions in firearm assaults and vandalism {Branas et al., 2011). 26 Teach Coping and Problem-Solving Skills Rationale Building life skills prepares individuals to successfully tackle every day challenges and adapt to stress and adversity. Life skills encompasses many concepts, but most often include coping and problem-solving skills, emotional regulation, conflict resolution, and critical thinking. Life skills are important in shielding individuals from suicidal behaviors (World Health Organization, 2014). Suicide prevention programs that focus on life and social skills training are drawn from social cognitive theories (Bandura, 1986), surmising that suicidal behavior is attributed to either direct learning and modeling or environmental and individual hopelessness) characteristics. The inability to employ adequate strategies to cope with immediate stressors or identify and find solutions for problems has been characterized among suicide attempters {Pollock 8: Williams, 2004). Teaching and providing youth with the skills to tackle every day challenges and stressors is, therefore, an important component to suicide prevention. Approaches Social emotional learning programs and parenting skill and family relationship programs are two approaches for teaching coping and problem-solving skills. . Social emotional learning programs focus on developing and strengthening communication and problem-solving skills, emotion regulation, conflict resolution, help seeking and coping skills. These approaches address a range of risk and protective factors for suicidal behavior. They provide children and youth with skills to resolve problems in relationships, school, and with peers, and help youth to address other negative influences le.g., substance use) associated with suicide. These approaches are typically delivered to all students in a particular grade or school, although some programs also focus on groups of students considered to be at high risk for suicide. Opportunities to practice and reinforce skills are an important part of programs that work (Herman, Borden, Reinke, 8L Webster-Stratton, 2011). I Parenting skill and family relationship programs provide caregivers with support and are designed to strengthen parenting skills, enhance positive parent-child interactions, and improve children?s behavioral and emotional skills and abilities. Programs are typically designed for parents or caregivers with children in a specific age range and can be self-directed or delivered to individual or groups of families. Some programs have sessions primarily with parents while others include sessions for parents, youth, and the family. Specific program content typically varies by the age of the child but often has consistent themes ofchild development, parent-child communication and relationships, and youth?s interpersonal and problem-solving skills. 27 Potential Outcomes Comment Should we add references for some of the svstematic reviews on school and parentingj'famllv programs? Comment IAI: Dropped Signs of Suicide Reductions in suicide attempts and suicide ideation Reductions in suicide risk behaviors li.e., depression, ansietv, conduct problems, substance abuse] I i Consider adding Two examples - mav be ?ne here, so not sure we need to Improvements in help-seeking behavior add another program. Improvements in social competence and emotional regulation skills Improvements in problem?solving and conflict management skills . i i rigorous evaluations to Improve resilience and reduce risk factors for various behavior including ones Evidence Several social emotional learning and parenting and family relationship programs have been shown in closelv related to suicide, such as depression, internalizing behaviors, and substance abuse (M. S. KnoxBurkhart, Hunter, 2010). a Social emotional learning rogramd. The Youth Aware of Mental Health Program (YAM) is a program developed for teenagers to teach adolescents about the risk and protective factors associated with suicide {including knowledge about depression and anxiety} and enhances their problem-solving skills for dealing with adverse life events, stress, school and other problems (Wasserman et al., 2014). In a cluster-randomized controlled trial conducted across 10 European Union countries and 158 schools, students in schools randomized to YAM were significantlv less likelv to attempt suicide and have severe suicidal ideation at the 12-month follow-up compared to students in control schools which receiVed educational materials and care as usual. Overall, the relative risk of youth suicide attempts among the YAM group was red Liced bv over 50% demonstrating that out of 1000 students, five attempted suicide in the MM group compared to 11 in the control group. Additionallv, related to severe suicide ideation, in the MM group absolute risk fell bv 0.50% and relative risk fell bv 49.6% {Wasserman et al., 2014). Another example is the Good Behavior Game (GEE), which is a classroom-based program for elementarv school children aged 6?10. The program uses a team?based behavior management strategy that promotes good behavior bv setting clear expectations for good behavior and consequences for maladaptive behavior. The goal of the 656 program is to create an integrated classroom social svstem that is supportive of all children being able to learn with little aggressive or disruptive behavior [Wilcox et al., 2008}. Two cohorts of vouths participated in the program in 1935-86 and 1986-8? school vears when thev were in the first and second grades. A number of proximal and distal outcomes were assessed among the two cohorts over time. With respect to distal suicide-related outcomes, an outcome evaluation of the EEG indicated that individuals in the first cohort who were assigned to participate in 23 (336 when they were in the first grade reported half the adjusted odds of suicidal ideation and suicide attempts when assessed approximately 15 years later, between the ages of 19 to 21, compared to peers who had been in a standard classroom setting. The beneficial effect of the program was consistent for suicidal ideation regardless of whether baseline covariates were included. The EEG effect on attempts was less robust in some adjusted models including caregiver mental health. In the second cohort of 656 students, neither suicidal ideation nor suicide attempts were significantly different between 636 and the control interventions (Wilcox et al., 2008). The researchers believed this may have been due to a lack of implementation fidelity. 636 was also found to be associated with reduced risk of later substance abuse, 3 risk factor for suicide (Kellam et al., 2008). Parenting skill and family relationship programs. Parenting and family skills training approaches have shown promising impacts in preventing key risk factors associated with suicide. For example, the incredible Years is a comprehensive group training program for parents, teachers and children designed to reduce conduct and substance abuse problems, two important suicide riskfactors in youth by improving protective factors such as responsive and positive parent-teacher-child interactions and relationships, emotion self-regulation and social competence {all protective factors for suicide) (Herman et al., 2011). The program includes 9-20 sessions offered in community-based settings religious, recreation centers, mental health treatment centers, and hospitals). Several studies have demonstrated the effect of the program on reducing internalizing such as anxiety and depression, and child conduct problems (C. H. liliebster-Stratton, Reid, 81 Beauchaine, 2011; Webster-Stratton, Jamila Reid, 8: Stoolmiller, 2008). The program is also associated with improved problem-solving and conflict management; these skills were maintained at 1-year follow-up (Reid, Webster-Stratton, 8: Hammond, 2003; C. Webster-Stratton 8: Hammond, 1997; C. Webster-Stratton, Reid, Hammond, 2001). The program demonstrated greater benefits as the dosage ofthe intervention increased (Herman et al., 2011). Additionally, Strengthening Families 10-14 is a program that involves sessions between parents, youth, and family with the goal of improving parents? skills for disciplining, managing emotions and conflict, and communicating with their children; promoting youths? interpersonal and problem-solving skills; and creating family activities to build cohesion and positive parent-child interactions. The premise of the program is that developing these skills for both parents and children will reduce internalizing behavior and adolescent substance abuse, two important risk factors for suicide (Spoth, Guyll, 8: Day, 2002). Strengthening has been shown to significantly decrease externalizing behaviors, such as aggression, alcohol use, and drug use among youth participants, as well as reduce depression, alcohol use, and drug use among participating families (Spoth et al., 2002). 29 {Comment Add LGBTonpulations? 1 Identify and Support People AtsRisk Rationale In order to decrease suicide, attention to people at increased risk is necessary, as these individuals tend to experience suicidal behavior at higher than average rates. These vulnerable or disadvantaged populations include, but are not limited to, individuals with lower socio?economic status or who are living with a mental health problem; people who have attempted suicide previously; Veterans and active duty military personnel; individuals who are institutionalized, have been victims of violence, or are homeless?anc? members of certain racial and ethnic minority groups. SUpporting these vulnerable groups requires proactive case finding along with access to, and retention in, mental health services. Finding effective ways of identifying at-risk or vulnerable groups, customizing services to make them accessible and engaged in care remain key challenges. For example, simply improving services does not guarantee that those services will be used by those most in need ofthem, nor will it necessarily increase the number people who follow treatments that are recommended. People who are disadvantaged face social and economic issues that may adversely affect their ability to access care and treatment. Approaches The following three approaches focus on identifying and supporting people at increased risk. Gatekeeper training is designed to train teachers, coaches, clergy, emergency responders, primary and urgent care providers, and others in the community to identify people who may be at risk of suicide and to respond effectively, including facilitating treatment seeking and support 0 services. Gatekeeper training may be implemented in a variety of settings to identify and support people at risk. Screening combined with care management and overall continuity of care has been used in primary care and behavioral health care settings to assure that people who may be at high?risk of suicide are identified and receive ongoing treatment as needed, particularly after inpatient discharge and other transitions within the healthcare system so they don?t ?slip through the cracks?. These approaches typically employ screening for depression andy?or suicide combined with collaborative treatment planning between patients and their providers and patient follow? up. Crisis intervention. These approaches provide support and referral services, typically by connecting a person in crisis [or a friend or family member of someone at?risk} to trained Volunteers or professional staff via telephone hotline, online chat, text messaging, or in-person. I Crisis intervention approaches are intended to impact key risk factors for suicide, including 3D Potential Outcomes Reductions in suicide attempts feelings of depression, hopelessness, and subsequent mental health care utilization. Like means reduction, crisis interventions can put space or time between an individual who may be considering suicide and harmful behavior. Comment IAI: Moved ASIST here per reviewers comments. Dropped MHFA - consider incorporating that program in another category? Reductions in suicide deaths Increases in identification ofindividuals at?risk for suicidal behavior Increases in at-risk individuals in treatment Increases in community members trained to identify at~risl< individuals Increases in referrals for health care Evidence The current evidence suggests that identifying people at risk of suicide and the continued provision of support for these individuals can positively impact suicide and its associated risk factors. I Gatekeeper training. Appiied Suicide intervention Training {?45511} is a widely implemented -.-. training program that helps hotline counselors, emergency workers, and other gatekeepers toJ identify and connect with suicidal individuals, understand their reasoning for living and dying, and assist with safely connecting those in need to available resources. In a study employing a randomized controlled trial, Gould, Cross, Pisani, Munfakh, Kleinman (2013] evaluated the training across the National Suicide Prevention tifeiine network of hotlines over the period 2008- 2009. Using data from 1,410 suicidal individuals who called 1? Lifeline centers, the researchers found that compared to callers who spoke to counselors that received the usual care training, individuals who spoke with counselors without training in ASIST were signi?cantly more likely to feel depressed, suicidal, more overwhelmed, and less hopeful by the end of their call to the hotline compared to those with training in Counselors trained in were also more skilled at keeping callers on the phone longer and establishing a connection with them. However, training in did not result in more comprehensive suicide risk assessments than usual care training (Gould et al., 2013). Gatekeeper training has also been a primary component of the Garret tee Smith {(315) Suicide Prevention Program, which is in place in 49 states and 48 tribes. A multi-site evaluation assessed the impact of community gatekeeper training on suicide attempts and deaths by comparing the change in suicide rates and nonfatal suicidal behavior among young people aged 10-24 in counties implementing GL5 trainings, with the trajectory observed in similar counties that did not 31 implement these trainings. Counties that implemented GL5 trainings had significantly lower youth suicide rates one year following the training implementation (Walrath, Garraza, Reid, Goldston, 8: McKeon, 2015}. This finding equates to a decrease of 1 suicide death per 100,000 among youth ages 10 to 24, or the prevention of approximately 237 deaths in the age group, between 2007 and 2010. Counties implementing GL5 program activities also had significantly lower suicide attempt rates among youth ages 16 to 23 in the year following implementation of the GL5 program than did similar counties that did not implement GL5 activities (4.9 fewer attempts per 1000 youths; Godoy Garraza, Walrath, Goldston, Reid, McKeon, 2015). More than 79,000 suicide attempts may have been prevented during the period examined, following implementation of the GL5 program. Screening combined with care management and overall continuity of care. The Henry Ford healthcare system is a large health maintenance organization (HMO) in the state of Michigan. Henry Ford?s Perfect Depression Care program was the pre-cursor to what is now called Zero Suicide, and its overall goal was to eliminate suicide among its members. More broadly, the goal of the program was to redesign delivery of depression care to achieve ?breakthrough improvement? in quality and safety by focusing on effectiveness, safety, patient centeredness, timeliness, efficiency, and equity among patients. The program screened and assessed each patient for suicide risk and implemented coordinated continuous follow-up care system wide (C. E. Coffey, 2006). An examination of the impact of the program found that there was a dramatic and statistically significant decrease in the rate of suicide between the baseline years, 1999 and 2000, prior to the intervention to the intervention years, 2002-2009. During this time period, the suicide rate fell by 82% (C. E. Coffey, 2006,- C. E. Coffey, Coffey, Ahmedani, 2013). Further, among HMO members who received mental health specialty services, the suicide rate significantly decreased over time from 1999 to 2010 (110.3 to 47.6 per 100,000; p<.04) with a mean of 36.2 per 100,000 over the period. Additionally, for those HMO members who accessed only general medical services as opposed to specialty mental health services, the suicide rate increased from 2.7 to 5.6 per 100,000 Similarly, in the state of Michigan, rates of suicide in the general population increased over the period from 9.8 to 12.5 per 100,000 lp<.001) (M. Coffey, Coffey, Ahmedani, 2015]. Crisis intervention. Suicide prevention hotlines are one way to provide crisis intervention. In an evaluation of the effectiveness of the Notionai Suicide Prevention Lifeiine to prevent suicide, 1,085 suicidal individuals who called the hotline completed a standard risk assessment for suicide, and 380 of those completed a follow-up assessment between 1 and 52 days (mean=13.5 days) after the initial assessment. Researchers found that over half of the initial sample were seriously considering suicide when they called, and they had a plan for their suicide. Researchers also found that among follow-up participants, there was a significant decrease in 32 pain, hopelessness, and intent to die between initiation of the call (time 1) to follow-up (time 3). Between time 2 {end of the call} to time 3, the effect remained for pain and hopelessness, but was not significant for intent to die (Gould, Kalafat, Harrismunfakh, Kleinman, 2007). 33 Comment IAI: Wonderif it wouldjust be better to end the sentence after the Intervene to Lessen Harms and Prevent Future Risk word ?clinicians"? Rationale Individuals who have experienced mental health challenges, suicidal ideation, who have made suicide attempts or engaged in non-suicidal self-injury are at increased risk of suicide (US. Office ofthe Surgeon General 8% National Action Alliance for Suicide Prevention, 2012]. Risk of suicide can also increase among those who have lost a friend, family member, co-worker, or other acquaintance to suicide [Pitman, Osborn, King, St Erlangsen, 2014). Exposure to sensationalized or uninformed reporting regarding on suicide may heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion lEtzersdorfer 8.: Sonneck, 1998; Niederkrotenthaier SI Sonneck, 200?]. Approaches There are a number of approaches that can be used to lesson harms and reduce future risk of suicide including various therapeutic treatments and approaches providing continuity of care, caring for the bereaved, and safe reporting following a suicide. Treatment for people at-risk of suicide typically includes various forms of delivered by licensed providers to heip individuals with mental health problems and other risk factors for suicide with problem-solving, impulsivity and emotion regulation. Treatment usually takes place in a one on one or group format betwoen patients and cliniciansEn mental healthcare i settings, but may also involve primary care several weeks to ongoing therapy for years in some cases. - Treatment to prevent re?attempts. These approaches typically include follow-up contact and use diverse modalities le.g., home visits, mail, telephone, e-mail] to engage recent suicide attempt survivors in continued treatment to prevent re?attempts. Treatment may focus on improved coping skills, mindfulness, and other emotional regulation skills, and may include case management home visits to increase adherence to treatment and continuity of care; and one? on-one interpersonal therapy andfor group therapy. Approaches that engage and connect attempters to peers and providers are especially important because many attempters do not present to aftercare; 1296-2594:. reattempt within a year, and 396-996 of attempt survivors die by suicide within 1 to 5 years of their initial attempt {lnagaki et al., 2015] - Postvention approaches are implemented after a suicide has taken place and may include debriefing sessions, counseling, andfor bereavement support groups for surviving friends and family members/loved ones. These programs have not typically been evaluated for their impact on suicide or suicidal behavior but may reduce survivors? guilt, feelings of depression, and complicated grief {Szumilas Si. Kutcher, 2011). 34 Safe reporting following a suicide. The manner in which information on a recent suicide is communicated to the public leg. school assemblies, mass media, social media) can heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion. Therefore, responsible and safe reporting may help prevent suicide and suicide contagion. Potential Outcomes I Reductions in mental health-related sequelae ll'l I Improvements in coping skills - Improvements in messaging following suicide I Reductions in re-attempts I Reductions in contagion effects related to suicide Evidence Current evidence suggests that therapeutic treatments and other approaches for lessening harm can impact risk and protective factors for suicide. Treatment for people at?risk of suicide. One example of a treatment with evidence of impact on risk and protective factors for suicide is the improving Mood Promoting Access to Collaborative Treatment program. aims to prevent suicide among older primary care patients by reducing suicide ideation and depression in primary care settings. It facilitates the development of a therapeutic alliance, a personalized treatment plan that includes patient preferences, as well as proactive follow-up (biweekly during an acute phase and during continuation phase) by a depression care manager (Hunkeler et al., 2006}. The program has been shown to significantly improve quality of life, and to reduce functional impairment, depression and suicidal ideation over 24-months of follow-up (Hunkeler et al., 2006; Unutzer et al., 2006) relative to patients who received care as usual. Another example is Collaborative Assessment and Management of Suicidality (CAMS), which is a therapeutic approach for suicide-specific assessment and treatment of patient?s suicide risk. This flexible approach can be used across treatment settings and clinician theoretical orientations and involves the clinician and patient working together in an interactive assessment process to develop patient-specific treatment plans. CAMS sessions are collaborative and involve constant patient input about what is and is not working with the ultimate goal of enhancing the 35 therapeutic alliance and increasing treatment motivation in the suicidal patient. CAMS been tested and supported in 6 correlational studies lJobes, 2012), in a variety of inpatient and outpatient settings and in one RCT with several additional RCTs under way. CAMS has been associated with significant improvements in suicidal ideation, overall distress, and feelings of hopelessness at 12 month follow-up among a community-based sample of suicidal outpatients. {Comtois et al., 2011). Other examples include Dialectical Behavioral Therapy (DST) and Attachment-Based Family Therapy (ABFT). a multicomponent therapy for individuals at high risk for suicide and who may struggle with impulsivity and emotional regulation. The components of BET include individual therapy, group skills training, between-session telephone coaching and a therapist consultation team. In a randomized controlled trial of women with recent suicidal or self- injurious behavior, those receiving DBTwere half as likely to make a suicide attempt at two-year follow-up than women receiving community treatment (23% vs required less hospitalization for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined (Linehan et al., 2006}. ABFT is a program for adolescents aged 12-18 and is designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety (Diamond at al., 2010). A randomized controlled trial of ABFT found that suicidal adolescents assigned to ABFT experienced significantly greater improvement in suicidal ideation over 24 weeks of follow-up than did adolescents assigned to enhanced usual care. Additionally, a signi?cantly higher percentage of ABFT participants reported no suicidal ideation in the week prior to assessment at 12 weeks than did adolescents receiving enhanced usual care (69.2% vs. 34.6%) and at 24 weeks {82.1% vs. 46.2%) (Diamond at al., 2010). Treatment to prevent re-attempts. Several strategies that aim to prevent re- attempts have {at 1, 2,4, 7, 11 weeks and 4, 6, 12, 18 months} Follow- up contacts are either conducted by phone or through home visits according to a specific time line for up to 18-months. A randomized controlled trial that enrolled suicide attempters from eight hospital emergency departments in five countries (Brazil, India, Sri Lanka, lran, and China} found that a brief intervention combined with 9 follow-up visits over 18-months was associated with significantly fewer deaths from suicide relative to a treatment-as-usual group versus respectively) {Fleischmann et al., 2008). 36 Another example of treatment to prevent re-attempts involves active foiiow?up contact approaches such as postcards, letters, and telephone calls intended to increase a patient?s sense of connectedness with health care providers and decrease isolation. These approaches include expression of care and support and typically invite patients to reconnect with their provider. Contacts are made periodically or every few months in the first 12 months post- discharge with some programs continuing contact for two or more years). In a meta-analysis conducted by lnagaki et al. {2015), interventions to prevent repeat . Lj?TZ?II-iflfi?i?i in patients admitted to an emergency department for suicide attempt were found to reduce reattempts by approximately 17% for up to 12 months post-discharge; however, the effects of these approaches beyond 12 months on reattempts has not yet been demonstrated. Also, because the number of trials and associated sample sizes included in this meta-analysis were small, it was not possible to determine the effect of active contact and follow-up approaches on death by suicide. in a randomized controlled trial ofthe post-crisis suicide prevention long-term follow?up contact approach, Motto and Bostrom (2001} found that patients who refused ongoing care but who were randomized to be contacted by letter four times per year had a lower rate of suicide over two years of follow-up than did patients in the control group who received no further contact. Other studies have also shown post-crisis letters and coping cards to be protective against suicide ideation and attempts (Hassanian-Moghaddam, Sarjami, Kolahi, 8: Carter, 2011; Wang et al., 2016i Finally, Cognitive Behavior Therapy for Suicide Prevention is an example of a therapeutic approach to prevent re-attempts. It uses a risk-reduction, relapse prevention approach that includes an analysis of proximal risk factors and stressors relationship problems, school or work-related difficulties) leading up to and following the suicidal event; safety plan development; skill building; and CST-5P also has family skill modules focused on family support and communication patterns as well as improving the family?s problem solving skills. A randomized controlled trial of CST-SP found that 10-session outpatient cognitive therapy designed to prevent repeat suicide attempts resulted in a 50% reduction in the likelihood of a suicide reattempt among adults who had been admitted to an emergency department for a suicide attempt relative to treatment as usual [Brown et al., 2005). Postvention programs are implemented with the goal of providing support to survivors of others? suicide to reduce their own risk of suicide. One example of a postvention program, StandBy Response Service (StandBy), provides clients with face-to-face outreach and telephone support through a professional crisis response team. Site coordinators develop customized case management plans, referring clients to other existing community services matched to their needs 37 {Vissen Comans, 8i. Scuffham, 2014). In a study by Visser et al. (2014), StondBv clients were significantly less likely to be at high risk for suicidality than a suicide bereaved comparison group who had not had contact with the StondBy program {48% and 64% respectively). Additionally, research suggests that active postvention approaches in which outreach to suicide survivors occurs at the scene of a suicide is associated with intake into treatment sooner, greater attendance at support group meetings, and attendance at more meetings compared to passive postvention (versus passive approaches where survivors self-refer for services) (J. Cerel Campbell, 2008}. Safe reporting following a suicide. One way to ensure safe reporting following a suicide is to encourage news media adhere to Recommendations for Reporting on Suicide Reports that are both inclusive of suicide prevention messages, stories of hope and resilience, risk and protective factors, and links to helping resources hotiine), and that avoid sensationalizing events or reducing suicide to one cause, can help reduce the likelihood of suicide contagion. The most compelling evidence supporting these recommendations for reporting comes from Austria. After a sharp increase in suicides on the Viennese subway, media guidelines were introduced and an interrupted time series design was used to evaluate the national impact of the guidelines on subsequent suicides. Changes in the quality and quantity of media reporting resulted in a nationwide significant reduction of 81 suicides annually {Niederkrotenthaler Sonneck, 200?}. Finally, research suggests that not only does reporting on suicide in a negative way reporting on suicide and repetition} have harmful effects on suicide, but reporting on positive coping skills in the face of adversity can also demonstrate protective effects against suicide (Niederkrotenthaler et al., 2010). Reports of individual suicidal ideation not accompanied by reports ofsuicide or suicide attempts, along with reports describing a "mastery? of a crisis situation where adversities were overcome, was associated with significant decreases in suicide rates in the time period immediately following such reports {Niederkrotenthaler et al., 2010). 38 Sector Involvement Public health can play an important and unique role in addressing suicide. Public health agencies, which typically place prevention at the forefront of efforts and work to create broad population-level impact, can bring critical leadership and resources to bear on this problem. For example, these agencies can serve as a convener, bringing together partners and stakeholders to plan, prioritize, and coordinate suicide prevention efforts. Public health agencies are also well positioned to collect and disseminate data, implement preventive measures, evaluate programs, and track progress. Although public health can play a leadership role in preventing suicide, the strategies and approaches outlined in this technical package cannot be accomplished by the public health sector alone. As noted in the National Strategy to Prevent Suicide, the integration and coordination of prevention activities across sectors and settings is critical for expanding the reach and impact of suicide prevention efforts. Other sectors vital to implementing this package include, but are not limited to, education, government {locaL state, and federal}, social services, health services, business, labor, justice, housing, media, and organizations that comprise the civil society sector such as faith-based organizations, youth-serving organizations, foundations, and other non-governmental organizations. Collectively, these sectors can make a difference in preventing suicide by impacting the various contexts and underlying risks that contribute to suicide. The strategies and approaches described in this technical package are summarized in Appendix A along with the relevant sectors that are well positioned to lead implementation efforts. For example, business and labor, health care insurers and providers, and government entities are in the best position to implement programs and policies that Strengthen Economic Supports and Access to Mental Health Care. These types of supports go beyond individual behavior change and require commitment and support from those sectors that can directly address some of the underlying risks and the environmental contexts that increase the risk for suicide. Public health entities can play an important role by gathering and information to inform policy, raise awareness, and evaluate the effectiveness of various policies. Moreover, partnerships with non-governmental and community organizations can be instrumental in increasing awareness of and garnering support for policies affecting individuals and families. The public health sector has been atthe forefront of many community-based prevention efforts, working collaboratively with schools and community-based organizations, to change social norms and positively impact health behavior. Public health is well suited to take on a similar leadership role in Promoting Connectedness through peer norm and community engagement activities and supporting the development, evaluation, and adoption of effective programs that Teach Coping and Problem-Solving Skills to prevent suicide from happening in the first place. These programs are often delivered in school 39 and community settings, making education and non-governmental organizations vital partners in prevention. Businesses, workplaces, and local and state government entities, on the other hand, are in the best position to establish policies and support practices that Create Protective Environments where people live, work, and play. Public health entities can play an important role by gathering and information, working with other agencies within the executive branch of their state or local government in support of policy and other approaches, and evaluating the effectiveness of measures taken. in a similar fashion, public health entities can partner with schoois, workplaces, and community organizations to implement and evaluate prevention programs, policies and practices geared toward creating safe, healthy, and supportive environments. Finally, this technical package includes a number of interventions delivered in hospital, primary care, behavioral health care, and community settings designed to identify and Support People At-Risk and to Lessen Harms and Prevent Future Risk. The intensity and activities of these interventions require the expertise of professionals who are licensed and trained to deliver critical intervention support. The health care, social services, and justice sectors can work collaboratively to support individuals at high- risk for suicide and their families. These activities also require coordination of supports across various service providers and community organizations. Regardless of strategy, action by many sectors will be necessary for the successful implementation of this package. In this regard, all sectors can play an important and influential role in preventing suicide from happening in the first place and lessening the immediate and long-term harms of suicidal behavior by helping those in times of crisis get the services and support they need. 40 Monitoring and Evaluation Monitoring and evaluation are necessary components of the public health approach to prevention. it is important to have timely and reliable data to monitor the extent of the problem and to evaluate the impact of prevention efforts. Data are also necessary for prevention planning and implementation. Gathering ongoing and systematic data is important for prevention efforts. However, it is also important to gather data that are uniform and consistent across systems. Consistent data allow public health and other entities to better gauge the scope. of the problem identify high-risk groups and monitor the 3+ .373". 551i! help ensure that data are collected in a consistent manner across surveillance systems and data collection sites A.E. Crosby, Ortega, et al., 2011). Surveillance data help researchers and practitioners track changes in the burden of suicide. Surveillance systems exist at the federal, state, and local levels. it is important to assess the availability of surveillance data and data systems across these levels to identify and address gaps in the systems. CDC's National Vital Statistics System (NVSS) and the National Violent Death Reporting System are examples of surveillance systems that provide data on deaths from suicide. NVSS is a nationwide surveillance system that collects demographic, geographic, and ca use-of?death data from death certificates. is a state-based surveillance system {currently in 40 states, DC and Puerto Rico} that combines data from death certificates, law enforcement reports, and coroner or medical examiner reports to provide detailed information on the circumstances of violent deaths, including suicide, which can assist communities in guiding prevention approaches (Blair, Fowler, Jack, Ea. Crosby, 2016). The National Electronic Injury Surveillance System-All Injury Program provides nationally representative data about all types and causes of nonfatal injuries treated in US. hospital emergency departments, and can be used to assess national rates of, and trends in, self-harm injuries by cause falls, poisoning, etc.}, age, race/ethnicity, sex, disposition (where the injured person goes when released from the Emergency Department). in addition to information on deaths and nonfatal injuries, there are also surveillance systems that provide national, state, and some local estimates of suicidal behavior. The Youth Risk Behavior Surveillance System collects information from a nationally representative sample of 9-12 grade students and is a key resource in monitoring health-risk behaviors among youth, including whether youth have seriously considered attempting suicide, attempted suicide, made a plan, or required treatment by a doctor or nurse for a suicide attempt that resulted in an injury, poisoning, or overdose (Brener et al., 2013). The data are obtained from a national school-based survey conducted by CDC as well as from state, territorial, tribal, and large urban school district surveys conducted by education and health agencies. The National Survey on Drug Use and Health (NSDUH) is an annual survey of the civilian, non- institutionalized population aged 12 years and older. NSDUH provides both national and state-level 41 estimates of substance use (alcohol, tobacco, illicit drugs, and non-medical use of prescription drugs); mental health (past year mental illness, co-occurring illnesses); and service utilization, along with suicide ideation, suicide plans, and suicide attempts. NSDUH is a key resource to track trends in suicide-related risk factors in the population and to help identify groups at increased risk. it is also important at all levels (local, state, and federal) to address gaps in responses, track progress of prevention efforts and evaluate the impact of those efforts, including the impact of this technical package. Evaluation data, produced through program implementation and monitoring, is essential to provide information on what does and does not work to reduce rates of suicide and its associated risk and protective factors. Theories of change and logic models that identify short, intermediate, and long? term outcomes are an important part of program evaluation. The evidence-base for suicide prevention has advanced greatly over the last few decades. However, additional research is needed to understand the impact of programs, policies, and practices on suicide {and suicide attempts, at a minimum), as opposed to merely examining their effectiveness on riskfactors. More research is also needed to examine the effectiveness of primary prevention strategies [before risk occurs) and community-level strategies to prevent suicide at the population level. Lastly, it will be important for researchers to test the effectiveness of combinations of the strategies and approaches included in this package. Most existing evaluations focus on approaches implemented in isolation, but there is potential to understand the synergistic effects within a comprehensive prevention approach. Conclusion Suicide is a serious public health problem whose rates have been on the rise for more than a decade and whose costs stretch well into the billions of dollars each year. While suicide is a rare outcome statistically, its human impact has a ripple effect that is far-reaching. Each of us likely interacts with suicide survivors, those with lived experience, and those with thoughts of suicide on a daily basis at home, at work, and in our communities. Suicide and suicide attempts are public health issues of societal concern. There are a number of barriers that have impeded progress, including, for example, stigma related to help-seeking, mental illness, being a survivor and fear related to asking someone about suicidal thoughts. Fortunately, like many public health problems, suicide is preventable, and more is being done to prevent suicide than ever before, as evidenced by the work of the National Action Alliance for Suicide Prevention, the release of the first world report on suicide, and more timely surveillance data, to name just a few examples. In an effort to continue pushing the field and society further towards prevention, this technical package includes strategies and approaches that ideally would be used in a comprehensive, multi-level and multi- sectoral way. It includes strategies and approaches to prevent suicide from occurring in the first place, as well as strategies focused on lessening the immediate and long-term harms of suicidal behavior. It includes strategies that range from a focus on the whole population regardless of risk to strategies 42 designed to support people at highest risk. Importantly, this technical package extends the bounds of the typical prevention strategies to consider approaches that go beyond individual behavior change to better address risk factors impacting communities and populations more broadly economic policies to strengthen housing and financial security). While the evidence base continues to emerge, the collection of programs, policies, and practices laid out here are available for implementation now. In keeping with good public health practice, the intent is that monitoring and evaluation will play a key role in that implementation. Moreover, as new evidence becomes available, this technical package can be refined to reflect the current state of the science. In closing, and in keeping with a message of resilience as spoken by those with lived experience, ?hope, help, and healing is possible.? 43 References Archer, J., Bower, P., Gilbody, S., Lovell, K., Richards, D., Gask, L., . . . Coventry, P. (2012). 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H., LoMurrav, M, Schmeelk-Cone, K., Petrova, M., Yu, (1., . . . Wang, W. (2010). An outcome evaluation of the Sources of Strength suicide prevention program delivered by adolescent peer leaders in high schools. Am Public Health, 100(9), 1653-1661. doi: Yip, P., Caine, E., Yousuf, 5., Chang, 5.-5., Wu, K., Chen, Y.-Y. (2012). Means restriction for suicide prevention. Lancet, 379. 50 Appendix A: Summary of Strategies and Approaches to Prevent Suicide Strategy Approach/Program, Practice or Policy Strengthen household financial security Suicide Best Available Evidence Other Risk;r Protective Factors for Suicide Suicide Attempts or ldeation Lead Sectors1 Government (local, Unemployment benefit programs 1/ state, Federal) Strengthen economic Other income supports Businessflabor . . . . . . Housmg stabilization policies Government (local, The National Neighborhood Stabilization state, Federal) Program Coverage of mental health conditions in health insurance policies Health care Strengthen Mental Health Parity Lows 1? 1/ access to Government (state, mental health Fadera? ca re Reducing access to lethal means among persons at-risk Government (local, intervening at suicide hot spots state) 1/ Safe storage practices Public Health 1/ 1/ Create . protective Organizational pollcles and culture Busmesstabar . Together for Lg?e environments Government (local, US Air Force Suicide Prevention Program 1/ state, Fed eral) 50 Best Available Evidence Community?based policies to reduce excessive alcohol use Alcohol outlet density Government (local, state] Business/labor Promote connectedness Peer norm approaches Public Health Sources of Strength Education Communityrengagement activities Public Health Greening vacant urban spaces Government {local} Applied Suicide intervention Skills Training Social emotional learning Public Health Youth Aware of Mental Health Program Education Signs of Suicide Good Behavior Game 50"?ng Skins Parenting skill and family relationship approaches Public Health The incredible Years Education Strengthening Families 10-14 Gatekeeper training Public Health Healthcare 51 Identify and support people at-risk Screening combined with care management Best Available Evidence Henry Ford Perfect Depression Care (Pre- cursor to Zero Suicide) Healthcare Social Services Crisis Intervention Public Health National Suicide Prevention Lifeline Social Services Treatment for people at risk of suicide Healthcare improving Mood Promoting Access to Social Services Collaborative Treatment Justice Collaborative Assessment and Management Intervene to of Suicidality M3) lessen harms and revent Dialectical Behavioral Therapy 1/ future risk Attachment-Based Family Therapy Treatment to prevent re-attempts Health ca re ED Brief intervention with Follow-up Visits Social Services Active follow-up contact approaches CBT for Suicide Prevention Postvention Healthcare StandBy Response Service 52 Best Available Evidence Safe reporting following a suicide Public Health Media Guidelines Media 1This column refers to the lead sectors well positioned to bring leadership and resources to implementation efforts. For each strategy, there are many other sectors such as non-governmental organizations that are instrumental to prevention planning and implementing specific activities. 53 ?If Preventing Suicide: A Technical Package of Policy, Programs, and Practices Prepared by: Deb Stone, MSW, MPH Kristin Holland, MPH Brad Bartholow, Alex Crosby, MD, MPH Shane Davis, Natalie Wilkins, Division of Violence Prevention National Center for Injury Prevention and Control (NCIPC) Centers for Disease Control and Prevention 2017 Comment [Aft Additional comments fromjim: This looks great. I just have a few suggestionsicomments which I?ll summarize here: 1. Page 7 or somewhere: Although it is mentioned that violent victimization is a risk factor for suicide on page 7 I think that somewhere in this area we ought to punch up that fact. That is the prevention of interpersonal violence is a strategy for suicide prevention because I think it will be useful when we come back to look at cross-cutting strategies. So I?d suggest in just a sentence or two that we somehow put a little emphasis on that particular risk factor. 2. Economic toll of suicide: Across the board we have to be very careful of the way we use the economic estimates. The re methods vary to such a great extent its tricky to compare them. On page 9 the CDCIFIorence estimates are compared with the Shepard study. The suggestion is that the difference is due to the Shepard study adjusting for suicide underreporting. However, I believe that there are many other differences in the costs included in these two methods as well. I would amend to briefly mention how the Shepard estimates also includes other domains of cost as compared to the estimate. 3. Page The second bit of evidence in support of the health insurance policies isn?t really supportive as it isjust limited to how much it costs per suicide prevented. lfthat could be compared to the cost of a suicide to society then you have a costfbenefit results. As is it's not really evidence of effectiveness. We may want to consider dropping if we can't reword or re? contextualize this. 4. Page 40: While the word upstream is pretty weil recognized within public health circles it might not be WW Preventing Suicide: A Technical Package of Policies, Programs, and Practices is a publication of the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention. Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director National Center for injury Prevention and Control Debra E. Houry, MD, MPH, Director Division of Violence Prevention James A. Mercy, Director Suggested Citation: Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, 5., and Wilkins, N. Preventing Suicide: A Technical Package of Poiicies, Programs, and Practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2017. Contents Acknowledgements 4 External Reviewers 5 Overview of Technical Package 6 Strengthen Economic Strengthen Access to Mental Health Care 16 Create Protective Environments 18 Promote Connectedness 22 Teach Coping and Problem-Solving Skills 24 Identity and Support People At-Risk 28 Intervene to Lessen Harms and Prevent Future Risk 32 Sector Involvement 37 Monitoring and Evaluation 39 Conclusion 40 References 42 Appendix A 50 Acknowledgments [to be inserted later] External Reviewers [to be inserted later] Overview This technical package represents a select group of strategies based on the best available evidence to help communities and states sharpen their focus on prevention activities with the greatest potential to prevent suicide. These strategies include strengthening economic supports; strengthening access to mental health care; creating protective environments; promoting connectedness; teaching coping and problem-solving skills; identifying and supporting people at-risk; and intervening to lessen harms and prevent future risk. The strategies represented in this package include those with a focus on preventing suicide from happening in the first place as well as approaches to lessen the immediate and long-term harms of suicidal behavior for individuals, families, communities, and society. The strategies in the technical package support the goals and objectives of the National Strategy for Suicide Prevention and the National Action Alliance for Suicide Prevention?s priority to strengthen community-based prevention. Commitment, cooperation, and leadership from numerous sectors, including public health, education, justice, health care, social services, business, labor, and government can bring about the successful implementation of this package. What is a Technical Package? A technical package is a compilation of a core set of strategies to achieve and sustain substantial reductions in a specific risk factor or outcome {Friedem 2014). Technical packages help communities and states prioritize prevention activities based on the best available evidence. This technical package has three components. The first component is the strategy or the preventive direction or actions to achieve the goal of preventing suicide. The second component is the approach. The approach includes the specific ways to advance the strategy. This can be accomplished through programs, policies, and practices. The approaches included come primarily from studies based in the United States. The evidence for each of the approaches in preventing suicide or its associated risk factors is included as the third component. This package is intended as a resource to guide and inform prevention decision-making in communities and states. Preventing Suicide is a Priority Suicide, as defined by the Centers for Disease Control and Prevention (CDC), is part of a broader class of behavior called seif?directeo? vioience. Self-directed violence refers to behavior directed at oneself that deliberately results in injury or the potentiai for injury (A.E. Crosby, Ortega, 81 Melanson, 2011). Self- directed violence may be suicide! or non-suicidal in nature. For the purposes of this document, we refer only to behavior where suicide is intended: - Suicide is a death caused by self-directed injurious behavior with any intent to die as a result of the behavior. Suicide attempt is defined as a non-fotoiself-directed and potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury. Suicide is highly prevalent. Suicide presents a major challenge to public health in the United States and worldwide. it contributes to premature death, morbidity, lost productivity, and health care costs (U.S. Office of the Surgeon General 8c National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). In 2014 (the most recent year of available death data), suicide was responsible for 42,773 deaths in the U.S., which is approximately one suicide every 12 minutes (Centers for Disease Control and Prevention, 2016c). In 2014, suicide ranked as the 10th leading cause of death and has been among the top 12 leading causes of death since 1975 in the U.S (Centers for Disease Control and Prevention, 2016c). Overall suicide rates have increased 24% from 1999 to 2014 (Curtin, Warner, Hedegaard, 2016). Suicide is a problem throughout the life span; it is the second leading cause of death among those aged 10?34 years; it is the fourth leading cause among persons in their 405 and seventh among persons in their 505. Suicide rates vary by race/ethnicity with the highest rates, across the lifespan, occurring among non-Hispanic American Indian/Alaska Native (rate: Among young people are disproportionately at increased risk of suicide with young males aged 25?29 experiencing the highest rates (rate: Moreover, suicide rates among non-Hispanic AIIAN have increased by 48.7% since 1999 (Centers for Disease Control and Prevention, 2016c). Suicides reflect only a portion of the problem (A.E. Crosby, Han, Ortega, Parks, Gfroerer, 2011). Substantially more people are hospitalized as a result of nonfatal suicidal behavior suicide attempts) than are fatally injured, and an even greater number are either treated in ambulatory settings emergency departments) or not treated at all (A.E. Crosby, Han, et al., 2011). For example, during 2014, among adults aged 18 years and older, for every one suicide there were 9 adults treated in hospital emergency departments for self-harm injuries, 27 who reported making a suicide attempt, and over 227 who reported seriously considering suicide ideation) (Ferdon et al., in press). Suicide is associated with several risk and protective factors. Suicide, like other human behaviors, has no single determining cause. Instead, suicide occurs in response to multiple biological, interpersonal, environmental and societal influences that interact with one another, often over time. The social-ecological modeI-? encompassing multiple levels of focus from the individual, relationship, community, and societal-- is a useful framework for viewing and understanding suicide risk factors identified in the literature (Dahlberg 84 Krug, 2002). Risk and protective factors for suicide exist at each level. For example, risk factors include: Individual level: History of depression and other mental illnesses, hopelessness, substance abuse, certain health conditions, previous suicide attempt, violence victimization and perpetration, and genetic and biological determinants Relationship level: High conflict or violent relationships, sense of isolation and lack of social support, familyfloved one?s history of suicide, financial and work stress 0 Community level: Inadequate community connectedness, barriers to health care lack of access to providers and medications} Societal level: Availability of lethal means of suicide, unsafe media portrayals of suicide, stigma associated with help-seeking and mental illness (US. Office of the Surgeon General 3; National Action Alliance for Suicide Prevention, 2012,- World Health Organization, 2014i. CI It is important to recognize that the vast majority of individuals who are depressed or who have other risk factors noted, do not die by suicide. Furthermore, the relevance of each risk factor can vary by age, race, gender, sexual orientation, residential geography, and socio-cultural and economic status Office of the Surgeon General 8: National Action Alliance for Suicide Prevention, 2012; World Health 2014). Protective factors, or those influences that guard ogoinst the risk for suicide, can also be found across the different levels of the socialvecological model. Protective factors identified in the literature include: effective coping and problem solving skills, moral objections to suicide, strong and supportive relationships with partners, friends, and family; connectedness to school, community and other social institutions; availability of quality and ongoing physical and mental health care, and reduced access to lethal means Office ofthe Surgeon General 31 National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). These protective factors can either counter a specific risk factor or guard against a number of risks associated with suicide. Suicide is connected to other forms of violence. Suicide and other forms of violence often share some of the same root causes iButchart, Phinney, Check, 8: Villaveces, 2004,- Klevens, Simon, Chen, 2012). For example, in neighborhoods where there is low social cohesion, or where residents don't support and trust each other, people are at higher risk for suicide [Desai, Dausey, 8t Rosenheck, 2005) as well as perpetration of child maltreatment [Coulton, Crampton, lrwin, Spilsbury, 8L Korbin, 2007; Freisthler, Merritt, El. LaS-cala, 2006}, teen dating violence [Capaldi, Knoble, Shortt, 8: Kim, 2012}, intimate partner violence (Pinchevsky Bl. Wright, 2012), and youth violence (Sampson, Morenoff, 8t Gannon-Rowley, 2002}. Additionally, a lack of economic opportunities and unemployment are associated with suicide {Luo, Florence, Quispe-Agnoli, Ouyang, 3i. Crosby, 2011,- Reeves et al., 2012], as well as perpetration of child maltreatment Runyan, Wattam, Ikeda, Hassan, E: Ramiro, 2002}, intimate partner violence {Heise 3r. Garcia-Moreno, 2002; Pinchevsky 8t Wright, 2012}, sexual violence (Centers for Disease Control and Prevention, 2016b} and youth violence (Wilson, 2011). Other shared risk factors for suicide and violence occur at the individual level and include substance abuse, mental health problems, witnessing violence, and a lack of problem?solving skills {Centers for Disease Control and Prevention, 2016a, 2016b, 2016d; US. Office of the Surgeon General National Action Alliance for Suicide Prevention, 2012}. Just as risk factors may be shared across suicide and violence, so too may protective factors overlap. For Esxamplq connectedness to one?s community (Kleiman, Riskind, Schaefer, BI Weingarden, 2012}, school Comment IAI: Took out many of the citations to facilitate reading as suggested. (Carter, McGee, Taylor, Williams, 2007], family (Maimon, Browning, 8i. Brooks-Gunn, 2010), caring adults (Capaldi et al., 2012; Losel Farrington, 2012), and pro-social peers (Wyman et al., 2010) enhances resilience to suicide and other forms of violence. The health and economic consequences of suicide are substantial. Suicide and suicide attempts have far reaching consequences for individuals, families, and communities (Dunne, E: Dunne- Maxim, 1987'; Mishara, 1995; National Action Alliance for Suicide Prevention: Suicide Attempt Survivors Task Force, 2014; National Action Alliance for Suicide Prevention: Survivors of Suicide Loss Task Force, 2015). In an early study, Crosby and Sacks (2002} estimated that 7% of the U.S. adult population, or 13.2 million adults, knew someone in the prior 12 months who had died by suicide. They also estimated that for each suicide, 425 adults were exposed, or knew about the death. in a more recent study, in one state, Cerel et. al (2016) found that 48% of the population knew at least one person who died by suicide in their lifetimes. Research indicates that the impact of knowing someone who died by suicide andlor having lived experience having attempted suicide oneself) is much more extensive than injury and death. People with lived experience may suffer long-term health and mental health consequences ranging from anger, guilt, and physical impairment, depending on the means and severity of the attempt (Chapman 8: Dixon-Gordon, 200?). Similarly, survivors of a loved one?s suicide may experience ongoing pain and suffering including complicated grief (Mitchell, Kim, Prigerson, Mortimer-Stephens, 2004}, stigma, depression, anxiety, post-traumatic stress disorder, and increased risk of suicidal ideation and suicide (Julie Cerel, McIntosh, Neimeyer, Maple, 8: Marshall, 2014; Sudak, Maxim, Carpenter, 2003). Less discussed but no less important, are the financial and occupational effects for those left behind (Florence, Simon, Haegerich, Luo, Zhou, 2015]. The economic toll of suicide is immense as well. According to conservative estimates, in 2013, suicide cost $50.8 billion in estimated lifetime medical and work-loss costs (Florence et al., 2015). By another estimate, the total lifetime costs associated with nonfatal injuries and deaths caused by self-directed violence in 2013 were approximately $93.5 billion after adjusting for under-reporting of suicide (Shepard, Gurewich, Lwin, Reed, Silverman, 2016). The overwhelming burden of these costs results from lost productivity over the life course, with the average cost per suicide being over $1.3 million (Shepard et al., 2016). Suicide can be prevented. Despite the surrounding suicide, like most public health problems, suicide is preventable (U.S. Public Health Service, 1999}. And while progress will continue to be made into the future, evidence for numerous programs, practices, and policies currently exists, and many programs are ready to be implemented now. Just as suicide is not caused by a single factor, research suggests that suicide will not be prevented by any single intervention taking place in any single setting (Silverman Maris, 1995; U.S. Office of the Surgeon General National Action Alliance for Suicide Prevention, 2012). Rather, suicide prevention is best achieved by a focus across the individual, relationship, family, community, and societal-levels and across all sectors, private and public 9 business, public health, physical and behavioral healthcare, justice, education, labor] (National Action Alliance for Suicide Prevention, 2014; World Health Organization, 2014}. Assessing the Evidence This technical package includes programs, practices, and policies with evidence of impact on suicide or risk or protective factors for suicide. To be considered for inclusion in the technical package, the program, practice, or policy selected had to meet at least one of these criteria: a} meta-analyses or systematic reviews showing impact on suicide; b) evidence from at least one rigorous randomized controlled trial or quasi-experimental design) evaluation study that found significant preventive effects on suicide; c} meta-analyses or systematic reviews showing impact on risk or protective factors for suicide, or d) evidence from at least one rigorous RCT or quasi-experimental design) evaluation study that found significant impacts on risk or protective factors for suicide. Finally, consideration was also given to the likelihood of achieving beneficial effects on multiple forms of violence; no evidence of harmful effects on specific outcomes or with particular subgroups; and feasibility of implementation in a U.S. context if the program, policy, or practice has been evaluated in another country. Within this technical package, some approaches do not yet have research evidence demonstrating impact on rates of suicide but instead are supported by evidence indicating impacts on risk or protective factors for suicide help-seeking, stigma reduction, depression, connectedness). In terms of the strength of the evidence, programs that have demonstrated effects on suicidal behavior reductions in deaths, attempts) provide a higher-level of evidence, but the evidence base is not that strong in all areas. For instance, there has been less evaluation of community engagement and family programs on suicidal behavior. Thus, approaches in this package that have effects on risk or protective factors reflect the developing nature of the evidence base and the use of the best available evidence at a given time. It is also important to note that there is often significant heterogeneity among the programs, policies, or practices that fall within one approach or strategy area in terms of the nature and quality of the available evidence. Not all programs, policies, or practices that utilize the same approach gatekeeper training) are equally effective, and even those that are effective may not work across all populations. Tailoring programs and more evaluation may be necessary to address different population groups. The examples provided are not intended to be a comprehensive list of evidence-based programs, policies, or practices for each approach, but rather illustrate models that have been shown to impact suicide or have beneficial effects on risk or protective factors for suicide. In practice, the effectiveness of the programs, policies and practices identified in this package will be strongly dependent on the quality of their implementation and the communities in which they are implemented. Implementation guidance to assist practitioners, organizations and communities will be developed separately. 10 Context and Cross-Cutting Themes The strategies and approaches that have been included in this technical package represent different levels of the social ecology, with efforts intended to impact the community and societal levels, as well individual and relationship levels. The strategies and approaches are intended to work in combination and reinforce each other to prevent suicide {see box below). The strategies are arranged in order such that those strategies hypothesized to have the greatest potential for broad public health impact on suicide are included first, followed by those that might impact more select populations persons who have already made a suicide attempt}. Preventing Suicide Strategy Approach Strengthen economic supports I Strengthen household financial security Housing stabilization policies Strengthen access to mental health care 0 Coverage of mental health conditions in health insurance policies Create protective environments I Reducing access to lethal means among persons at-risk of suicide I Organizational policies and culture a Community-based policies to reduce excessive alcohol use Promote connectedness - Peer norm approaches It Community engagement activities Teach coping and problem-solving skills . Social-emotional learning I Parenting skill and family relationship approaches Identify and support people at risk I Gatekeeper training Screening combined with care management Crisis intervention Treatment for people at-risk of suicide Treatment to prevent re-attempts Postvention Safe messaging following a suicide Intervene to lessen harms and prevent future risk The example programs, policies, and practices have been implemented within particular contexts. The social and cultural context of communities is critically important to take into account when selecting strategies and approaches. Practitioners in the field may be in the best position to assess the needs and of their communities and work with community members to make decisions about the combination of approaches included here that are best suited to their contest. 11 Suicide ideation, attempts, morbidity and mortality vary by gender, race/ethnicity, age, occupation, and other important population characteristics. Barriers to disclosure, help seeking, timely access to quality care, and ongoing support may also vary by population and community characteristics. ideally, the availability of multiple approaches tailored to the economic, cultural, and environmental context of individuals and communities are desirable as they may increase the likelihood of removing barriers to supportive and effective care and provide opportunities to develop individual and community resilience. These culturally appropriate approaches can then be included in comprehensive strategies to maximize the public health impact on reducing suicide-related morbidity and mortality among individuals and within communities. This package includes strategies where public health agencies are well positioned to bring leadership and resources to implementation efforts. it also includes strategies where public health can serve as an important collaborator strategies addressing community and societal level risks), but where leadership and commitment from other sectors such as business, labor or health care is critical to implement a particular policy or program le.g., workplace policies; screening combined with care management). The role of various sectors in the implementation of a strategy or approach in preventing suicide is described further in the section on Sector involvement. in the sections that follow, the strategies and approaches with the best available evidence for preventing suicide are described. 12 Strengthen Economic Supports Rationale Studies from the U.S. examining historical trends indicate that suicide rates increase during economic recessions marked by high unemployment rates, job losses, and economic instability and decrease during economic expansions and periods marked by low unemployment rates, particularly for working- age individuals 25 to 64 years old {Luo et al., 2011; Fowler et al., 2015). Economic and financial strain, such as job loss, long periods of unemployment, reduced income, difficulty covering medical, food, and housing expenses, and even the anticipation of such financial stress, can directly increase an individual?s risk for suicide or can indirectly increase risk by exacerbating related physical and mental health problems; buffering these risks can therefore, potentially protect against suicide (Stack 8: Wasserman, 2007). For example, strengthening economic support systems can help people stay in their homes or obtain affordable housing while also paying for necessities such as food and medical care, job training, child care, among other expenses required for daily living. In providing this support, stress and anxiety and the potential for a crisis situation may be reduced, thereby preventing suicide. Approaches Economic supports for individuals and families can be strengthened by targeting household financial security and ensuring stability in housing during periods of economic stress. I Strengthening household financial security can potentially buffer the risk ofsuicide by providing individuals with the financial means to lessen the stress and hardship associated with a job loss or other unanticipated financial problems. The provision of unemployment benefits and other forms of temporary assistance, livable wages, medical benefits, and retirement and disability insurance to help cover the cost of necessities or to offset costs in the event of disability, are examples of ways to strengthen household financial security. I Housing stabilization policies aim to keep people in their homes and provide housing options for those in need during times of financial insecurity. This may occur through programs that provide affordable housing such as through government subsidies or through other options available to potential homebuyers such as loan modification programs, move-out planning, or financial counseling services that help minimize the risk or impact of foreclosures and eviction. Potential Outcomes 0 Reductions in suicide rates I Reductions in foreclosure rates - Reductions in eviction rates - Reductions in emotional distress 13 Evidence There is evidence suggesting that strengthening household financial security and stabilizing housing can reduce suicide risk. Strengthen household financial security. An examination of variations in U.S. unemployment benefit programs across states demonstrated that the impact of unemployment on suicide was offset in those states that provided greater than average unemployment benefits {Cylus, Glymour, 8i. Avendano, 2014). Another U.S. study examining the link between unemployment and suicide risk using suicide data, length of unemployment, and job losses found that the duration of unemployment, as opposed to just the loss of job, predicted suicide risk (Classen 8: Dunn, 2012). Together, these results suggest that not only should state unemployment benefit programs be generous in their financial allocations, but also in their duration. Other measures to strengthen household financial security transfer payments related to retirement and disability insurance, unemployment insurance compensation, medical benefits, and other forms of family assistance} have also shown an impact on suicide. A study by Flavin and Radcliff (2009] examined the impact of states? per capita spending on transfer payments, medical benefits, and family assistance (Temporary Assistance to Needy Families - TANF) and total state spending on suicide rates between 1990-2000, controlling for a number of suicide risk factors le.g., residential mobility, divorce rate, unemployment rate} at the state level. As per capita spending on total transfer payments, medical benefits, and family assistance increased there was an associated decrease in state suicide rates. Moreover, it wasn't spending in general that was associated with the reduction but spending on these types of assistance. In terms of lives saved, Flavin 8c Radcliff calculated the cost of reducing a state's suicide rate by a full point for the years studied. At the national level, they estimated that 3,000 fewer suicides would occur per year nationwide if every state increased its per capita spending on these types of assistance by $45 per year (Flavin 8: Radcliff, 2009}. Although this was a correlational study, the results demonstrate the potential benefits of policies that reach particularly vulnerable individuals during periods of great need and increased risk for suicide. More evaluation studies are needed to further understand the outcomes impacted by programs such as these. Housing stabilization policies. The National Neighborhood Stabilization Program was designed to help neighborhoods suffering from high rates of foreclosure and abandonment by slowing the deterioration ofthe neighborhoods and providing affordable housing options for low, moderate, and middle-income homebuyers. This program also offers financial assistance to eligible individuals for the purchase of a new home. Although this program has not been rigorously evaluated for its impact on suicide outcomes, it addresses foreclosure and eviction, which are 14 risk factors for suicide. A longitudinal analysis of annual data on suicides and foreclosures demonstrated that as the proportion of foreclosed properties increased in U.S. states, so did the state suicide rate, particularly among working-aged adults (Houle Light, 2014}. Another study of data from 16 US. states participating in the National Violent Death Reporting System found that suicides precipitated by home foreclosures and evictions increased more than 100% from 2005 (before the housing crisis began) to 2010 (after it had peaked; Fowler, Gladden, Vagi, Barnes, and Frazier (2015)). Most of these suicides occurred prior to the actual loss of the decedent?s home. These findings suggest that integrating suicide prevention resources, messaging, and referrals into financial, foreclosure, and move-out planning and counseling services may help to prevent suicide. 15 Strengthen Access to Mental Health Care Rationale While most people with mental health problems do not attempt or die by suicide [Olfson, Gerhard, Huang, 8: Stroup, 2015; Owens, 2002), and the level of risk conferred by different types of mental illness varies {Arsenault-Lapierre, Kim, 81 Turecki, 2004; E. C. Harris 8: Barraclough, 1997; Tyrer, Reed, 8t Crawford, 2015), previous research indicates that mental illness is an important risk factor for suicide (E. C. Harris 3: Barraclough, 1998; World Health Organization, 2014}. Studies suggest that up to 90% of people who die by suicide may have had a mental illness or substance abuse problem at the time of their deaths {Arsenault?Lapierre et al., 2004; Cavanagh, Carson, Sharpe, 8: Lawrie, 2003; Isometsa, 2001). State-level suicide rates have also been found to be correlated with general mental health measures such as depression (Lang, 2013; Mark, Shern, Bagalman, 8; Cao, 2007). Findings from the National Comorbidity Survey indicate that relatively few people in the U.S. with mental health disorders receive treatment for those conditions (Kessler et al., 2005). Lack of access to mental health care is one of the contributing factors related to the underuse of mental health services (Cunningham, 2009). Identifying ways to improve access to timely, affordable, and quality mental health care for people in need is a critical component to suicide prevention (World Health Organization, 2014}. Apart from the treatment benefits, it can also serve to normalize help-seeking behavior and increase the use of such services. Approaches One approach to strengthening access to mental health care is through the provision of mental health coverage in health insurance policies. 0 Coverage of mental health conditions in health insurance policies. Federal and state laws include provisions for equal coverage of mental health services in health insurance plans that is on par with coverage for other health concerns mental health parity). Benefits and services covered include such things as the number of visits, co-pays, deductibles, inpatientfoutpatient services, prescription drugs, and hospitalizations. If a state has a stronger mental health parity law than the federal parity law, then insurance plans regulated by the state must follow the state parity law. If a state has a weaker parity law than the federal parity law includes coverage for some mental health conditions but not others), then the federal parity law will replace the state law. Equal coverage does not necessarily imply good coverage as health insurance plans vary in the extent to which benefits and services are offered to address various health conditions. Rather it helps to ensure that mental health services are covered on par with other health concerns. Potential Outcomes I Increases in utilization of mental health services 16 I Reductions in of mental illnesses. I Reductions in rates ofsuicide attempts I Reductions in rates of suicide Evidence There is evidence suggesting that coverage of mental health conditions in health insurance policies can reduce risk factors associated with suicide and may directly impact suicide rates. I Coverage of mental health conditions in health insurance policies. The National Survey of Drug Use and Health is a nationally representative survey of the U.S. population that provides data on substance use, mental health conditions, and services utilization. Using data from this survey, K. M. Harris, Carpenter, and Bao (2006} found that 12 months after states enacted merited.l health parity lows, self-reported use of mental healthcare services significantly increased. Moreover, subsequent research by Lang (2013) examined state mental health laws and suicide rates between 1990 and 2004 and found that mental health parity laws, specifically, were associated with an approximate 5% reduction in suicide rates. This reduction, in the 29 states with parity laws, equated to the prevention of 592 suicides per year (Lang, 2013). 17 Create Protective Environments Rationale Prevention efforts that focus not only on individual behavior change help-seeking, treatment interventions) but on changes to the environment can increase the likelihood of positive behavioral and health outcomes (Haddon, 1980). Creating environments that address risk and protective factors where individuals live, work, and play, can help prevent suicide (Dahlberg 8i Krug, 2002; U.S. Office of the Surgeon General National Action Alliance for Suicide Prevention, 2012}. For example, rates of suicide and suicide attempts are elevated in certain occupational groups (Han et al., 2016; McIntosh et al., 2016], therefore, changes to the organizational culture in these occupations, by way of implementation of supportive policies or even physical modifications to the workplace environment, can change social norms, encourage help?seeking, and demonstrate that good health and mental health are valued and that stigma and other risk factors for suicide are not (K. L. Knox et al., 2010; National Action Alliance for Suicide Prevention Workplace Task Force, 2015). Similarly, modifying the characteristics of the environment to prevent harmful behavior such as access to lethal means can reduce suicide rates, particularly in times of crisis {Beautrais, Gibb, Fergusson, Horwood, 8i. Larkin, 2009; A.E. Crosby, Espitia- Hardeman, Ortega, 8i. Lozano, 2013; Kaplan et al., 2013; Miller, Warren, Hemenway, Azrael, 2015; C. W. Runyan et al., 2016}. Approaches The current evidence suggests three potential approaches for creating environments that protect against suicide. - Reducing access to lethal means among persons at-risk of suicide. Means of suicide such as firearms, hanging/suffocation, orjumping from heights provide little opportunity for rescue and, as such, have high case fatality rates about 85% of people who use a firearm in a suicide attempt will die from the injury]. Research also indicates that 1) the interval between thinking about and attempting suicide can be as short as 5 or 10 minutes (Deisenhammer et al., 2009; Simon et al., 2001) and 2) that people tend not to substitute a different method when a highly lethal method is unavailable or difficult to access {Hawton, 2007; Yip et al., 2012). Therefore, increasing the time interval between the thought and the suicide attempt, for example, by making it more difficult to access lethal means, can be lifesaving. The following are examples of approaches reducing access to lethal means for persons at-risk of suicide: 0 intervening or Suicide Hotsoots. Suicide hotspots, or places where suicides may take place relatively easily, include tall structures bridges and cliffs), railway tracks, and isolated locations such as parks. Efforts to prevent suicide at these locations include 18 erecting barriers to prevent jumping and installing signs and telephones to encourage individuals who are considering suicide, to seek help {Cox et al., 2013). 0 Safe Storage Practices. Safe storage of medications, firearms, and other household products can reduce the risk for suicide by separating individuals who may be vulnerable and/or impulsive from easy access to lethal means. Such practices may include education and counseling around storing firearms-- ocked in a secure place leg, in a gun safe or lock box], unloaded and separate from the ammunition-?and keeping medicines in a locked cabinet or other secure location awayfrom people who may be at risk or who have made prior attempts lRowhani-Rahbar, Simonetti, Rivara, 2016; C. W. Runyan et al., 2015i - Organizational policies and culture that promote protective environments may be implemented in places of employment. Such policies and cultural values may promote prosocial behavior asking for help}, skill building, changing social norms, referral and access to helping services mental health, substance abuse treatment, financial counseling), and encourage leadership support from the top down. Such policies and cultural shifts can positively impact organizational climate and morale and help prevent suicide and its related risk factors depression, social isolation) (National Action Alliance for Suicide Prevention Workplace Task Force, 2015]. - Community-based policies to reduce excessive alcohol use. Research studies in the United States have found that greater alcohol availability is positively associated with alcohol-involved suicides (Escobedo 8: Ortiz, 2002; Giesbrecht et al., 2015}. Policies to reduce excessive alcohol use broadly include zoning to limit alcohol outlet locations and density, taxes on alcohol, and bans on the sale of alcohol for individuals under the legal drinking age. These policies are important because acute alcohol use has been found to be associated with more than one-third of suicides and approximately 40% of suicide attempts {Cherpitel, Borges, 8L Wilcox, 2004). Potential Outcomes - Increases in safe storage of means - Reductions in suicide attempts Reductions in suicide deaths I Increases in help-seeking I Reductions in alcohol-related suicide deaths Evidence The evidence suggests that creating protective environments can reduce suicide and suicide attempts and increase protective behaviors. 19 Reducing access to lethal means among persons at-risk of suicide. A meta-analysis examining the impact of suicide hotspot interventions implemented in combination or in isolation, both in the US. and abroad, found associated reduced rates of suicide (Cox et al., 2013; Pirkis et al., 2015). For example, after erecting a barrier on the Jacques-Cartier bridge in Canada, the suicide rate from jumping from the bridge decreased from about 10 suicide deaths per year to about 3 deaths per year (Perron, Burrows, Fournier, Perron, Oueliet, 2013). Moreover, the reduction in suicides by jumping was sustained even when all bridges and nearby jumping sites were considered, suggesting little to no displacement of suicides to otherjumping sites {Perron et al., 2013). Further evidence for the effectiveness of bridge barriers was demonstrated by a study examining the impact of the removoi of safety barriers from the Grafton Bridge in Auckland, New Zealand. After removal of the barrier, both the number and rate of suicide increased fivefold (Beautrais, 2001; Beautrais et al., 2009}. Another form of means reduction involves implementation of safe storage practices. In a case- control study of firearm-related events identified from 37 counties in Washington, Oregon, and Missouri, and from 5 trauma centers, Grossman et al. (2005) found that storing firearms unloaded, separate from ammunition, in a locked place or secured with a safety device was protective of suicide attempts among adolescents. Further, a recent systematic review of clinic and community-based education and counseling interventions suggested that the provision of safety devices significantly increased safe firearm storage practices compared to counseling alone or compared to the provision of economic incentives to acquire safety devices on one?s own (Rowhani-Rahbar et al., 2016). Another program, The Emergency Department Counseiing on Access to Lethoi Means ED CALM), trained emergency clinicians in a large children?s hospital to provide lethal means counseling and safe storage boxes to parents of patients under age 18 receiving care for suicidal behavior. In a pre?post quality improvement project, Runyan et al (2016} found that at post-test (of the 55% of parents followed up, n=114j reported that all medications in the home were locked up as compared to fewer than 10% at the time of the initial emergency department visit. Among parents who indicated the presence of guns in the home at pre?test (Le. all (100%) reported guns were currently locked up at post-test (C. W. Runyan et al., 2016). Organizational policies and culture. Togetherfor Life is a workplace program of the Montreal Police Force implemented to address suicide among officers. Policy and program components were designed to foster an organizational culture that promoted mutual support and solidarity among all members of the Force. The program included training of supervisors, managers and all units to improve competencies in identifying suicidal risk and to improve use and awareness of existing resources. The program also included an education campaign to improve awareness and help-seeking (Mishara St Martin, 2012). Police suicides were tracked over 12 years and 20 compared to rates in the control city of Quebec. The suicide rate in the intervention group decreased significantly by 78.9% to a rate of 6.4 suicides per 100,000 population per year compared to an 11% increase in the control city (29.0 per 100,000] (Mishara 8: Martin, 2012]. Another example of this approach is the United States Air Force Suicide Prevention Program (AFSPP). AFSPP included 11 policy and education initiatives and was designed to change the culture ofthe Air Force surrounding suicide. The program uses leaders as role models and agents of change, establishes expectations for behavior related to awareness of suicide risk, develops population skills and knowledge education and training}, and investigates every suicide outcomes measurement}. The program represents a fundamental shift from viewing suicide and mental illness solely as medical problem and instead sees them as larger service- wide problems impacting the whole community (K. L. Knox, Litts, Talcott, Feig, 8; Caine, 2003). Using a time-series design to examine the impact of the AFSPP program on various violence- related outcomes, researchers found that the program was associated with a 33% relative risk reduction in suicide (K. L. Knox et al., 2003).The program was also associated with relative risk reductions in related outcomes including moderate and severe family violence (30% and 54%, respectively}, homicide and accidental death (K. L. Knox et al., 2003). A longitudinal assessment of the program over the period 1981 to 2008 (16 years before the 1997 launch of the program and 11 years post-launch) found significantly lower rates of suicide after the program was launched than before (K. L. Knox et al., 2010}. These effects were sustained over time, except in 2004, which the authors found was associated with less rigorous implementation in that year than in the other years (K. L. Knox et al., 2010}. - Community?based policies to reduce excessive alcohol use. While multiple policies to limit excessive use of alcohol exist, several studies on alcohol outlet density, specifically, suggest that measures to reduce alcohol outlet density can potentially reduce alcohol-involved suicides. Additionally, a longitudinal analysis of alcohol outlet density, suicide mortality, and hospitalizations for suicide attempts over 5 years in 581 California zip codes indicated that the density of bars, specifically, is related to suicide and suicide attempts, particularly in rural areas (Johnson, Gruenewald, 8a Remer, 2009}. Promote Connectedness 21 Rationale Sociologist, Emile Durkheim theorized in 1897 that weak social bonds, Le. lack of connectedness, are among the chief causes for suicidality (Durkheim, 1897/1951}. Connectedness is the degree to which an individual or group of individuals are socially close, interrelated, or share resources with others (Centers for Disease Control and Prevention, 2009). Social connections can be formed within and between multiple levels of the social ecology (Dahlberg 3L Krug, 2002}, for instance between individuals peers, neighbors, co-workers), families, schools, neighborhoods, workplace, faith communities, cultural groups, and society as a whole. Related to connectedness, social capitol refers to a sense of trust in one?s community and neighborhood, social integration, and also the availability and participation in social organizations (Beyer, Layde, Hamberger, 8t Laud, 2015; Muennig, Cohen, Palmer, 3.: Zhu, 2013}. Many ecological cross-sectional and longitudinal studies have examined the impact of aspects of social capital on depression depressive disorder, mental health more generally, and suicide. While the evidence is limited, existing studies suggest the pattern is towards a positive association between social capital measured by social trust, community/neighborhood engagement, and improved mental health. Connectedness and social capital together can serve to protect against suicidal behaviors by decreasing isolation, encouraging adaptive coping behaviors, increasing belongingness, personal value and worth all of which helps individuals to build resilience in the face of adversity. Connectedness can also provide individuals with better access to formal supports and resources, mobilize communities to meet the needs of its members and provide collective primary prevention activities to the community as a whole (Centers for Disease Control and Prevention, 2009]. Approaches Promoting connectedness among individuals and within communities through modeling peer norms and enhancing community engagement can protect against suicide. I Peer norm approaches seek to normalize protective factors for suicide such as help-seeking, reaching out and talking to trusted adults, and promote peer connectedness. These approaches typically target youth and are delivered in school settings but can also be implemented in community settings. I Community engagement activities. Community engagement is an aspect of social capital. Community engagement approaches may involve residents participating in a range of activities, including religious activities, community clean-up and greening activities, and physical exercise. These activities provide opportunities for residents to become more involved in the community and to connect with other community members, organizations, and resources, resulting in enhanced overall physical health, reduced stress, and decreased depressive thereby reducing risk of suicide. 22 Potential Outcomes Reductions in maladaptive coping attitudes and behaviors Increases in healthy coping attitudes and behaviors Increases in referrals for youth in distressed Increases help-seeking behaviors Increases in positive perceptions of adult support Evidence Current evidence suggests that peer norm approaches and community engagement can reduce risk factors associated with suicidal behaviors. Peer norm approaches. Evaluations show that programs such as Sources of Strength can improve school norms and beliefs about suicide that are created and disseminated by student peers. In a randomized controlled trial of Sources ofStrength conducted with 18 high?schools (6 metropolitan, 12 rural}, Wyman et al. (2010} found that the program improved adaptive norms regarding suicide among peer leaders, connectedness to adults, and school engagement. Peer leaders were also more likely than controls to refer a suicidal friend to an adult. For students, the program resulted in increased perceptions of adult support for suicidal youths, particularly among those with a history of suicidal ideation, and the acceptability of help-seeking behaviors. Finally, trained peer leaders also reported a greater decrease in maladaptive coping attitudes compared with untrained leaders (Wyman et al., 2010). More evaluation research is needed to examine whether these improvements in factors that protect against suicidal behavior translate into reduced suicidal behavior and suicide. Community engagement activities. A vacant lot greening initiative was undertaken in Philadelphia between 1999 and 2003. Local residents and community members worked together to green 4,436 lots (or 7.8 million square feet) in 4 areas ofthe city. Researchers found significant reductions in community residents? self-reported level of stress, which is a risk factor for suicide, and engagement in more physical exercise, a protective factor for suicide, than residents in control vacant lot areas. Other benefits included reductions in firearm assaults and vandalism {Branas et al., 2011). 23 Teach Coping and Problem-Solving Skills Rationale Building life skills prepares individuals to successfully tackle every day challenges and adapt to stress and adversity. Life skills encompasses many concepts, but most often include coping and problem-solving skills, conflict resolution, and critical thinking. Life skills are important in shielding individuals from suicidal behaviors {World Health Organization, 2014]. Suicide prevention programs that focus on life and social skills training are drawn from social cognitive theories {Bandura, 1986), surmising that suicidal behavior is attributed to either direct learning and modeling or environmental and individual hopelessness) characteristics. The literature linking life skills and suicide is robust. The inability to employ adequate strategies to cope with immediate stressors or identify and find solutions for problems has been characterized among suicide attempters (Pollock E: Williams, 2004). Treatments that include bolstering skills (Goldsmith, Pellmar, Kleinman, 8t Bunney, 2002land include problem-solving techniques {Ghahramanlou-Holloway, Bhar, Brown, Olsen, Beck, 2012; Townsend et al., 2001} appear to reduce suicidal ideation and attempts more effectively. Prevention programs focused on teaching these skills target youth, parents and families and have been used with both universal and at-risk populations. While many do not target suicidal behaviors directly, these programs strive to train youth and parents in important life skills to offset the underlying vulnerabilities that contribute to engaging in high-risk behaviors early in life. Approaches Current evidence provides support for the following two approaches: . Social emotional learning programs focus on developing and strengthening communication and problem-solving skills, emotion regulation, conflict resolution, help seeking and coping skills. These approaches address a range of risk and protective factors for suicidal behavior. They provide children and youth with skills to resolve problems in relationships, school, and with peers, and help youth to address other negative influences le.g., substance use} associated with suicide. These approaches are typically delivered to all students in a particular grade or school, although some programs also focus on groups of students considered to be at high risk for suicide. Opportunities to practice and reinforce skills are an important part of programs that work (Herman, Borden, Reinke, El. Webster-Stratton, 2011). - Parenting skill and family relationship programs are designed to strengthen parenting skills, enhance positive parent-child interactions, and improve children?s behavioral and emotional skills and abilities. Several parenting and family relationship programs have been shown in rigorous evaluations to improve resilience and reduce risk factors for various behaviors, including 24 ones closely related to suicide, such as depression, internalizing behaviors, and substance abuse (M. S. Knox, Burkhart, 81 Hunter, 2010). Potential Outcomes Reductions in suicide attempts and suicide ideation I Improvements in knowledge of risk and protective factors associated with suicide 0 Reductions in suicide risk behaviors depression, anxiety, conduct problems, substance abuse) . Improvements in help-seeking behavior 0 Improvements in social competence and emotional regulation skills - Improvements in problem-solving and conflict management skills Evidence There are several programs with evidence that support teaching social, emotional and parenting skills to reduce suicidal behaviors and associated risk factors. Social emotional learning programs. The Youth Aware of Mental Health Program (YAM) is a program developed for teenagers aged 14-16 that uses interactive dialogue and role-playing to teach adolescents about the risk and protective factors associated with suicide (including knowledge about depression and anxiety} and enhances their problem-solving skills for dealing with adverse life events, stress, school and other problems. The program includes three hours of role-play sessions and interactive workshops combined with a booklet that students can keep, educational posters displayed in classroom, and interactive lectures about mental health at the beginning and end of the program (Wasserman et al., 2014). In a cluster- randomized controlled trial conducted across 10 European Union countries and 168 schools, students in schools randomized to YAM were significantly less likely to attempt suicide and have severe suicidal ideation at the 12-month follow-up compared to students in control schools which received educational materials and care as usual. Overall, the relative risk of youth suicide attempts among the YAM group was reduced by over 50%_demonstrating that out of 1000 students, five attempted suicide in the YAM group compared to 11 in the control group. Additionally, related to severe suicide ideation, in the YAM group absolute risk fell by 0.50% and relative risk fell by 49.6% {Wasserman et al., 2014]. Signs ofSur'cia'e {505) is another school-based prevention program for students aged 13-17. The program includes guided classroom discussions about suicide and depression. As part of the program, students are screened for depression and suicide risk and referred for professional help as indicated. The program is designed to increase knowledge about suicide and risk factors associated with suicidal behavior as well as improve and normalize help- 25 seeking behavior (Schilling, Aseltine, 81 James, 2016). In a randomized controlled trial, 505 was shown to reduce self-reported suicide attempts at 3-months post intervention among participating students compared to control students. The SOS program also increased students? knowledge of how to get help for themselves or friends for depression andfor suicidal thoughts, and favorable attitudes toward help-seeking. SOS participants with a lifetime history of suicide attempt were also less likely to report planning a suicide in the 3 months following the program compared to lower-risk participants {Schilling et al., 2016). Finally, the Good Behavior Game {666) is a classroom-based program for elementary school children aged 6-10. The program uses a team-based behavior management strategy that promotes good behavior by setting clear expectations for good behavior and consequences for maladaptive behavior. The goal of the 636 is to create an integrated classroom social system that is supportive of all children being able to learn with little aggressive or disruptive behavior (Wilcox et al., 2008). Two cohorts of youths participated in the program in 1985-85 and 1986-86 school years when they were in the first and second grades. A number of proximal and distal outcomes were assessed among the two cohorts over time. With respect to distal suicide-related outcomes, an outcome evaluation of the EEG indicated that individuals in the first cohort who were assigned to participate in 636 when they were in the first grade reported half the adjusted odds of suicidal ideation and suicide attempts when assessed approximately 15 years later, between the ages of 19 to 21, compared to peers who had been in a standard classroom setting. The beneficial effect ofthe program was consistent for suicidal ideation regardless of whether baseline covariates were included. The 636 effect on attempts was less robust in some adjusted models including caregiver mental health. In the second cohort of 686 students, neither suicidal ideation nor suicide attempts were significantly different between 636 and the control interventions (Wilcox et al., 2008}. The researchers believed this may have been due to a lack of implementation fidelity and pointed to the need for (336 to be delivered with precision, consistency, and teacher support. 636 was also found to be associated with reduced risk of later substance abuse, a risk factor for suicide [Kellam et al., 2008). Parenting skill and family relationship programs. Parenting and family skills training approaches have shown promising impacts in preventing key risk factors associated with suicide. For example, the incredible Years (W) is a comprehensive group training program for parents, teachers and children designed to reduce conduct and substance abuse problems, two important suicide risk factors, in youth by improving protective factors such as responsive and positive parent-teacher-child interactions and relationships, emotion self-regulation and social competence (all protective factors for suicide} [Herman et al., 2011). The program includes 9- 20 sessions offered in community-based settings religious, recreation 26 centers, mental health treatment centers, and hospitals). Several studies have demonstrated the effect of the 0? program on reducing internalizing such as anxiety and depression, and child conduct problems (C. H. Webster-Stratton, Reid, Beauchaine, 2011; Webster-Stratton, iamila Reid, 8: Stoolmiller, 2008). The program is also associated with improved problem-solving and conflict management; these skills were maintained at 1-year follow-up (Reid, Webster-Stratton, 8: Hammond, 2003; C. Webster?Stratton Hammond, 1997?; C. Webster-Stratton, Reid, Hammond, 2001). The program demonstrated greater benefits as the dosage of the intervention increased (Herman et al., 2011). Additionally, Strengthening Families 10-14 is a program that involves sessions between parents, youth, and family with the goal of improving parents? skills for disciplining, managing emotions and conflict, and communicating with their children; promoting youths? interpersonal and problem-solving skills; and creating family activities to build cohesion and positive parent-child interactions. The premise of the program is that developing these skills for both parents and children will reduce internalizing behavior and adolescent substance abuse, two important risk factors for suicide (Spoth, Guvll, E: Dav, 2002). Strengthening has been shown to significantly decrease externalizing behaviors, such as aggression, alcohol use, and drug use among youth participants, as well as reduce depression, alcohol use, and drug use among participating families (Spoth et al., 2002). 27 Identify and Support People At-Risk Rationale In order to decrease suicide, attention to people at increased risk is necessary, as these individuals tend to experience suicidal behavior at higher than average rates. These vulnerable or disadvantaged populations include, but are not limited to, individuals with lower socio?economic status or who are living with a mental health problem; people who have attempted suicide previously; individuals who are institutionalized, have been victims of violence, or are homeless; and members of certain racial and ethnic minority groups. Supporting these vulnerable groups requires proactive case finding along with access to, and retention in, mental health services. Finding effective ways of identifying at-risk or vulnerable groups, customizing services to make them accessible and engaged in care remain key challenges. For example, simply improving services does not guarantee that those services will be used by those most in need of them, nor will it necessarily increase the number of people who follow treatments that are recommended. People who are disadvantaged face social and economic issues that may adversely affect their ability to respond to the treatments or advice that are offered. Approaches The following three approaches focus on identifying and supporting people at increased risk. a Gatekeeper training is designed to train teachers, coaches, providers and others in the community to identify people who may be at risk of suicide and to respond effectively, including facilitating treatment seeking and support services. Gatekeeper training is typically implemented in schools to identify at?risk youth and within health care settings to identify adults (and youth). I Screening combined with care management and overall continuity of care has been used in primary care and behavioral health care settings to assure that people who may be at high-risk of suicide are identified and receive ongoing treatment as needed, particularly after inpatient discharge and other transitions within the healthcare system so they don?t 'slip through the cracks?. These approaches typically employ screening for depression andfor suicide combined with collaborative treatment planning between patients and their providers and patient follow- up. In Crisis intervention. These approaches provide support and referral services, typically by connecting a person in crisis (or a friend or family member of someone at-risk) to trained volunteers or professional staff via telephone hotline, online chat, or text messaging. Crisis intervention approaches are intended to impact key risk factors for suicide, including feelings of depression, hopelessness, and subsequent mental health care utilization. Like means reduction, 28 crisis interventions can put space or time between an individual who may be considering suicide and harmful behavior. Potential Outcomes - Reductions in suicide attempts I Reductions in suicide deaths 0 Increases in identification of individuals at-risk for suicidal behavior I Increases in at?risk individuals in treatment I Increases in community members trained to identify at-risk individuals I Increases in referrals for health care Evidence The current evidence suggests that identifying people at risk of suicide and the continued provision of support for these individuals can positively impact both suicide risk factors as well as suicide mortality. Gatekeeper training. One example of gatekeeper training is the Mental Health First Aid program. This program is designed for the lay public and consists of three weekly sessions of three hours each. Participants learn the of people in mental health crises and/or in the early stages of mental health problems those experiencing suicidal thoughts and behavior, acute stress reaction, panic attacks and acute behavior, and depression, anxiety, and disorders), possible risk factors, and where and how to get effective help {Kitchener Jorm, 2004}. In a randomized controlled trial of 301 participants of MHFA, the intervention group, compared to the wait-listed control group, reported at 5 months follow-up, significantly greater feelings of confidence in helping someone (74.5% vs. 57.4%, greater likelihood of encouraging people to seek professional help (29.4% vs. 16.8%, improved agreement with health professionals about treatments and decreased stigmatizing attitudes towards mental illness Additionally, the intervention resulted in improved overall mental health ofthe participants themselves However, the percent who provided some or a lot of help did not differ between groups (Kitchener &Jorm, 2004). Additional research rigorously evaluating MHFA for its impact an intervention recipients? suicidal behavior is needed {Kitchener 8: Jorm, 2006). Gatekeeper training has also been a primary part of all Garret Lee Smith (GL5) Suicide Prevention Program which is in place in 49 states and 48 tribes. A multi-site evaluation assessed the impact of community gatekeeper training on suicide attempts and deaths by comparing the change in suicide rates and nonfatal suicidal behavior among young people aged 10-24 in counties 29 implementing GL5 trainings, with the trajectory observed in similar counties that did not CommenuAt: The extra paramheticaig implement these trainings. Counties that implemented (315 trainings had significantly lower *1 "0t ?BEES-?raili- ?lm 35 youth suicide rates one year following the training implementation [Walrath, Garraza, ?eld, :1 per voumsi?amw'm al" Goldston, Sr McKeon, 2015]. This finding equates to a decrease of 1 suicide death per 100,000 fl Gamma?! Ml: Done. among youth ages 10 to 2a, or the prevention of approximately 23? deaths in the age group, i between 2007 and 2010. Counties implementing GL5 program activities, including gatekeeper ,1 training, also had significantly lower suicide attempt rates among youth ages 15 to 23 in the year if" following implementation of the GL5 program than did similar counties that did not implement 615 activities 9 fewer attempts per 1000 brouthsk? Godoy_ Garraza, Walrath, Goldston, Reid, 0: i" McKeon, 2015). More than '29, 000 suicide attempts may have been prevented during the period examined, following implementation of the (315 program. Screening combined with care management and overall continuity of care. The Henry Ford healthcare system is a large health maintenance organization in the state of Michigan. Henry Ford's Perfect Depression Care program was the precursor to what is now called Zero Suicide, and its overall goal was to eliminate suicide among its members. More broadly, the goal of the program was to redesign delivery of depression care to achieve ?breakthrough improvement? in quality and safety by focusing on effectiveness, safety, patient centeredness, timeliness, efficiency, and equity among patients. The program screened and assessed each patient for suicide risk and implemented coordinated continuous follow-up care system wide (C. E. Coffey, 2006). An examination of the impact of the program found that there was a dramatic and statistically significant decrease in the rate of suicide between the baseline years, 1999 and 2000, prior to the intervention to the intervention years, 2002?2009. During this time period, the suicide rate fell by 32% (C. E. Coffey, 2006; C. E. Coffey, Coffey, E: Ahmedani, 2013). Further, among HMO members who received mental health specialty services, the suicide rate significantly decreased over time from 1999 to 2010 [110.3 to 47.6 per 100,000; p<.04l with a mean of 36.2 per 100,000 over the period. Additionally, for those HMO members who accessed only general medical services as opposed to specialty mental health services, the suicide rate increased from to 5.6 per 100,000 Similarly, in the state of Michigan, rates ofsuicide in the general population increased over the period from 9.8 to 12.5 per 100,000 (p<.001} Coffey, Coffey, 8: Ahmedani, 2015]. Crisis intervention. Suicide prevention hotlines are one way to provide crisis intervention. In an evaluation of the effectiveness of the Notionoi Suicide Prevention tifeiine to prevent suicide, 1,085 suicidal individuals who called the hotline completed a standard risk assessment for suicide, and 380 of those completed a follow-up assessment between 1 and 52 days (mean=13.5 days] after the initial assessment. Researchers found that over half of the initial sample vvere seriously considering suicide when they called, and they had a plan for their suicide. 30 Researchers also found that among follow-up participants, there was a significant decrease in pain, hopelessness, and intent to die between initiation of the call [time 1) to follow-up (time 3). Between time 2 (end of the call) to time 3, the effect remained for pain and hopelessness, but was not significant for intent to die (Gould, Kalafat, Harrismunfakh, 81 Kleinman, 2007). in another study, this time employing a randomized controlled trial, Gould, Cross, Pisani, Munfakh, and Kleinman (2013) assessed the impact of the Applied Suicide intervention Training a widely implemented training program that helps hotline counselors, emergency workers, and other gatekeepers to identify and connect with suicidal individuals, understand their reasoning for living and dying, and assist with safely connecting those in need to available resources. The training was evaluated across the NSPL network of hotlines over the period 2008-2009 (Gould et al., 2013). Using data from 1,410 suicidal individuals who called 17 Lifeline centers, the researchers found that compared to callers who spoke to counselors that received the usual care training, individuals who spoke with counselors without training in ASIST were significantly more likely to feel depressed, suicidal, more overwhelmed, and less hopeful by the end of their call to the hotline compared to those with training in Counselors trained in were also more skilled at keeping callers on the phone longer and establishing a connection with them. However, training in did not result in more comprehensive suicide risk assessments than usual care training (Gould et al., 2013). 31 Intervene to Lessen Harms and Prevent Future Risk Rationale Individuals who have experienced mental health challenges, suicidal ideation, who have made suicide attempts or engaged in non-suicidal self-injury are at increased risk of suicide Office ofthe Surgeon General 81 National Action Alliance for Suicide Prevention, 2012). Risk ofsuicide can also increase among those who have lost a friend, family member, co-worker, or other acquaintance to suicide (Pitman, Osborn, King, 8: Erlangsen, 2014}. Exposure to sensationalized or uninformed reporting regarding on suicide may heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion (Etzersdorfer Sonneck, 1998; Niederkrotenthaler Sonneck, 2007). Approaches There are a number of approaches that can be used to lesson harms and reduce future risk of suicide including various therapeutic treatments and approaches providing continuity of care, caring for the bereaved, and safe messaging around suicide. In Treatment for people at-risk of suicide typically includes various forms of delivered by licensed providers to help individuals with mental health problems and other risk factors for suicide with problem-solving, impulsivity and emotion regulation. Treatment usually takes place in a one on one or group format between patients and clinicians in mental healthcare settings and can vary in duration from several weeks to ongoing therapy for years in some cases. a Treatment to prevent re-attempts. These approaches typically include follow-up contact and use diverse modalities home visits, mail, telephone, e-mail) to engage recent suicide attempt survivors in continued treatment to prevent re-attempts. Treatment may focus on improved coping skills, mindfulness, and other emotional regulation skills, and may include case management home visits to increase adherence to treatment and continuity of care; and one- on-one interpersonal therapy and/or group therapy. Approaches that engage and connect attempters to peers and providers are especially important because many attempters do not present to aftercare; 1296-2596 reattempt within a year, and 396-996 of attempt survivors die by suicide within 1 to 5 years of their initial attempt {lnagaki et al., 2015) I Postvention approaches are implemented offer a suicide has taken place and may include debriefing sessions, counseling, and/'or bereavement support groups for surviving friends and family members/loved ones. These programs have not typically been evaluated for their impact on suicide or suicidal behavior but may reduce survivors? guilt, feelings of depression, and complicated grief (Szumilas 8: Kutcher, 2011}. 32 Safe messaging following a suicide. The manner in which information on a recent suicide is communicated to the public school assemblies, mass media, social media) can heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion. Therefore, responsible and safe reporting may help prevent suicide and suicide contagion. Potential Outcomes I Reductions in mental health-related sequelae 0 Increases in connectedness - Improvements in coping skills 0 Improvements in messaging following suicide - Reductions in re-attempts I Reductions in contagion effects related to suicide Evidence Current evidence suggests that therapeutic treatments and other approaches for lessening harm can impact risk and protective factors for suicide. Treatment for people at?risk of suicide. One example of a treatment with evidence of impact on risk and protective factors for suicide is the improving Mood Promoting Access to Collaborative Treatment program. aims to prevent suicide among older primary care patients by reducing suicide ideation and depression in primary care settings. It facilitates the development of a therapeutic alliance, a personalized treatment plan that includes patient preferences, as well as proactive follow-up (biweekly during an acute phase and during continuation phase) by a depression care manager (Hunkeler et al., 2006}. The program has been shown to significantly improve quality of life, and to reduce functional impairment, dapression and suicidal ideation over 24-months of follow-up (Hunkeler et al., 2006; Unutzer et al., 2006) relative to patients who received care as usual. Another example is Collaborative Assessment and Management ofSuicidaiity (CAMS), which is a therapeutic approach for suicide-specific assessment and treatment of patient?s suicide risk. This flexible approach can be used across treatment settings and clinician theoretical orientations and involves the clinician and patient working together in an interactive assessment process to develop patient-specific treatment plans. CAMS sessions are collaborative and involve constant patient input about what is and is not working with the ultimate goal of enhancing the 33 therapeutic alliance and increasing treatment motivation in the suicidal patient. CAMS been tested and supported in 6 correlational studies lJobes, 2012), in a variety of inpatient and outpatient settings and in one RCT with several additional RCTs under way. CAMS has been associated with significant improvements in suicidal ideation, overall distress, and feelings of hopelessness at 12 month follow-up among a community-based sample of suicidal outpatients. {Comtois et al., 2011). Other examples include Dialectical Behavioral Therapy (DST) and Attachment-Based Family Therapy a multicomponent therapy for individuals at high risk for suicide and who may struggle with impulsivity and emotional regulation. The components of 087' include individual therapy, group skills training, between-session telephone coaching and a therapist consultation team. In a randomized controlled trial of women with recent suicidal or self- injurious behavior, those receiving DBT were half as likely to make a suicide attempt at two-year follow-up than women receiving community treatment {23% vs required less hospitalization for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined (Linehan et al., 2006}. ABFT is a program for adolescents aged 12-18 and is designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety (Diamond et al., 2010). A randomized controlled trial of ABFT found that suicidal adolescents assigned to ABFT experienced significantly greater improvement in suicidal ideation over 24 weeks of follow-up than did adolescents assigned to enhanced usual care. Additionally, a significantly higher percentage participants reported no suicidal ideation in the week prior to assessment at 12 weeks than did adolescents receiving enhanced usual care {69.2% vs. 34.6%) and at 24 weeks {82.1% vs. 46.2%) (Diamond et al., 2010). Treatment to prevent re-attempts. Several strategies that aim to prevent re-attempts have demonstrated impact on reducing suicidal behavior. For example, Emergency Department Brief intervention with Follow-up Visits is a program that involves a one-hour discharge information session that addresses suicidal behavior, distress, risk and protective factors, alternatives to suicidal behavior, and referral options, combined with nine follow-up contacts over 18 months (at 1, 2, 4, 7, 11 weeks and 4, 6, 12, 18 months). Follow-up contacts are either conducted by phone or through home visits according to a specific time line for up to 18-months. A randomized controlled trial that enrolled suicide attempters from eight hospital emergency departments in five countries (Brazil, India, Sri Lanka, lran, and China) found that a brief intervention combined with 9 follow-up visits over 18-months was associated with significantly fewer deaths from suicide relative to a treatment-as-usual group versus respectively) (Fleischmann et al., 2008). 34 Another example of treatment to prevent re-attempts involves active follow-up contact approaches such as postcards, letters, and telephone calls intended to increase a patient?s sense of connectedness with health care providers and decrease isolation. These approaches include expression of care and support and typically invite patients to reconnect with their provider. Contacts are made periodically or every few months in the first 12 months post- discharge with some programs continuing contact for two or more years). In a meta-analysis conducted by lnagaki et al. {2015), interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for suicide attempt were found to reduce reattempts by approximately 17% for up to 12 months post-discharge; however, the effects of these approaches beyond 12 months on reattempts has not yet been demonstrated. Also, because the number of trials and associated sample sizes included in this meta-analysis were small, it was not possible to determine the effect of active contact and follow-up approaches on death by suicide. in a randomized controlled trial of the post-crisis suicide prevention long-term follow-up contact approach, Motto and Bostrom (2001} found that patients who refused ongoing care but who were randomized to be contacted by letter four times per year had a lower rate of suicide over two years of follow-up than did patients in the control group who received no further contact. Other studies have also shown post-crisis letters and coping cards to be protective against suicide ideation and attempts {Hassanian-Moghaddam, Sarjami, Kolahi, 8c Carter, 2011; Wang et al., 2016i Finally, Cognitive Behavior Therapy for Suicide Prevention (CST-5P) is an example of a therapeutic approach to prevent re-attempts. It uses a risk-reduction, relapse prevention approach that includes an analysis of proximal risk factors and stressors relationship problems, school or work-related difficulties) leading up to and following the suicidal event; safety plan development; skill building; and CRT-5P also has family skill modules focused on family support and communication patterns as well as improving the family?s problem solving skills. A randomized controlled trial of found that 10-session outpatient cognitive therapy designed to prevent repeat suicide attempts resulted in a 50% reduction in the likelihood of a suicide reattempt among adults who had been admitted to an emergency department for a suicide attempt relative to treatment as usual (Brown et al., 2005). Postvention programs are implemented with the goal of providing support to survivors of others' suicide to reduce their own risk of suicide. One example of a postvention program, StandBy Response Service (StandBy), provides clients with face-to-face outreach and telephone support through a professional crisis response team. Site coordinators develop customized case management plans, referring clients to other existing community services matched to their needs {Vissen Comans, 81 Scuffham, 2014). In a study by Visser et al. (2014), StandBy clients were significantly less likely to be at high risk for suicidality than a suicide bereaved comparison group 35 who had not had contact with the StondBy program {48% and 64% respectively). Additionally, research suggests that active postvention approaches in which outreach to suicide survivors occurs at the scene of a suicide is associated with intake into treatment sooner, greater attendance at support group meetings, and attendance at more meetings compared to passive postvention (versus passive approaches where survivors self-refer for services) lJ. Cerel 31 Campbell, 2008). Safe messaging following a suicide. Safe messaging after a suicide can help assure that reporting of the event is done in such a way to reduce risk to consumers of news media and other messaging who may be particularly vulnerable. One way to ensure safe messaging following a suicide is to encourage that reporters adhere to Recommendations for Reporting on Suicide Reports that are both inclusive of suicide prevention messages, stories of hope and resilience, risk and protective factors, and links to helping resources hotline) and that avoid sensationalizing events or reducing suicide to one cause can help reduce the likelihood of suicide contagion. The most compelling evidence supporting these recommendations for reporting comes from Austria. After a sharp increase in suicides on the Viennese subway, media guidelines were introduced and an interrupted time series design was used to evaluate the nationai impact of the guidelines on subsequent suicides. Changes in the quality and quantity of media reporting resulted in a nationwide significant reduction of 81 suicides annually (Niederkrotenthaler 8i. Sonneck, 200?}. Finally, research suggests that not only does reporting on suicide in a negative way reporting on suicide and repetition} have harmful effects on suicide, but reporting on positive coping skills in the face of adversity can also demonstrate protective effects against suicide (Niederkrotenthaler et al., 2010). Reports of individual suicidal ideation not accompanied by reports ofsuicide or suicide attempts, along with reports describing a ?mastery" of a crisis situation where adversities were overcome, was associated with significant decreases in suicide rates in the time period immediately following such reports (Niederkrotenthaler et al., 2010). 36 Sector Involvement Public health can play an important and unique role in addressing suicide. Public health agencies, which typically place prevention at the forefront of efforts and work to create broad population-level impact, can bring critical leadership and resources to bear on this problem. For example, these agencies can serve as a convener, bringing together partners and stakeholders to plan, prioritize, and coordinate suicide prevention efforts. Public health agencies are also well positioned to collect and disseminate data, implement preventive measures, evaluate programs, and track progress. Although public health can play a leadership role in preventing suicide, the strategies and approaches outlined in this technical package cannot be accomplished by the public health sector alone. As noted in the National Strategy to Prevent Suicide, the integration and coordination of prevention activities across sectors and settings is critical for expanding the reach and impact of suicide prevention efforts. Other sectors vital to implementing this package include, but are not limited to, education, government (local, state, and federal), social services, health services, business, labor, justice, housing, media, and organizations that comprise the civil society sector such as faith-based organizations, youth-serving organizations, foundations, and other non-governmental organizations. Collectively, these sectors can make a difference in preventing suicide by impacting the various contexts and underlying risks that contribute to suicide. The strategies and approaches described in this technical package are summarized in Appendix A along with the relevant sectors that are well positioned to lead implementation efforts. For example, business and labor, health care insurers and providers, and government entities are in the best position to implement programs and policies that Strengthen Economic Supports and Access to Mental Health Care. These types of supports go beyond individual behavior change and require commitment and support from those sectors that can directly address some of the underlying risks and the environmental contexts that increase the risk for suicide. Public health entities can play an important role by gathering and information to inform policy, raise awareness, and evaluate the effectiveness of various policies. Moreover, partnerships with non-governmental and community organizations can be instrumental in increasing awareness of and garnering support for policies affecting individuals and families. The public health sector has been atthe forefront of many community-based prevention efforts, working collaboratively with schools and community-based organizations, to change social norms and positively impact health behavior. Public health is well suited to take on a similar leadership role in Promoting Connectedness through peer norm and community engagement activities and supporting the development, evaluation, and adoption of effective programs that Teach Coping and Problem-Solving Skills to prevent suicide from happening in the first place. These programs are often delivered in school and community settings, making education and non-governmental organizations vital partners in prevention. 37 Businesses, workplaces, and local and state government entities, on the other hand, are in the best position to establish policies and support practices that Create Protective Environments where people live, work, and play. Public health entities can play an important role by gathering and information, working with other agencies within the executive branch of their state or local government in support of policy and other approaches, and evaluating the effectiveness of measures taken. In a similar fashion, public health entities can partner with schools, workplaces, and community organizations to implement and evaluate prevention programs, policies and practices geared toward creating safe, healthy, and supportive environments. Finally, this technical package includes a number of interventions delivered in hospital, primary care, behavioral health care, and community settings designed to identify and Support People At?Risk and to Lessen Harms and Prevent Future Risk. The intensity and activities of these interventions require the expertise of professionals who are licensed and trained to deliver critical intervention support. The health care, social services, and justice sectors can work collaboratively to support individuals at high- risk for suicide and their families. These activities also require coordination of supports across various service providers and community organizations. Regardless of strategy, action by many sectors will be necessary for the successful implementation of this package. In this regard, all sectors can play an important and influential role in preventing suicide from happening in the first place and lessening the immediate and long-term harms of suicidal behavior by helping those in times of crisis get the services and support they need. 38 Monitoring and Evaluation Monitoring and evaluation are necessary components of the public health approach to prevention. It is important to have timely and reliable data to monitor the extent of the problem and to evaluate the impact of prevention efforts. Data are necessary for program implementation as planning, implementation, and assessment all rely on accurate measurement of the problem. Surveillance data helps researchers and practitioners track changes in the burden of suicide. Surveillance systems exist at the federal, state, and local levels. It is important to assess the availability of surveillance data and data systems across these levels to identify and address gaps in the systems. CDC's National Vital Statistics System and the National Violent Death Reporting System are examples of surveillance systems that provide data on deaths from suicide. for example, is a state-based surveillance system that combines data from death certificates, law enforcement reports, and coroner or medical examiner reports to provide detailed information on the circumstances of violent deaths, including suicide, which can assist communities in guiding prevention approaches (Blair, Fowler, Jack, 8; Crosby, 2016}. The National Electronic Injury Surveillance System?All Injury Program provides nationally representative data about all types and causes of nonfatal injuries treated in U.S. hospital emergency departments, and can be used to assess national rates of, and trends in, self-harm injuries by cause falls, poisoning, etc.), age, race/ethnicity, sex, disposition {where the injured person goes when released from the Emergency Department). In addition to information on deaths and nonfatal injuries, there are also surveillance systems that provide national, state, and some local estimates of suicidal behavior. The Youth Risk Behavior Surveillance System collects information from a nationally representative sample of 9-12 grade students and is a key resource in monitoring health-risk behaviors among youth, including whether youth have seriously considered attempting suicide, attempted suicide, made a plan, or required treatment by a doctor or nurse for a suicide attempt that resulted in an injury, poisoning, or overdose (Brener et al., 2013). The data are obtained from a national school-based survey conducted by CDC as well as from state, territorial, tribal, and large urban school district surveys conducted by education and health agencies. The National Survey on Drug Use and Health (NSDUH) is an annual survey of the civilian, non- institutionalized population aged 12 years and older. NSDUH provides both national and state-level estimates of substance use (alcohol, tobacco, illicit drugs, and non-medical use of prescription drugs); mental health (past year mental illness, co-occurring illnesses); and service utilization, along with suicide ideation, suicide plans, and suicide attempts. NSDUH is a key resource to track trends in suicide-related risk factors in the population and to help identify groups at increased risk. It is also important at all levels (local, state, and federal) to address gaps in responses, track progress of prevention efforts and evaluate the impact of those efforts, including the impact of this technical package. Evaluation data, produced through program implementation and monitoring, is essential to provide information on what does and does not work to reduce rates of suicide and its associated risk 39 Comment IAI: This is a verv long sentence. Suggest breaking it up a bit. I also don?t believe we will be able to keep the piece about funding as we can't specificallv call for funding. [Comment Tried to tighten the sentence up further, and protective factors. Theories of change and logic models that identifv short, intermediate, and long- term outcomes are an important part of program evaluation. The evidence-base for suicide prevention has advanced greatlv over the last few decades. However, additional research is needed to understand the impact of programs, policies, and practices on suicide {and suicide attempts, at a minimum], as opposed to merelv examining their effectiveness on risk factors. More research is also needed to examine the effectiveness of primary prevention strategies {before risk occurs} and communitv-Ievel strategies to prevent suicide at the population level. Lastly, it will be important for researchers to test the effectiveness of combinations of the strategies and approaches included in this package. Most existing evaluations focus on approaches implemented in isolation, but there is potential to understand the synergistic effects within a comprehensive prevention approach. Conclusion Suicide is a serious public health problem whose rates have been on the rise for more than a decade and whose costs stretch well into the billions of dollars each year. While suicide is a rare outcome statisticallv, if its human impact has a ripple effect that is far?reaching. Each of us likelv interacts with suicide survivors, l. those with lived experience, and those with thoughts of suicide, on a dailv basis--at home, at work, and l: in our communities. Suicide and suicide attempts are therefore public health issues of societal concern. Fortunatelv, like manv public health problems, suicide is preventable, and more is being done to preVent suicide than ever before, as evidenced by the work of the National Action Alliance for Suicide Prevention, the release of the ?rst world report on suicide, and more timely surveillance data, to name just a few examples. [Unfortunatelv, suicide prevention is impeded by barrlers including: stigma related to help? seeking, mental illness, being a survivor, or someone with lived experience; fear related to asking about suicidal thoughts, hesitation to take up strategies known to be effective but perhaps unpopular; misinformation about suicide preventabilitv, harmful messaging about suicide, and disproportionate =15: funding given its public health burden] In an effort to continue pushing the field and society' further towards prevention, this technical package. includes strategies and approaches that ideallv would be used in a comprehensive, multi-Ievel and multi- sectoral way. This technical package includes strategies and approaches to prevent suicide from occurring in the first place, as well as strategies focused on lessening the immediate and long-te rm harms ofsuicidal behavior. It includes strategies that range from a focus on the whole population regardless of risk to strategies designed to support people at highest risk. lrnportantlv, this technical package extends the bounds of the tvpical prevention strategies to consider approaches that go beyond individual behavior change to better address risk factors impacting communities and populations more broadly policies to stabilize housing and communitv engagement initiatives]. 40 While the evidence base continues to emerge, the collection of programs, policies, and practices laid out here are available for implementation now. And in keeping with good public health practice, the intent is that monitoring and evaluation will play a key role in that implementation. 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When work disappears: The worid of the new urban poor: Vintage. 48 World Health Organization. (2014). Suicide Prevention: A Global imperative. Geneva, Switzerland: WHO Press. Wyman, P. A, Brown, C. H., LoMurrav, M., K., Petrova, M., Yu, (1., . . . Wang, W. (2010). An outcome evaluation ofthe Sources of Strength suicide prevention program delivered by adolescent peer leaders in high schools. Am Public Health, 100(9), 1653-1661. doi: Yip, P., Caine, E., Yousuf, 5., Chang, S.-S., Wu, K., 81 Chen, Y.-Y. (2012). Means restriction for suicide prevention. Lancet, 3?9. 49 Appendix A: Summary of Strategies and Approaches to Prevent Suicide Strategy Approach/Program, Practice or Policy Strengthen household financial security Suicide Best Available Evidence Other Risk] Protective Factors for Suicide Suicide Attempts or ldeation Lead Sectors1 Government (local, Unemployment benefit programs state, Federal) Strengthen economic Other income supports Businessflabor . . . . . . Housmg pollcles Government {locaL The National Neighborhood Stabilization state, Federal) Program Coverage of mental health conditions in health insurance policies Health ca re Strengthen Mental Health Parity Laws 1/ access to Government (state, mental health Fadera? ca re Reducing access to lethal means among persons at-risk Government (local, intervening at suicide hot spots state) 1/ Safe storage practices Public Health Establish protective Organlzatlonal pollcles and culture Busmesstabor . Together for Life envnronments Government (local, US Air Force Suicide Prevention Program 1/ state, Fed eral) 50 Best Available Evidence Communitywbased policies to reduce excessive alcohol use Alcohol outlet density 1/ Government {local, state] Businessllabor Promote connectedness Peer norm approaches Public Health Sources of Strength Education Communitvrengagement activities Public Health Greening vacant urban spaces Government {local} Social emotional learning Public Health Youth Aware of Mental Health Program Education Signs of Suicide Teach co in 3 Good Behavior Game and problem- solvmg Sklils Parenting skill and family relationship approaches Public Health The incredible Years Education Strengthening Families 10-14 Gatekeeper training Public Health Mental Health First Aid Healthcare Screening combined with care management Healthcare Identify and 51 support people alt-risk Henry Ford Perfect Depression Core {Pre- cursor to Zero Suicide) Best Available Evidence Social Services Crisis Intervention Public Health Active foiio w?up con toct approaches EST for Suicide Prevention Notionoi Suicide Prevention Lifeiine Social Services Appiied Suicide intervention Training Treatment for people at risk of suicide Health ca re improving Mood Promoting Access to v? Social Services Coiioborotive Treatment Justice Coiiohorotive Assessment and Management v? Suic?doii CAMS Intervene to I lessen harms Dioiecticoi Behovioroi Therapy and prevent future risk Attachment?Based Fomiiv Therapy Treatment to prevent re-attempts Health ca re ED Brief intervention with Foiiow-up Visits Social Services v? Postvention Heaithcare 52 Best Available Evidence StandBy Response Service Safe messaging following a suicide Media Guidelines 1/ Public Health Media 1This column refers to the lead sectors well positioned to bring leadership and resources to implementation efforts. For each strategy, there are many other sectors such as non-governmental organizations that are instrumental to prevention planning and implementing the specific programmatic activities. Preventing Suicide: A Technical Package of Policy, Programs, and Practices Prepared by: Deb Stone, MSW, MPH Kristin Holland, MPH Brad Bartholow, Alex Crosby, MD, MPH Shane Davis, Natalie Wilkins, Division of Violence Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention 2016 Policies, Programs, and Practices to Support individuals, Families, Communities: A Technical Package to Prevent Suicide is a publication of the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention. Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director National Center for injury Prevention and Control Debra E. Houry, MD, MPH, Director Division of Violence Prevention James A. Mercy, Director Suggested Citation: Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, 5., and Wilkins, N. Policies, Programs, and Practices to Support Individuals, Families, and Communities: A Technicai Package to Prevent Suicide. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2016. Contents Acknowledgements 4 External Reviewers 5 Overview of Technical Package 6 Strengthen Economic Strengthen Access to Mental Health Care 16 Create Protective Environments 18 Promote Connectedness 22 Teach Coping and Problem-Solving Skills 24 Identity and Support People At-Risk 28 Intervene to Lessen Harms and Prevent Future Risk 32 Sector Involvement 37 Monitoring and Evaluation 39 Conclusion 40 References 42 Appendix A 50 Acknowledgments [to be inserted later] External Reviewers [to be inserted later] Overview This technical package represents a select group of strategies based on the best available evidence to help communities and states sharpen their focus on prevention activities with the greatest potential to prevent suicide. These strategies include strengthening economic supports; strengthening access to mental health care; creating protective environments; promoting connectedness; teaching coping and problem-solving skills; identifying and supporting people at-risk; and intervening to lessen harms and prevent future risk. The strategies represented in this package include those with a focus on preventing suicide from happening in the first place as well as approaches to lessen the immediate and long-term harms of suicidal behavior for individuals, families, communities, and society. The strategies in the technical package support the goals and objectives of the National Strategy for Suicide Prevention and the National Action Alliance for Suicide Prevention?s priority to strengthen community-based prevention. Commitment, cooperation, and leadership from numerous sectors, including public health, education, justice, health care, social services, business, labor, and government can bring about the successful implementation of this package. What is a Technical Package? A technical package is a compilation of a core set of strategies to achieve and sustain substantial reductions in a specific risk factor or outcome {Friedem 2014). Technical packages help communities and states prioritize prevention activities based on the best available evidence. This technical package has three components. The first component is the strategy or the preventive direction or actions to achieve the goal of preventing suicide. The second component is the approach. The approach includes the specific ways to advance the strategy. This can be accomplished through programs, policies, and practices. The approaches included come primarily from studies based in the United States. The evidence for each of the approaches in preventing suicide or its associated risk factors is included as the third component. This package is intended as a resource to guide and inform prevention decision-making in communities and states. Preventing Suicide is a Priority Suicide, as defined by the Centers for Disease Control and Prevention (CDC), is part of a broader class of behavior called seif?directeo? vioience. Self-directed violence refers to behavior directed at oneself that deliberately results in injury or the potentiai for injury (A.E. Crosby, Ortega, 81 Melanson, 2011). Self- directed violence may be suicide! or non-suicidal in nature. For the purposes of this document, we refer only to behavior where suicide is intended: - Suicide is a death caused by self-directed injurious behavior with any intent to die as a result of the behavior. Suicide attempt is defined as a non-fotoiself-directed and potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury. Suicide is highly prevalent. Suicide presents a major challenge to public health in the United States and worldwide. it contributes to premature death, morbidity, lost productivity, and health care costs (U.S. Office of the Surgeon General 8c National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). In 2014 (the most recent year of available death data), suicide was responsible for 42,773 deaths in the U.S., which is approximately one suicide every 12 minutes (Centers for Disease Control and Prevention, 2016d). In 2014, suicide ranked as the 10th leading cause of death and has been among the top 12 leading causes of death since 1975 in the U.S (Centers for Disease Control and Prevention, 2016d). Overall suicide rates have increased 24% from 1999 to 2014 iCurtin, Warner, Hedegaard, 2016). Suicide is a problem throughout the life span; it is the second leading cause of death among those aged 10?34 years; it is the fourth leading cause among persons in their 405 and seventh among persons in their 505. Suicide rates vary by race/ethnicity with the highest rates, across the lifespan, occurring among non-Hispanic American Indian/Alaska Native (rate: Among young people are disproportionately at increased risk of suicide with young males aged 25?29 experiencing the highest rates (rate: Moreover, suicide rates among non-Hispanic AIIAN have increased by 48.7% since 1999 (Centers for Disease Control and Prevention, 2016d). Suicides reflect only a portion of the problem (A.E. Crosby, Han, Ortega, Parks, Gfroerer, 2011). Substantially more people are hospitalized as a result of nonfatal suicidal behavior suicide attempts) than are fatally injured, and an even greater number are either treated in ambulatory settings emergency departments) or not treated at all (A.E. Crosby, Han, et al., 2011). For example, during 2014, among adults aged 18 years and older, for every one suicide there were 9 adults treated in hospital emergency departments for self-harm injuries, 27 who reported making a suicide attempt, and over 227 who reported seriously considering suicide ideation) (Ferdon et al., in press). Suicide is associated with several risk and protective factors. Suicide, like other human behaviors, has no single determining cause. Instead, suicide occurs in response to multiple biological, interpersonal, environmental and societal influences that interact with one another, often over time. The social-ecological modeI-? encompassing multiple levels of focus from the individual, relationship, community, and societal-- is a useful framework for viewing and understanding suicide risk factors identified in the literature (Dahlberg 84 Krug, 2002). Risk and protective factors for suicide exist at each level. For example, risk factors include: Individual level: History of depression and other mental illnesses, hopelessness, substance abuse, certain health conditions, previous suicide attempt, violence victimization and perpetration, and genetic and biological determinants Relationship level: High conflict or violent relationships, sense of isolation and lack of social support, familyfloved one?s history of suicide, financial and work stress 0 Community level: Inadequate community connectedness, barriers to health care lack of access to providers and medications} Societal level: Availability of lethal means of suicide, unsafe media portrayals of suicide, stigma associated with help-seeking and mental illness (U.S. Office of the Surgeon General 8: National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). It is important to recognize that the vast majority of individuals who are depressed or who have other risk factors noted, do not die by suicide. Furthermore, the relevance of each risk factor can vary by age, race, gender, sexual orientation, residential geography, and socio-cultural and economic status (U.S. Office of the Surgeon General 8c National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). Protective factors, or those influences that guard against the risk for suicide, can also be found across the different levels of the social-ecological model. Protective factors identified in the literature include: effective coping and problem solving skills, moral objections to suicide, strong and supportive relationships with partners, friends, and family; connectedness to school, community and other social institutions; availability of quality and ongoing physical and mental health care, and reduced access to lethal means (U.S. Office of the Surgeon General National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). These protective factors can either counter a specific risk factor or guard against a number of risks associated with suicide. Suicide is connected to other forms of violence. Suicide and other forms of violence often share some of the same root causes (Butchart, Phinney, Check, 8: Villaveces, 2004; Klevens, Simon, 8L Chen, 2012). For example, in neighborhoods where there is low social cohesion, or where residents don?t support and trust each other, people are at higher risk for suicide (Desai, Dausey, 8: Rosenheck, 2005) as well as perpetration of child maltreatment (Coulton, Crampton, Irwin, Spilsbury, 8L Korbin, 2007; Freisthler, Merritt, 8: LaScaia, 2006), teen dating violence (Capaldi, Knoble, Shortt, Kim, 2012), intimate partner violence (Pinchevsky 8: Wright, 2012), and youth violence (Sampson, Morenoff, 8: Gannon-Rowley, 2002). Additionally, a lack of economic opportunities and unemployment are associated with suicide (Luo, Florence, Quispe-Agnoli, Ouyang, Ea. Crosby, 2011; Reeves et al., 2012), as well as perpetration of child maltreatment (D. Runyan, Wattam, lkeda, Hassan, Ramiro, 2002), intimate partner violence (Heise 8i Garcia-Moreno, 2002; Pinchevsky 8; Wright, 2012), sexual violence (Centers for Disease Control and Prevention, 2016c) and youth violence (Wilson, 2011). Other shared risk factors for suicide and violence occur at the individual level and include substance abuse, mental health problems, witnessing violence, and a lack of problem-solving skills (Centers for Disease Control and Prevention, 2016a, 2016c, 2016e; U.S. Office of the Surgeon General National Action Alliance for Suicide Prevention, 2012). Just as risk factors may be shared across suicide and violence, so too may protective factors overlap. For example, connectedness to one?s community (Basile, Hamburger, Swahn, 8t Choi, 2013; Borowsky, 8 Hogan, 8i. Ireland, 1997; Centers for Disease Control and Prevention, 2016b; Coulton et al., 2007; Kleiman, Riskind, Schaefer, Weingarden, 2012; Pinchevsky Wright, 2012; Widome, Sieving, Harpin, 8: Hearst, 2003), school (Basile, Espelage, Rivers, McMahon, Simon, 2009; Capaldi et al., 2012; Carter, McGee, Taylor, 81 Williams, 2007; DeGue et al., 2013; Hong, Kral, Espelage, 8: Allen-Meares, 2012; Losel 8.: Farrington, 2012), family (Capaldi et al., 2012; Centers for Disease Control and Prevention, 2016a; Elgar, Craig, Boyce, Morgan, Vella-Zarb, 2009; Maimon, Browning, Brooks-Gunn, 2010; Resnick, Ireland, 8: Borowsky, 2004), caring adults (Capaldi et al., 2012; Losel Farrington, 2012; Maimon et al., 2010), and pro-social peers (Capaldi et al., 2012; Losel Farrington, 2012) enhances resilience to suicide and other forms of violence. The health and economic consequences of suicide are substantial. Suicide and suicide attempts have far-reaching consequences for individuals, families, and communities (Dunne, McIntosh, 8: Dunne- Maxim, 198?; Mishara, 1995; National Action Alliance for Suicide Prevention: Suicide Attempt Survivors Task Force, 2014; National Action Alliance for Suicide Prevention: Survivors of Suicide Loss Task Force, 2015). in an early study, Crosby and Sacks (2002) estimated that 7% of the U.S. adult population, or 13.2 million adults, knew someone in the prior 12 months who had died by suicide. They also estimated that for each suicide, 425 adults were exposed, or knew about the death. in a more recent study, in one state, Cerel et. al (2016) found that 48% of the weighted survey population knew at least one person who died by suicide in their lifetimes. Research indicates that the impact of knowing someone who died by suicide and/or having lived experience he having attempted suicide oneself) is much more extensive than injury and death. People with lived experience may suffer long-term health and mental health consequences ranging from anger, guilt, and physical impairment, depending on the means and severity of the attempt (Chapman 8: Dixon?Gordon, 2007). Similarly, survivors of a loved one?s suicide may experience ongoing pain and suffering including complicated grief (Mitchell, Kim, Prigerson, Mortimer-Stephens, 2004), stigma, depression, anxiety, post-traumatic stress disorder, and increased risk of suicidal ideation and suicide (Julie Cerel, Neimeyer, Maple, 8: Marshall, 2014; Sudak, Maxim, St Carpenter, 2008). Less discussed but no less important, are the financial and occupational effects for those left behind (Florence, Simon, Haegerich, Luo, Zhou, 2015). The economic toll of suicide is immense as well. According to conservative estimates, in 2013, suicide cost $50.8 billion in estimated lifetime medical and work-loss costs (Florence et al., 2015). By another estimate, the total lifetime costs associated with nonfatal injuries and deaths caused by self-directed violence in 2013 were approximately $93.5 billion after adjusting for under-reporting of suicide (Shepard, Gurewich, Lwin, Reed, Silverman, 2016). The overwhelming burden of these costs results from lost productivity over the life course, with the average cost per suicide being over $1.3 million (Shepard et al., 2016). Suicide can be prevented. Despite the surrounding suicide, like most public health problems, suicide is preventable (U.S. Public Health Service, 1999). And while progress will continue to be made 9 into the future, evidence for numerous programs, practices, and policies currently exists, and many programs are ready to be implemented now. Just as suicide is not caused by a single factor, research suggests that suicide will not be prevented by any single intervention taking place in any single setting {Silverman Maris, 1995; U.S. Office of the Surgeon General 81 National Action Alliance for Suicide Prevention, 2012}. Rather, suicide prevention is best achieved by a focus across the individual, relationship, family, community, and societalslevels and across all sectors, private and public business, public health, physical and behavioral healthcare, justice, education, labor} (National Action Alliance for Suicide Prevention, 2014; World Health Organization, 2014}. Assessing the Evidence This technical package includes programs, practices, and policies with evidence of impact on suicide or risk or protective factors for suicide. To be considered for inclusion in the technical package, the program, practice, or policy selected had to meet at least one of these criteria: a} meta-analyses or systematic reviews showing impact on suicide; b) evidence from at least one rigorous randomized controlled trial or quasi-experimental design} evaluation study that found significant preventive effects on suicide; c) meta-analyses or systematic reviews showing impact on risk or protective factors for suicide, or d) evidence from at least one rigorous RCT or quasi-experimental design) evaluation study that found significant impacts on risk or protective factors for suicide. Finally, consideration was also given to the likelihood of achieving beneficial effects on multiple forms of violence; no evidence of harmful effects on specific outcomes or with particular subgroups; and feasibility of implementation in a U.S. context if the program, policy, or practice has been evaluated in another country. Within this technical package, some approaches do not yet have research evidence demonstrating impact on rates of suicide but instead are supported by evidence indicating impacts on risk or protective factors for suicide help-seeking, stigma reduction, depression, connectedness). In terms of the strength of the evidence, programs that have demonstrated effects on suicidal behavior reductions in deaths, attempts) provide a higher-level of evidence, but the evidence base is not that strong in all areas. For instance, there has been less evaluation of community engagement and family programs on suicidal behavior. Thus, approaches in this package that have effects on risk or protective factors reflect the developing nature of the evidence base and the use of the best available evidence at a given time. it is also important to note that there is often significant heterogeneity among the programs, policies, or practices that fall within one approach or strategy area in terms of the nature and quality of the available evidence. Not all programs, policies, or practices that utilize the same approach gatekeeper training) are equally effective, and even those that are effective may not work across all populations. Tailoring programs and more evaluation may be necessary to address different population groups. The examples provided are not intended to be a comprehensive list of evidence-based programs, policies, or practices for each approach, but rather illustrate models that have been shown to impact suicide or have beneficial effects on risk or protective factors for suicide. In practice, the effectiveness of the programs, 10 policies and practices identified in this package will be strongly dependent on the quality of their implementation and the communities in which they are implemented. Implementation guidance to assist practitioners, organizations and communities will be developed separately. Context and Cross-Cutting Themes The strategies and approaches that have been included in this technical package represent different levels of the social ecology, with efforts intended to impact the community and societal levels, as well individual and relationship levels. The strategies and approaches are intended to work in combination and reinforce each other to prevent suicide {see box below). The strategies are arranged in order such that those strategies hypothesized to have the greatest potential for broad public health impact on suicide are included first, followed by those that might impact more select populations persons who have already made a suicide attempt). Preventing Suicide Strategy Approach Strengthen economic supports Strengthen household financial security Housing stabilization policies Strengthen access to mental health care Coverage of mental health conditions in health insurance policies Create protective environments Reducing access to lethal means among persons at-risk of suicide Organizational policies and culture Community-based policies to reduce excessive alcohol use Promote connectedness Peer norm approaches Community engagement activities Teach coping and problem-solving skills Social-emotional learning Parenting skill and family relationship approaches Identify and support people at risk Gatekeeper training SCreening combined with care management Crisis intervention intervene to lessen harms and prevent future risk I II I Treatment for people at-risk of suicide Treatment to prevent re-attempts Postvention Safe messaging following a suicide 11 The example programs, policies, and practices have been implemented within particular contexts. The social and cultural context of communities is critically important to take into account when selecting strategies and approaches. Practitioners in the field may be in the best position to assess the needs and of their communities and work with community members to make decisions about the combination of approaches included here that are best suited to their context. Suicide ideation, attempts, morbidity and mortality vary by gender, racefethnicity, age, occupation, and other important population characteristics. Barriers to disclosure, help seeking, timely access to quality care, and ongoing support may also vary by population and community characteristics. Ideally, the availability of multiple approaches tailored to the economic, cultural, and environmental context of individuals and communities are desirable as they may increase the likelihood of removing barriers to supportive and effective care and provide opportunities to develop individual and community resilience. These culturally appropriate approaches can then be included in comprehensive strategies to maximize the public health impact on reducing suicide-related morbidity and mortality among individuals and within communities. This package includes strategies where public health agencies are well positioned to bring leadership and resources to implementation efforts. it also includes strategies where public health can serve as an important collaborator strategies addressing community and societal level risks}, but where leadership and commitment from other sectors such as business, labor or health care is critical to implement a particular policy or program workplace policies; screening combined with care management). The role of various sectors in the implementation of a strategy or approach in preventing suicide is described further in the section on Sector involvement. In the sections that follow, the strategies and approaches with the best available evidence for preventing suicide are described. 12 Strengthen Economic Supports Rationale Studies from the U.S. examining historical trends indicate that suicide rates increase during economic recessions marked by high unemployment rates, job losses, and economic instability and decrease during economic expansions and periods marked by low unemployment rates, particularly for working- age individuals 25 to 64 years old {Luo et al., 2011; Fowler et al., 2015). Economic and financial strain, such as job loss, long periods of unemployment, reduced income, difficulty covering medical, food, and housing expenses, and even the anticipation of such financial stress, can directly increase an individual?s risk for suicide or indirectly increase risk by exacerbating related physical and mental health problems; buffering these risks can therefore, potentially protect against suicide (Stack 8i Wasserman, 2007). For example, strengthening economic support systems can help people stay in their homes or obtain affordable housing while also paying for necessities such as food and medical care, job training, child care, among other expenses required for daily living. In providing this support, stress and anxiety and the potential for a crisis situation may be reduced, thereby preventing suicide. Approaches Economic supports for individuals and families can be strengthened by targeting household financial security and ensuring stability in housing during periods of economic stress. I Strengthening household financial security can potentially buffer the risk ofsuicide by providing individuals with the financial means to lessen the stress and hardship associated with a job loss or other unanticipated financial problems. The provision of unemployment benefits and other forms of temporary assistance, livable wages, medical benefits, and retirement and disability insurance to help cover the cost of necessities or to offset costs in the event of disability, are examples of ways to strengthen household financial security. I Housing stabilization policies aim to keep people in their homes and provide housing options for those in need during times of financial insecurity. This may occur through programs that provide affordable housing such as through government subsidies or through other options available to potential homebuyers such as loan modification programs, move-out planning, or financial counseling services that help minimize the risk or impact of foreclosures and eviction. Potential Outcomes 0 Reductions in suicide rates I Reductions in foreclosure rates - Reductions in eviction rates - Reductions in emotional distress 13 Evidence There is evidence suggesting that strengthening household financial security and stabilizing housing can reduce suicide risk. Strengthen household financial security. An examination of variations in U.S. unemployment benefit programs across states demonstrated that the impact of unemployment on suicide was offset in those states that provided greater than average unemployment benefits {Cylus, Glymour, 8i. Avendano, 2014). Another U.S. study examining the link between unemployment and suicide risk using suicide data, length of unemployment, and job losses found that the duration of unemployment, as opposed to just the loss of job, predicted suicide risk (Classen 8: Dunn, 2012). Together, these results suggest that not only should state unemployment benefit programs be generous in their financial allocations, but also in their duration. Other measures to strengthen household financial security transfer payments related to retirement and disability insurance, unemployment insurance compensation, medical benefits, and other forms of family assistance} have also shown an impact on suicide. A study by Flavin and Radcliff (2009] examined the impact of states? per capita spending on transfer payments, medical benefits, and family assistance (Temporary Assistance to Needy Families - TANF) and total state spending on suicide rates between 1990-2000, controlling for a number of suicide risk factors le.g., residential mobility, divorce rate, unemployment rate} at the state level. As per capita spending on total transfer payments, medical benefits, and family assistance increased there was an associated decrease in state suicide rates. Moreover, it wasn't spending in general that was associated with the reduction but spending on these types of assistance. In terms of lives saved, Flavin 8c Radcliff calculated the cost of reducing a state's suicide rate by a full point for the years studied. At the national level, they estimated that 3,000 fewer suicides would occur per year nationwide if every state increased its per capita spending on these types of assistance by $45 per year (Flavin 8L Radcliff, 2009}. Although this was a correlational study, the results demonstrate the potential benefits of policies that reach particularly vulnerable individuals during periods of great need and increased risk for suicide. More evaluation studies are needed to further understand the outcomes impacted by programs such as these. Housing stabilization policies. The National Neighborhood Stabilization Program was designed to help neighborhoods suffering from high rates of foreclosure and abandonment by slowing the deterioration ofthe neighborhoods and providing affordable housing options for low, moderate, and middle-income homebuyers. This program also offers financial assistance to eligible individuals for the purchase of a new home. Although this program has not been rigorously evaluated for its impact on suicide outcomes, it addresses foreclosure and eviction, which are 14 risk factors for suicide. A longitudinal analysis of annual data on suicides and foreclosures demonstrated that as the proportion of foreclosed properties increased in U.S. states, so did the state suicide rate, particularly among working-aged adults (Houle Light, 2014}. Another study of data from 16 US. states participating in the National Violent Death Reporting System found that suicides precipitated by home foreclosures and evictions increased more than 100% from 2005 (before the housing crisis began) to 2010 (after it had peaked; Fowler, Gladden, Vagi, Barnes, and Frazier (2015)). Most of these suicides occurred prior to the actual loss of the decedent?s home. These findings suggest that integrating suicide prevention resources, messaging, and referrals into financial, foreclosure, and move-out planning and counseling services may help to prevent suicide. 15 Strengthen Access to Mental Health Care Rationale While most people with mental health problems do not attempt or die by suicide [Olfson, Gerhard, Huang, 8: Stroup, 2015; Owens, 2002), and the level of risk conferred by different types of mental illness varies {Arsenault-Lapierre, Kim, 81 Turecki, 2004; E. C. Harris 8: Barraclough, 1997; Tyrer, Reed, 8t Crawford, 2015), previous research indicates that mental illness is an important risk factor for suicide (E. C. Harris 8: Barraclough, 1998; World Health Organization, 2014}. Studies suggest that up to 90% of people who die by suicide may have had a mental illness or substance abuse problems at the time of their deaths (ArsenauIt-Lapierre et al., 2004; Cavanagh, Carson, Sharpe, 8: Lawrie, 2003; Isometsa, 2001). State-level suicide rates have also been found to be correlated with general mental health measures such as depression (Lang, 2013; Mark, Shern, Bagalman, 8; Cao, 2007). Findings from the National Comorbidity Survey indicate that relatively few people in the US. with mental health disorders receive treatment for those conditions (Kessler et al., 2005). Lack of access to mental health care is one of the contributing factors related to the underuse of mental health services (Cunningham, 2009). Identifying ways to improve access to timely, affordable, and quality mental health care for people in need is a critical component to suicide prevention (World Health Organization, 2014). Apart from the treatment benefits, it can also serve to normalize help-seeking behavior and increase the use of such services. Approaches One approach to strengthening access to mental health care is through the provision of mental health coverage in health insurance policies. 0 Coverage of mental health conditions in health insurance policies. Federal and state laws include provisions for equal coverage of mental health services in health insurance plans that is on par with coverage for other health concerns mental health parity). Benefits and services covered include such things as the number of visits, co-pays, deductibles, inpatientfoutpatient services, prescription drugs, and hospitalizations. If a state has a stronger mental health parity law than the federal parity law, then insurance plans regulated by the state must follow the state parity law. If a state has a weaker parity law than the federal parity law includes coverage for some mental health conditions but not others), then the federal parity law will replace the state law. Equal coverage does not necessarily imply good coverage as health insurance plans vary in the extent to which benefits and services are offered to address various health conditions. Rather it helps to ensure that mental health services are covered on par with other health concerns. Potential Outcomes I Increases in utilization of mental health services 16 I Reductions in of mental illnesses. I Reductions in rates ofsuicide attempts I Reductions in rates of suicide Evidence There is evidence suggesting that coverage of mental health conditions in health insurance policies can reduce risk factors associated with suicide and may directly impact suicide rates. Coverage of mental health conditions in health insurance policies. The National Survey of Drug Use and Health is a nationally representative survey of the U.S. population that provides data on substance use, mental health conditions, and services utilization. Using data from this survey, K. M. Harris, Carpenter, and Bao (2006) found that 12 months after states enacted mental health parity lows, self-reported use of mental healthcare services significantly increased. Moreover, subsequent research by Lang (2013) examined state mental health laws and suicide rates between 1990 and 2004 and found that mental health parity laws, specifically, were associated with an approximate 5% reduction in suicide rates. This reduction, in the 29 states with parity laws, equated to the prevention of 592 suicides per year. Lang et al. {2013] estimated the cost of saving a life through such mandates as mental health parity by comparing the loss in wages attributable to the policy, via increased premiums, to the number of lives saved. Based on these calculations, the cost of saving one life was between 51.3-31.1 million per suicide prevented. However, this calculation did not take into account the saving associated with improved mental health among non-suicidal individuals, increases in productivity, or quality oflife associated with increased mental health care. As such, this figure is considered the upper bounds on costs incurred and should be interpreted with caution (Lang, 2013}. 17 Create Protective Environments Rationale Prevention efforts that focus not only on individual behavior change help-seeking, treatment interventions) but on changes to the environment can increase the likelihood of positive behavioral and health outcomes (Haddon, 1980). Creating environments that address risk and protective factors where individuals live, work, and play, can help prevent suicide (Dahlberg 8i Krug, 2002; U.S. Office of the Surgeon General National Action Alliance for Suicide Prevention, 2012}. For example, rates of suicide and suicide attempts are elevated in certain occupational groups (Han et al., 2016; McIntosh et al., 2016], therefore, changes to the organizational culture in these occupations, by way of implementation of supportive policies or even physical modifications to the workplace environment, can change social norms, encourage help?seeking, and demonstrate that good health and mental health are valued and that stigma and other risk factors for suicide are not (K. L. Knox et al., 2010; National Action Alliance for Suicide Prevention Workplace Task Force, 2015). Similarly, modifying the characteristics of the environment to prevent harmful behavior such as access to lethal means can reduce suicide rates, particularly in times of crisis {Beautrais, Gibb, Fergusson, Horwood, 8i. Larkin, 2009; A.E. Crosby, Espitia- Hardeman, Ortega, 8i. Lozano, 2013; Kaplan et al., 2013; Miller, Warren, Hemenway, Azrael, 2015; C. W. Runyan et al., 2016}. Approaches The current evidence suggests three potential approaches for creating environments that protect against suicide. - Reducing access to lethal means among persons at-risk of suicide. Means of suicide such as firearms, hanging/suffocation, orjumping from heights provide little opportunity for rescue and, as such, have high case fatality rates about 85% of people who use a firearm in a suicide attempt will die from the injury]. Research also indicates that 1) the interval between thinking about and attempting suicide can be as short as 5 or 10 minutes (Deisenhammer et al., 2009; Simon et al., 2001) and 2) that people tend not to substitute a different method when a highly lethal method is unavailable or difficult to access {Hawton, 2007; Yip et al., 2012). Therefore, increasing the time interval between the thought and the suicide attempt, for example, by making it more difficult to access lethal means, can be lifesaving. The following are examples of approaches reducing access to lethal means for persons at-risk of suicide: 0 intervening or Suicide Hotsoots. Suicide hotspots, or places where suicides may take place relatively easily, include tall structures bridges and cliffs), railway tracks, and isolated locations such as parks. Efforts to prevent suicide at these locations include 18 erecting barriers to prevent jumping and installing signs and telephones to encourage individuals who are considering suicide, to seek help {Cox et al., 2013). 0 Safe Storage Practices. Safe storage of medications, firearms, and other household products can reduce the risk for suicide by separating individuals who may be vulnerable and/or impulsive from easy access to lethal means. Such practices may include education and counseling around storing firearms-- ocked in a secure place leg, in a gun safe or lock box], unloaded and separate from the ammunition-?and keeping medicines in a locked cabinet or other secure location awayfrom people who may be at risk or who have made prior attempts lRowhani-Rahbar, Simonetti, Rivara, 2016; C. W. Runyan et al., 2015i - Organizational policies and culture that promote protective environments may be implemented in places of employment. Such policies and cultural values may promote prosocial behavior asking for help}, skill building, changing social norms, referral and access to helping services mental health, substance abuse treatment, financial counseling), and encourage leadership support from the top down. Such policies and cultural shifts can positively impact organizational climate and morale and help prevent suicide and its related risk factors depression, social isolation) (National Action Alliance for Suicide Prevention Workplace Task Force, 2015]. - Community-based policies to reduce excessive alcohol use. Research studies in the United States have found that greater alcohol availability is positively associated with alcohol-involved suicides (Escobedo 8: Ortiz, 2002; Giesbrecht et al., 2015}. Policies to reduce excessive alcohol use broadly include zoning to limit alcohol outlet locations and density, taxes on alcohol, and bans on the sale of alcohol for individuals under the legal drinking age. These policies are important because acute alcohol use has been found to be associated with more than one-third of suicides and approximately 40% of suicide attempts {Cherpitel, Borges, 8L Wilcox, 2004). Potential Outcomes - Increases in safe storage of means - Reductions in suicide attempts Reductions in suicide deaths I Increases in help-seeking I Reductions in alcohol-related suicide deaths 19 Evidence The evidence for the effectiveness of preventing suicide by reducing access to lethal means and otherwise establishing protective environments for individuals at risk of suicide is strong, particularly compared to existing evidence for other prevention strategies (Zalsman et al., 2016}. 0 Reducing access to lethal means among persons at-risk of suicide. A meta-analysis examining the impact of suicide hotspot interventions implemented in combination or in isolation, both in the U.S. and abroad, found associated reduced rates of suicide (Cox et al., 2013; Pirkis et al., 2015}. For example, after erecting a barrier on the Jacques-Cartier bridge in Canada, the suicide rate from jumping from the bridge decreased from about 10 suicide deaths per year to about 3 deaths per year (Perron, Burrows, Fournier, Perron, 8; Uuellet, 2013}. Moreover, the reduction in suicides by jumping was sustained even when all bridges and nearby jumping sites were considered, suggesting little to no displacement of suicides to other jumping sites {Perron et al., 2013). Further evidence for the effectiveness of bridge barriers was demonstrated by a study examining the impact of the removal of safety barriers from the Grafton Bridge in Auckland, New Zealand. After removal of the barrier, both the number and rate of suicide increased fivefold (Beautrais, 2001; Beautrais et al., 2009}. Another form of means reduction involves implementation of safe storage practices. in a case- control study of firearm-related events identified from 37 counties in Washington, Oregon, and Missouri, and from 5 trauma centers, Grossman et al. (2005} found that storing firearms unloaded, separate from ammunition, in a locked place or secured with a safety device was protective of suicide attempts among adolescents. Further, a recent systematic review of clinic and community-based education and counseling interventions suggested that the provision of safety devices significantly increased safe firearm storage practices compared to counseling alone or compared to the provision of economic incentives to acquire safety devices on one?s own {Rowhani-Rahbar et al., 2016}. Another program, The Emergency Department Counseling on Access to Lethal Means (ED CALM), trained emergency clinicians in a large children?s hospital to provide lethal means counseling and safe storage boxes to parents of patients under age 18 receiving care for suicidal behavior. In a pre?post quality improvement project, Runyan et al (2016} found that at post-test 76% (of the 55% of parents followed up, n=114} reported that all medications in the home were locked up as compared to fewer than 10% at the time of the initial emergency department visit. Among parents who indicated the presence of guns in the home at pre-test (Le. all (100%} reported guns were currently locked up at post-test (C. W. Runyan et al., 2016}. 0 Organizational policies and culture. Togetherfor Life is a workplace program of the Montreal Police Force implemented to address suicide among officers. Policy and program components 20 were designed to foster an organizational culture that promoted mutual support and solidarity among all members of the Force. The program included training of supervisors, managers and all units to improve competencies in identifying suicidal risk and to improve use and awareness of existing resources. The program also included an education campaign to improve awareness and help-seeking (Mishara 8: Martin, 2012). Police suicides were tracked over 12 years and compared to rates in the control city of Quebec. The suicide rate in the intervention group decreased significantly by 78.9% to a rate of 6.4 suicides per 100,000 population per year compared to an 11% increase in the control city (29.0 per 100,000) (Mishara 8: Martin, 2012). Another example of this approach is the United States Air Force Suicide Prevention Program (AFSPP). AFSPP included 11 policy and education initiatives and was designed to change the culture ofthe Air Force surrounding suicide. The program uses leaders as role models and agents of change, establishes expectations for behavior related to awareness of suicide risk, develops population skills and knowledge education and training), and investigates every suicide outcomes measurement]. The program represents a fundamental shift from viewing suicide and mental illness solely as medical problem and instead sees them as larger service- wide problems impacting the whole community (K. L. Knox, Litts, Talcott, Feig, 8: Caine, 2003}. Using a time-series design to examine the impact of the AFSPP program on various violence- related outcomes, researchers found that the program was associated with a 33% relative risk reduction in suicide (K. L. Knox et al., 2003).The program was also associated with relative risk reductions in related outcomes including moderate and severe family violence (30% and 54%, respectively}, homicide and accidental death (K. L. Knox et al., 2003). A longitudinal assessment of the program over the period 1981 to 2008 (16 years before the 1997 launch of the program and 11 years post-launch) found significantly lower rates of suicide after the program was launched than before (K. L. Knox et al., 2010]. These effects were sustained over time, except in 2004, which the authors found was associated with less rigorous implementation in that year than in the other years (K. L. Knox et al., 2010]. Community-based policies to reduce excessive alcohol use. While multiple policies to limit excessive use of alcohol exist, several studies on alcohol outlet density, specifically, suggest that measures to reduce alcohol outlet density can potentially reduce alcohol-involved suicides. Additionally, a longitudinal analysis of alcohol outlet density, suicide mortality, and hospitalizations for suicide attempts over 6 years in 581 California zip codes indicated that the density of bars, specifically, is related to suicide and suicide attempts, particularly in rural areas (Johnson, Gruenewald, 8: Remer, 2009]. 21 Promote Connectedness Rationale Sociologist, Emile Durkheim theorized in 1897 that weak social bonds, i.e. lack of connectedness, are among the chief causes for suicidality (Durkheim, 1897/1951}. Connectedness is the degree to which an individual or group of individuals are socially close, interrelated, or share resources with others (Centers for Disease Control and Prevention, 2009). Social connections can be formed within and between multiple levels ofthe social ecology {Dahlberg 8: Krug, 2002), for instance between individuals peers, neighbors, co-workers), families, schools, neighborhoods, workplace, faith communities, cultural groups, and society as a whole. Related to connectedness, sociol capitol refers to a sense of trust in one?s community and neighborhood, social integration, and also the availability and participation in social organizations (Beyer, Layde, Hamberger, 8: Laud, 2015; Muennig, Cohen, Palmer, 8; Zhu, 2013}. Many ecological cross-sectional and longitudinal studies have examined the impact of aspects of social capital on depression depressive disorder, mental health more generally, and suicide. While the evidence is limited, existing studies suggest the pattern is towards a positive association between social capital measured by social trust, community! neighborhood engagement, and improved mental health. Connectedness and social capital together can serve to protect against suicidal behaviors by decreasing isolation, encouraging adaptive coping behaviors, increasing belongingness, personal value and worth all of which helps individuals to build resilience in the face of adversity. Connectedness can also provide individuals with better access to formal supports and resources, mobilize communities to meet the needs of its members and provide collective primary prevention activities to the community as a whole (Centers for Disease Control and Prevention, 2009). Approaches Promoting connectedness among individuals and within communities through modeling peer norms and enhancing community engagement can protect against suicide. Peer norm approaches seek to normalize protective factors for suicide such as help-seeking, reaching out and talking to trusted adults, and promote peer connectedness. These approaches typically target youth and are delivered in school settings but can also be implemented in community settings. 22 Community engagement activities. Community engagement is an aspect of social capital. Community engagement approaches may involve residents participating in a range of activities, including religious activities, community clean-up and greening activities, and physical exercise. These activities provide opportunities for residents to become more involved in the community and to connect with other community members, organizations, and resources, resulting in enhanced overall physical health, reduced stress, and decreased depressive thereby reducing risk of suicide. Potential Outcomes - Reductions in maladaptive coping attitudes and behaviors Increases in healthy coping attitudes and behaviors I Increases in referrals for youth in distressed I Increases help-seeking behaviors I Increases in positive perceptions of adult support Eviden ce Current evidence suggests that peer norm approaches and community engagement can reduce risk factors associated with suicidal behaviors. Peer norm approaches. Evaluations show that programs such as Sources of Strength can improve school norms and beliefs about suicide that are created and disseminated by student peers. In a randomized controlled trial of Sources ofStrength conducted with 18 high-schools (6 metropolitan, 12 rural}, Wyman et al. (2010) found that the program improved adaptive norms regarding suicide among peer leaders, connectedness to adults, and school engagement. Peer leaders were also more likely than controls to refer a suicidal friend to an adult. For students, the program resulted in increased perceptions of adult support for suicidal youths, particularly among those with a history of suicidal ideation, and the acceptability of help?seeking behaviors. Finally, trained peer leaders also reported a greater decrease in maladaptive coping attitudes compared with untrained leaders (Wyman et al., 2010}. More evaluation research is needed to examine whether these improvements in factors that protect against suicidal behavior translate into reduced suicidal behavior and suicide. Community engagement activities. A vacant lot greening initiative was undertaken in Philadelphia between 1999 and 2008. Local residents and community members worked together to green 4,436 lots (or 7.8 million square feet) in 4 areas ofthe city. Researchers found significant reductions in community residents? self-reported level of stress, which is a risk factor for suicide, and engagement in more physical exercise, a protective factor for suicide, than residents in 23 control vacant lot areas. Other benefits included reductions in firearm assaults and vandalism {Branas et al., 2011). Teach Coping and Problem-Solving Skills Rationale Building life skills prepares individuals to successfully tackle every day challenges and adapt to stress and adversity. Life skills encompasses many concepts, but most often include coping and problem-solving skills, conflict resolution, and critical thinking. Life skills are important in shielding individuals from suicidal behaviors (World Health Organization, 2014]. Suicide prevention programs that focus on life and social skills training are drawn from social cognitive theories {Bandura, 1986}, surmising that suicidal behavior is attributed to either direct learning, modeling, or environmental and individual hopelessness) characteristics. The literature linking life skills and suicide is robust. The inability to employ adequate strategies to cope with immediate stressors or identify and find solutions for problems has been characterized among suicide attempters (Pollock 81 Williams, 2004). Treatments that include bolstering skills (Goldsmith, Pellmar, Kleinman, 81 Bunney, 2002)and include problem-solving techniques (Ghahramanlou-Holloway, Bhar, Brown, Olsen, 8: Beck, 2012; Townsend et al., 2001} appear to reduce suicidal ideation and attempts more effectively. Prevention programs focused on teaching these skills target youth, parents and families and have been used with both universal and at-risk populations. While many do not target suicidal behaviors directly, these programs strive to train youth and parents in important life skills to offset the underlying vulnerabilities that contribute to engaging in high-risk behaviors early in life. Approaches Current evidence provides support for the following two approaches: . Social emotional learning programs focus on developing and strengthening communication and problem-solving skills, emotion regulation, conflict resolution, help seeking and coping skills. These approaches address a range of risk and protective factors for suicidal behavior. They provide children and youth with skills to resolve problems in relationships, school, and with peers, and help youth to address other negative influences le.g., substance use) associated with suicide. These approaches are typically delivered to all students in a particular grade or school, although some programs also focus on groups of students considered to be at high risk for suicide. Opportunities to practice and reinforce skills are an important part of programs that work (Herman, Borden, Reinke, El Webster-Stratton, 2011). 24 II Parenting skill and family relationship programs are designed to strengthen parenting skills, enhance positive parent-child interactions, and improve children?s behavioral and emotional skills and abilities. Several parenting and family relationship programs have been shown in rigorous evaluations to improve resilience and reduce risk factors for various behaviors, including ones closely related to suicide, such as depression, internalizing behaviors, and substance abuse (M. S. Knox, Burkhart, 8: Hunter, 2010]. Potential Outcomes - Reductions in suicide attempts and suicide ideation - Improvements in knowledge of risk and protective factors associated with suicide 0 Reductions in suicide risk behaviors depression, anxiety, conduct problems, substance abuse) I Improvements in help-seeking behavior I Improvements in social competence and emotional regulation skills I Improvements in problem-solving and conflict management skills Eviden ce There are several programs with evidence that support teaching social, emotional and parenting skills to reduce suicidal behaviors and associated risk factors. Social emotional learning programs. The Youth Aware of Mental Health Program (YAM) is a program developed for teenagers that uses interactive dialogue and role-playing to teach adolescents about the risk and protective factors associated with suicide (including knowledge about depression and anxiety} and enhances their problem-solving skills for dealing with adverse life events, stress, school and other problems. The program includes 3 hours of role-play sessions and interactive workshops combined with a booklet that students can keep, educational posters displayed in classroom, and interactive lectures about mental health at the beginning and end of the program {Wasserman et al., 2014}. In a cluster- randomized controlled trial of YAM conducted across 10 European Union countries and 168 schools, students aged 14-16 participating in the TAM program were significantly less likely to attempt suicide and have severe suicidal ideation at the 12-month follow-up compared to the control group which did not participate in an intervention. Overall, the relative risk of youth suicide attempts among the YAM group was reduced by over 50%demonstrating that out of 1000 students, five attempted suicide in the YAM group compared to 11 in the control group. Additionally, related to severe suicide ideation, in the YAM group absolute risk fell by 0.50% and relative risk fell by 49.5% {Wasserman et al., 2014). 25 Signs ofSuicide (505) is another school-based prevention program for students aged 13-17. The program includes guided classroom discussions about suicide and depression. As part of the program, students are screened for depression and suicide risk and referred for professional help as indicated. The program is designed to increase knowledge about suicide and risk factors associated with suicidal behavior as well as improve and normalize help- seeking behavior (Schilling, Aseltine, James, 2016). In a randomized controlled trial, $05 was shown to reduce self-reported suicide attempts at 3-months post intervention among participating students compared to control students. The 505 program also increased students? knowledge of how to get help for themselves or friends for depression and/or suicidal thoughts, and favorable attitudes toward help-seeking. 505 participants with a lifetime history of suicide attempt were also less likely to report planning a suicide in the 3 months following the program compared to lower-risk participants (Schilling et al., 2016). Finally, the Good Behavior Game {636) is a classroom-based program for elementary school children aged 6-10. The program uses a team-based behavior management strategy that promotes good behavior by setting clear expectations for good behavior and consequences for maladaptive behavior. The goal of the GBG is to create an integrated classroom social system that is supportive of all children being able to learn with little aggressive or disruptive behavior (Wilcox et al., 2008). Two cohorts of youths participated in the program in 1985-85 and 1986-86 school years when they were in the first and second grades. A number of proximal and distal outcomes were assessed among the two cohorts over time. With respect to distal suicide-related outcomes, an outcome evaluation of the EEG indicated that individuals in the first cohort who were assigned to participate in 656 when they were in the first grade reported half the adjusted odds of suicidal ideation and suicide attempts when assessed approximately 15 years later, between the ages of 19 to 21, compared to peers who had been in a standard classroom setting. The beneficial effect ofthe program was consistent for suicidal ideation regardless of whether baseline covariates were included. The EEG effect on attempts was less robust in some adjusted models including caregiver mental health. In the second cohort of 636 students, neither suicidal ideation nor suicide attempts were significantly different between (386 and the control interventions (Wilcox et al., 2008}. The authors surmise this finding likely arose due to the lack of implementation fidelity and pointed to the need for 636 to be delivered with precision, consistency, and teacher support. 636 was also found to be associated with reduced risk of later substance abuse, a risk factor for suicide (Kellam et al., 2008}. Parenting skill and family relationship programs. Parenting and family skills training approaches have shown promising impacts in preventing key risk factors associated with suicide. For example, the incredibie Yeors (W) is a comprehensive group training program for 26 parents, teachers and children designed to reduce conduct and substance abuse problems, two important suicide risk factors, in youth by improving protective factors such as responsive and positive parent-teacher-child interactions and relationships, emotion self-regulation and social competence {all protective factors for suicide} (Herman et al., 2011). The program includes 9- 20 sessions offered in community-based settings religious, recreation centers, mental health treatment centers, and hospitals). Several studies have demonstrated the effect of the 0? program on reducing internalizing such as anxiety and depression, and child conduct problems (C. H. Webster-Stratton, Reid, Beauchaine, 2011; Webster-Stratton, iamila Reid, 8: Stoolmiller, 2008). The program is also associated with improved problem-solving and conflict management; these skills were maintained at 1-year follow-up (Reid, Webster-Stratton, 8: Hammond, 2003; C. Webster-Stratton 8: Hammond, 199?; C. Webster-Stratton, Reid, 8? Hammond, 2001). The program demonstrated greater benefits as the dosage of the intervention increased (Herman et al., 2011). Additionally, Strengthening Families 10-14 is a program that involves sessions between parents, youth, and family with the goal of improving parents? skills for disciplining, managing emotions and conflict, and communicating with their children; promoting youths? interpersonal and problem-solving skills; and creating family activities to build cohesion and positive parent-child interactions. The premise of the program is that developing these skills for both parents and children will reduce internalizing behavior and adolescent substance abuse, two important risk factors for suicide (Spoth, Guy?, 8: Day, 2002). Strengthening Families has been shown to significantly decrease externalizing behaviors, such as aggression, alcohol use, and drug use among youth participants, as well as reductions in depression, alcohol use, and drug use among participating families (Spoth et al., 2002). 27 Identify and Support People At-Risk Rationale In order to decrease suicide, attention to people at increased risk, for example people with prior suicide attempts, is necessary, as these individuals tend to experience suicidal behavior at higher than average rates. These vulnerable or disadvantaged populations include, but are not limited to, individuals with lower socio-economic status or who are living with a mental health problem; people who have attempted suicide previously; individuals who are institutionalized, have been victims ofviolence, or are homeless; and members of certain racial and ethnic minority groups. Supporting these vulnerable groups requires proactive case finding along with access to, and retention in, mental health services. Finding effective ways of identifying at-risk or vulnerable groups, customizing services to make them accessible and engaged in care remain key challenges. For example, simply improving services does not guarantee thatthose services will be used by those most in need ofthem, nor will it necessarily increasethe number of people who follow treatments that are recommended. People who are disadvantaged face social and economic issues that may adversely affect their ability to respond to the treatments or advice that are offered. Approaches The following three approaches focus on identifying and supporting people at increased risk. I Gatekeeper training is designed to train teachers, coaches, providers and others in the community to identify people who may be at risk of suicide and to respond effectively, including facilitating treatment seeking and support services. Gatekeeper training is typically implemented in schools to identify at-risk youth and within health care settings to identify adults (and youth). 0 Screening combined with care management and overall continuity of care has been used in primary care and behavioral health care settings to assure that people who may be at high-risk of suicide are identified and receive ongoing treatment as needed, particularly after inpatient discharge and other transitions within the healthcare system so they don?t 'slip through the cracks?. These approaches typically employ screening for depression andfor suicide combined with collaborative treatment planning between patients and their providers and patient follow- up. 0 Crisis intervention. These approaches provide support and referral services, typically by connecting a person in crisis (or a friend or family member of someone at-risk) to trained volunteers or professional staff via telephone hotline, online chat, or text messaging. Crisis intervention approaches are intended to impact key risk factors for suicide, including feelings of 28 depression, hopelessness, and subsequent mental health care utilization. Like means reduction, crisis interventions can put space or time between an individual who may be considering suicide and harmful behavior. Potential Outcomes I Reductions in suicide attempts I Reductions in suicide deaths I Increases in identification of individuals at-risk for suicidal behavior I Increases in at?risk individuals in treatment I Increases in community members trained to identify at-risk individuals I Increases in referrals for health care Evidence Identifying people at risk of suicide can positively impact both suicide risk factors as well as suicide mortality, however sustained implementation of programs and practices appears critical. Among people who identify themselves through calls to suicide hotlines, preliminary evidence finds reductions in suicide risk factors. Gatekeeper training. One example of gatekeeper training is the Mental Health First Aid program. This program is designed for the lay public and consists of three weekly sessions of three hours each. Participants learn the of people in mental health crises and/or in the early stages of mental health problems those experiencing suicidal thoughts and behavior, acute stress reaction, panic attacks and acute behavior, and depression, anxiety, and disorders}, possible risk factors, and where and how to get effective help {Kitchener 3n Jorm, 2004}. In a randomized controlled trial of 301 participants of MHFA, the intervention group, compared to the wait-listed control group, reported at 5 months follow-up, significantly greater feelings of confidence in helping someone (74.5% vs. 57.4%, greater likelihood of encouraging people to seek professional help (29.4% vs. 16.8%, improved agreement with health professionals about treatments (p<.036l, and decreased stigmatizing attitudes towards mental illness Additionally, the intervention resulted in improved overall mental health of the participants themselves However, the percent who provided some or a lot ofhelp did not differ between groups (Kitchener& Jorrn, 2004). Additional research rigorously evaluating MHFA for its impact on intervention recipients? suicidal behavior is needed (Kitchener 8: .Iorm, 2006). 29 Gatekeeper training has also been a primary part of all Gorret Lee Smith (GL5) Suicide Prevention Program which is in place in 49 states and 48 tribes. A multi-site evaluation assessed the impact of community gatekeeper training on suicide attempts and deaths by comparing the change in suicide rates and nonfatal suicidal behavior among young people aged 10-24 in counties implementing GL5 trainings, with the trajectory observed in similar counties that did not implement these trainings. Counties that implemented GL5 trainings had significantly lower youth suicide rates one year following the training implementation {Walrath, Garraza, Reid, Goldston, 8L McKeon, 2015). This finding equates to a decrease of 1 suicide death per 100,000 among youth ages 10 to 24, or the prevention of approximately 237 deaths in the age group, between 2007 and 2010. Counties implementing GL5 program activities, including gatekeeper training, also had significantly lower suicide attempt rates among youth ages 16 to 23 in the year following implementation of the GL5 program than did similar counties that did not implement GL5 activities (4.9 fewer attempts per 1000 youths; (Godoy Garraza, Walrath, Goldston, Reid, 8L McKeon, 2015)). More than 79,000 suicide attempts may have been prevented during the period examined, following implementation of the GL5 program. Screening combined with care management and overall continuity of care. The Henry Ford healthcare system is a large health maintenance organization (HMO) in the state of Michigan. Henry Ford?s Perfect Depression Core program was the pre-cursor to what is now called Zero Suicide, and its overall goal was to eliminate suicide among its members. More broadly, the aim was to redesign delivery of depression care to achieve "breakthrough improvement" in quality and safety by focusing on six aims: effectiveness, safety, patient centeredness, timeliness, efficiency, and equity among patients. The program screened and assessed each patient for suicide risk and implemented coordinated continuous follow-up care system wide (C. E. Coffey, 2006). An examination of the impact of the program found that there was a dramatic and statistically significant decrease in the rate ofsuicide between the baseline years, 1999 and 2000, prior to the intervention to the intervention years, 2002-2009. During this time period, the suicide rate fell by 82% (C. E. Coffey, 2006; C. E. Coffey, Coffey, 8L Ahmedani, 2013}. Further, among HMO members who received mental health specialty services, the suicide rate decreased from in 1999 to 47.6i100,000 in 2010 with a mean of over the time period. Additionally, for those HMO members who accessed only general medical services as opposed to specialty mental health services, the suicide rate increased, from 27/100,000 to 56/100,000 Similarly, in the state of Michigan, rates of suicide in the general population increased over the period from 98/100,000 to 12.5f100,000 {p<.001) (M. Coffey, Coffey, Ahmedani, 2015). Crisis intervention. Suicide prevention hotlines are one way to provide crisis intervention. In an evaluation of the effectiveness of the Notionoi Suicide Prevention Lifeline (NSPL) to prevent 30 suicide, 1,085 suicidal individuals who called the hotline completed a standard risk assessment for suicide, and 380 of those completed a follow-up assessment between 1 and 52 days (mean=13.5 days) after the initial assessment. Researchers found that over half of the initial sample were seriously considering suicide when they called, and they had a plan for their suicide. Researchers also found that among follow-up participants, there was a significant decrease in pain hopelessness p<.001) and intent to die p<.01) between initiation of the call (time 1} to follow-up (time 3). Between time 2 (end of the call) to time 3, the effect remained for pain and hopelessness p<.001) but was not significant for intent to die. (Gould, Kalafat, Harrismunfakh, 8t Kleinman, 2007). In another study, this time employing a randomized controlled trial, Gould, Cross, Pisani, Munfakh, and Kleinman (2013] assessed the impact of the Applied Suicide intervention Training a widely implemented training program that helps hotline counselors, emergency workers, and other gatekeepers to identify and connect with suicidal individuals, understand their reasoning for living and dying, and assist with safely connecting those in need to available resources. The training was evaluated across the NSPL network of hotlines over the period 2008-2009. Using data from 1,410 suicidal individuals who called 17 Lifeline centers, researchers found that compared to callers who spoke to counselors that received the usual care training, individuals who spoke with counselors without training in significantly more likely to feel depressed (1.01, suicidal (1.39, more overwhelmed (1.18, 1.82), and less hopeful (1.35 (1.04, 1.77)} by the end of their call to the hotline compared to those with training in Counselors trained in were also more skilled at keeping callers on the phone longer and establishing a connection with them. However, training in did not result in more comprehensive suicide risk assessments than usual care training (Gould et al., 2013]. 31 Intervene to Lessen Harms and Prevent Future Risk Rationale Individuals who have experienced mental health challenges, suicidal ideation, who have made suicide attempts or engaged in non-suicidal self-injury are at increased risk of suicide Office ofthe Surgeon General 81 National Action Alliance for Suicide Prevention, 2012). Risk ofsuicide can also increase among those who have lost a friend, family member, co-worker, or other acquaintance to suicide (Pitman, Osborn, King, 8: Erlangsen, 2014}. Exposure to sensationalized or uninformed reporting regarding on suicide may heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion (Etzersdorfer Sonneck, 1998; Niederkrotenthaler 81'. Sonneck, 2007}. Approaches The four approaches included here to lesson harms and reduce future risk of suicide among those at increased risk focus on providing appropriate mental healthcare, continuity of care, caring for the bereaved, and providing safe messaging around suicide. a Treatment for people at-risk of suicide typically includes various forms of delivered by licensed providers to help individuals with mental health problems and other risk factors for suicide with problem-solving, impulsivity and emotion regulation. Treatment usually takes place in a one on one or group format between patients and clinicians in mental healthcare settings and can vary in duration from several weeks to ongoing therapy for years in some cases. a Treatment to prevent re-attempts. These approaches typically include follow-up contact and use diverse modalities home visits, mail, telephone, e-mail) to engage recent suicide attempt survivors in continued treatment to prevent re-attempts. Treatment may focus on improved coping skills, mindfulness, and other emotional regulation skills, and may include case management home visits to increase adherence to treatment and continuity of care; and one- on-one interpersonal therapy and/or group therapy. Approaches that engage and connect attempters to peers and providers are especially important because many attempters do not present to aftercare; 1296-2596 reattempt within a year, and 396-996 of attempt survivors die by suicide within 1 to 5 years of their initial attempt {lnagaki et al., 2015) I Postvention approaches are implemented offer a suicide has taken place and may include debriefing sessions, counseling, and/'or bereavement support groups for surviving friends and family members/loved ones. These programs have not typically been evaluated for their impact on suicide or suicidal behavior but may reduce survivors? guilt, feelings of depression, and complicated grief (Szumilas 8: Kutcher, 2011}. 32 Safe messaging following a suicide. The manner in which information on a recent suicide is communicated to the public school assemblies, mass media, social media) can heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion. Therefore, responsible and safe reporting may help prevent suicide and suicide contagion. Potential Outcomes I Reductions in mental health-related sequelae 0 Increases in connectedness - Improvements in coping skills 0 Improvements in messaging following suicide - Reductions in re-attempts I Reductions in contagion effects related to suicide Evidence The evidence addressing strategies to lesson harm and prevent future risk of suicide includes the evaluation of effects of specific approaches on risk and protective factors as well as suicide-related mortality. However, because the evaluation of suicide-related mortality requires large sample sizes and extended follow-up, much of the evidence in this area primarily focuses on risk and protective factors. Treatment for people at-risk of suicide. There are a number of treatments with evidence of impact on risk and protective factors for suicide. One example is the improving Mood? Promoting Access to Collaborative Treatment program. aims to prevent suicide among older primary care patients by reducing suicide ideation and depression in primary care settings. it facilitates the development of a therapeutic alliance, a personalized treatment plan that includes patient preferences, as well as proactive follow-up {biweekly during an acute phase and during continuation phase} by a depression care manager (Hunkeler et al., 2006}. The program has been shown to significantly improve quality of life, and to reduce functional impairment, depression and suicidal ideation over 24-months of follow-up (Hunkeler et al., 2006; Unutzer et al., 2006) relative to patients who received care as usual. Another example is Collaborative Assessment and Management ofSuicialality (CAMS), which is a therapeutic approach for suicide-specific assessment and treatment of patient?s suicide risk. This flexible approach can be used across treatment settings and clinician theoretical orientations and involves the clinician and patient working together in an interactive assessment process to 33 develop patient-specific treatment plans. CAMS sessions are collaborative and involve constant patient input about what is and is not working with the ultimate goal of enhancing the therapeutic alliance and increasing treatment motivation in the suicidal patient. CAMS been tested and supported in 6 correlational studies (Jobes, 2012), in a variety of inpatient and outpatient settings and in one RCT with several additional RCTs under way. CAMS has been associated with significant improvements in suicidal ideation, overall distress, and feelings of hopelessness at 12 month follow-up among a community-based sample of suicidal outpatients. (Comtois et al., 2011). Other examples include Dialectical Behavioral Therapy (DST) and Attachment-Based Family Therapy (ABFT). a multicomponent therapy for individuals at high risk for suicide and who may struggle with impulsivity and emotional regulation. The components of BET include individual therapy, group skills training, between-session telephone coaching and a therapist consultation team. In a randomized controlled trial of women with recent suicidal or self- injurious behavior, those receiving DBT were half as likely to make a suicide attempt at two-year follow-up than women receiving community treatment (23% vs required less hospitalization for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined (Linehan et al., 2006). ABFT is a program for adolescents aged 12-18 and is designed to treat clinically diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxiety (Diamond et al., 2010). A randomized controlled trial of ABFT found that suicidal adolescents assigned to ABFT experienced significantly greater improvement in suicidal ideation over 24 weeks of follow-up than did adolescents assigned to enhanced usual care. Additionally, a significantly higher percentage participants reported no suicidal ideation in the week prior to assessment at 12 weeks than did adolescents receiving enhanced usual care (69.2% vs. 34.6%) and at 24 weeks (82.1% vs. 46.2%) (Diamond et al., 2010). Treatment to prevent re-attempts. Several strategies that aim to prevent re-attempts have demonstrated impact on reducing suicidal behavior. For example, Emergency Department Brief intervention with Foiiow-ap Visits is a program that involves a one-hour discharge information session that addresses suicidal behavior, distress, risk and protective factors, alternatives to suicidal behavior, and referral options, combined with nine follow-up contacts over 18 months (at 1, 2, 4, 2, 11 weeks and 4, 6, 12, 18 months). Follow-up contacts are either conducted by phone or through home visits according to a specific time line for up to 18-months. A randomized controlled trial that enrolled suicide attempters from eight hospital emergency departments in five culturally different countries (Brazil, India, Sri Lanka, Iran, and China) found that a brief intervention combined with 9 follow-up visits over 18-months was associated with significantly 34 fewer deaths from suicide relative to a treatment-as-usual group versus respectively} {Fleischmann et al., 2008). Another example of treatment to prevent re-attempts involves active foiiow?up contact approaches such as postcards, letters, and telephone calls intended to increase a patient?s sense of connectedness with health care providers and decrease isolation. These approaches include expression of care and support and typically invite patients to reconnect with their provider. Contacts are made periodically or every few months in the first 12 months post- discharge with some programs continuing contact for two or more years). In a meta-analysis conducted by lnagaki et al. {2015), interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for suicide attempt were found to reduce reattempts by approximately 17% for up to 12 months post-discharge; however, the effects of these approaches over periods of time longer than one year on reattempts has not yet been demonstrated. Also, because the number of trials and associated sample sizes included in this meta-analysis were small, it was not possible to determine the effect of active contact and follow- up approaches on death by suicide. In a randomized controlled trial of the post-crisis suicide prevention long-term follow-up contact approach, Motto and Bostrom (2001) found that patients who refused ongoing care but who were randomized to be contacted by letterfourtimes per year had a lower rate of suicide over two years of follow-up than did patients in the control group who received no further contact. Other studies have also shown post-crisis letters and coping cards to be protective against suicide ideation and attempts (Hassanian-Moghaddam, Sarjami, Kolahi, Carter, 2011; Wang et al., 2016). Finally, Cognitive Behavior Therapy for Suicide Prevention (CST-5P) is an example of a therapeutic approach to prevent re-attempts. It uses a risk-reduction, relapse prevention approach that includes an analysis of proximal risk factors and stressors relationship problems, school or work-related difficulties) leading up to and following the suicidal event; safety plan development; skill building; and also has family skill modules focused on family support and communication patterns as well as improving the family?s problem solving skills. A randomized controlled trial of found that 10-session outpatient cognitive therapy designed to prevent repeat suicide attempts resulted in a 50% reduction in the likelihood of a suicide reattempt among adults who had been admitted to an emergency department for a suicide attempt relative to treatment as usual (Brown et al., 2005). Postvention programs are implemented with the goal of providing support to survivors of others? suicide to reduce their own risk of suicide. One example of a postvention program, StandBy Response Service (StandBy), provides clients with face-to-face outreach and telephone support through a professional crisis response team. Site coordinators develop customized case 35 management plans, referring clients to other existing community services matched to their needs {Vissen Comans, 8; Scuffham, 2014). in a study by ?v'isser et al. [2014), StonolBy clients were significantly less likely to be at high risk for suicidality than a suicide bereaved comparison group who had not had contact with the StondBy program {48% and 64% respectively). Additionally, research suggests that active postvention approaches in which outreach to suicide survivors occurs at the scene of a suicide is associated with intake into treatment sooner, greater attendance at support group meetings, and attendance at more meetings compared to passive postvention (versus passive approaches where survivors self-refer for services) (J. Cerel Campbell, 2008). Safe messaging following a suicide. Safe messaging after a suicide can help assure that reporting of the event is done in such a way to reduce risk to consumers of news media and other messaging who may be particularly vulnerable. One way to ensure safe messaging following a suicide is to encourage that reporters adhere to Recommendations for Reporting on Suicide Reports that are both inclusive of suicide prevention messages, stories of hope and resilience, risk and protective factors, and links to helping resources hotline) and that avoid sensationalizing events or reducing suicide to one cause can help reduce the likelihood of suicide contagion. The most compelling evidence supporting the effect of recommendations for reporting on suicide on reduction in suicides comes from Austria. After a sharp increase in suicides on the Viennese subway, media guidelines were introduced and an interrupted time series design was used to evaluate the national impact ofthe guidelines on subsequent suicides. Changes in the quality and quantity of media reporting resulted in a nationwide significant reduction of 81 suicides annually (Niederkrotenthaler 8.1 Sonneck, 2007). Finally, research suggests that not only does reporting on suicide in a negative way reporting on suicide and repetition) have harmful effects on suicide, but reporting on positive coping skills in the face of adversity can also demonstrate protective effects against suicide (Niederkrotenthaler et al., 2010). Reports of individual suicidal ideation not accompanied by reports of suicide or suicide attempts, along with reports describing a ?mastery? of a crisis situation where adversities were overcome, associated with significant decreases in suicide rates in the time period immediately following such reports {Niederkrotenthaler et al., 2010). 36 Sector Involvement Public health can play an important and unique role in addressing suicide. Public health agencies, which typically place prevention at the forefront of efforts and work to create broad population-level impact, can bring critical leadership and resources to bear on this problem. For example, these agencies can serve as a convener, bringing together partners and stakeholders to plan, prioritize, and coordinate suicide prevention efforts. Public health agencies are also well positioned to collect and disseminate data, implement preventive measures, evaluate programs, and track progress. Although public health can play a leadership role in preventing suicide, the strategies and approaches outlined in this technical package cannot be accomplished by the public health sector alone. As noted in the National Strategy to Prevent Suicide, the integration and coordination of prevention activities across sectors and settings is critical for expanding the reach and impact of suicide prevention efforts. Other sectors vital to implementing this package include, but are not limited to, education, government (local, state, and federal), social services, health services, business, labor, justice, housing, media, and organizations that comprise the civil society sector such as faith-based organizations, youth-serving organizations, foundations, and other non-governmental organizations. Collectively, these sectors can make a difference in preventing suicide by impacting the various contexts and underlying risks that contribute to suicide. The strategies and approaches described in this technical package are summarized in Appendix A along with the relevant sectors that are well positioned to lead implementation efforts. For example, business and labor, health care insurers and providers, and government entities are in the best position to implement programs and policies that Strengthen Economic Supports and Access to Mental Health Care. These types of supports go beyond individual behavior change and require commitment and support from those sectors that can directly address some of the underlying risks and the environmental contexts that increase the risk for suicide. Public health entities can play an important role by gathering and information to inform policy, raise awareness, and evaluate the effectiveness of various policies. Moreover, partnerships with non-governmental and community organizations can be instrumental in increasing awareness of and garnering support for policies affecting individuals and families. The public health sector has been atthe forefront of many community-based prevention efforts, working collaboratively with schools and community-based organizations, to change social norms and positively impact health behavior. Public health is well suited to take on a similar leadership role in Promoting Connectedness through peer norm and community engagement activities and supporting the development, evaluation, and adoption of effective programs that Teach Coping and Problem-Solving Skills to prevent suicide from happening in the first place. These programs are often delivered in school and community settings, making education and non-governmental organizations vital partners in prevention. 37 Businesses, workplaces, and local and state government entities, on the other hand, are in the best position to establish policies and support practices that Create Protective Environments where people live, work, and play. Public health entities can play an important role by gathering and information, working with other agencies within the executive branch of their state or local government in support of policy and other approaches, and evaluating the effectiveness of measures taken. In a similar fashion, public health entities can partner with schools, workplaces, and community organizations to implement and evaluate prevention programs, policies and practices geared toward creating safe, healthy, and supportive environments. Finally, this technical package includes a number of interventions delivered in hospital, primary care, behavioral health care, and community settings designed to identify and Support People At?Risk and to Lessen Harms and Prevent Future Risk. The intensity and activities of these interventions require the expertise of professionals who are licensed and trained to deliver critical intervention support. The health care, social services, and justice sectors can work collaboratively to support individuals at high- risk for suicide and their families. These activities also require coordination of supports across various service providers and community organizations. Regardless of strategy, action by many sectors will be necessary for the successful implementation of this package. In this regard, all sectors can play an important and influential role in preventing suicide from happening in the first place and lessening the immediate and long-term harms of suicidal behavior by helping those in times of crisis get the services and support they need. 38 Monitoring and Evaluation Monitoring and evaluation are necessary components of the public health approach to prevention. It is important to have timely and reliable data to monitor the extent of the problem and to evaluate the impact of prevention efforts. Data are necessary for program implementation as planning, implementation, and assessment all rely on accurate measurement of the problem. Surveillance data helps researchers and practitioners track changes in the burden of suicide. Surveillance systems exist at the federal, state, and local levels. It is important to assess the availability of surveillance data and data systems across these levels to identify and address gaps in the systems. CDC's National Vital Statistics System and the National Violent Death Reporting System are examples of surveillance systems that provide data on deaths from suicide. for example, is a state-based surveillance system that combines data from death certificates, law enforcement reports, and coroner or medical examiner reports to provide detailed information on the circumstances of violent deaths, including suicide, which can assist communities in guiding prevention approaches (Blair, Fowler, Jack, 8t Crosby, 2016}. The National Electronic Injury Surveillance System?All Injury Program provides nationally representative data about all types and causes of nonfatal injuries treated in U.S. hospital emergency departments, and can be used to assess national rates of, and trends in, self-harm injuries by cause falls, poisoning, etc.), age, race/ethnicity, sex, disposition {where the injured person goes when released from the Emergency Department). In addition to information on deaths and nonfatal injuries, there are also surveillance systems that provide national, state, and some local estimates of suicidal behavior. The Youth Risk Behavior Surveillance System collects information from a nationally representative sample of 9-12 grade students and is a key resource in monitoring health-risk behaviors among youth, including whether youth have seriously considered attempting suicide, attempted suicide, made a plan, or required treatment by a doctor or nurse for a suicide attempt that resulted in an injury, poisoning, or overdose (Brener et al., 2013). The data are obtained from a national school-based survey conducted by CDC as well as from state, territorial, tribal, and large urban school district surveys conducted by education and health agencies. The National Survey on Drug Use and Health (NSDUH) is an annual survey of the civilian, non- institutionalized population aged 12 years and older. NSDUH provides both national and state-level estimates of substance use, including alcohol, tobacco, illicit drugs, and non-medical use of prescription drugs; and mental health, including past year mental illness, co-occurring illnesses, service utilization, along with suicide ideation, suicide plans, and suicide attempts. NSDUH is a key resource to track trends in suicide-related risk factors in the population and to help identify groups at increased risk. It is also important at all levels (local, state, and federal) to address gaps in responses, track progress of prevention efforts and evaluate the impact of those efforts, including the impact of this technical package. Evaluation data, produced through program implementation and monitoring, is essential to provide information on what does and does not work to reduce rates of suicide and its associated risk 39 and protective factors. Theories of change and logic models that identify short, intermediate, and long- term outcomes are an important part of program evaluation. The evidence-base for suicide prevention has advanced greatly over the last few decades. However, additional research is needed to understand the impact of programs, policies, and practices on suicide (and suicide attempts, at a minimum), as opposed to merely examining their effectiveness on riskfactors. More research is also needed to examine the effectiveness of upstream {before risk occurs) and community-level strategies to prevent suicide at the population level. Lastly, it will be important for researchers to test the effectiveness of combinations of the strategies and approaches included in this package. Most existing evaluations focus on approaches implemented in isolation, but there is potential to understand the synergistic effects within a comprehensive prevention approach. Conclusion Suicide is a serious public health problem whose rates have been on the rise for more than a decade and whose costs stretch well into the billions of dollars each year. While suicide is a rare outcome statistically, its human impact has a ripple effect that is far-reaching. Each of us likely interacts with suicide survivors, those with lived experience, and those with thoughts of suicide, on a daily basis--at home, at work, and in our communities. Suicide and suicide attempts are therefore public health issues of societal concern. Fortunately, like many public health problems, suicide is preventable, and fortunately more is being done to prevent suicide than ever before, as evidenced by the work of the National Action Alliance for Suicide Prevention, the release of the first world report on suicide, and more timely surveillance data, to name just a few examples. Unfortunately and unlike most other public health problems, suicide prevention must still overcome the: stigma, shame, and secrecy related to help-seeking, mental illness, being a survivor, or someone with lived experience; misplaced fear related to asking someone about their risk of suicide {versus the fear and consequence of not asking), fear of taking up strategies known to be effective but perhaps unpopular; misinformation about suicide preventability, misplaced emphasis by the media and others on sensational aspects of suicide, and disproportionate funding given its public health burden. in an effort to continue pushing the field and society further towards prevention, this technical package. includes strategies and approaches that ideally would be used in a comprehensive fashion, in combination--in a multi-level, multi-sectoral way. This technical package includes strategies and approaches targeting upstream prevention social emotional learning for children and youth), as well as strategies focused more le.g., cognitive behavioral treatment to prevent re- attempts). It includes strategies that range from a focus on the whole population regardless of risk to strategies designed to support people at highest risk. Importantly, this technical package extends the bounds of the typical prevention strategies to consider approaches that go beyond individual behavior 40 change to better address risk factors impacting communities and populations more broadly policies to stabilize housing and community engagement initiatives. While the evidence base continues to emerge, the collection of programs, policies, and practices laid out here are available for implementation now. And in keeping with good public health practice, the intent is that monitoring and evaluation will play a key role in that implementation. 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Housmg pollcles Government {locaL The National Neighborhood Stabilization state, Federal) Program Coverage of mental health conditions in health insurance policies Health ca re Strengthen Mental Health Parity Laws 1/ access to Government (state, mental health Fadera? ca re Reducing access to lethal means among persons at-risk Government (local, intervening at suicide hot spots state) 1/ Safe storage practices Public Health Establish protective Organlzatlonal pollcles and culture Busmesstabor . Together for Life envnronments Government (local, US Air Force Suicide Prevention Program 1/ state, Fed eral) 50 Best Available Evidence Communitywbased policies to reduce excessive alcohol use Alcohol outlet density 1/ Government {local, state] Businessllabor Promote connectedness Peer norm approaches Public Health Sources of Strength Education Communitvrengagement activities Public Health Greening vacant urban spaces Government {local} Social emotional learning Public Health Youth Aware of Mental Health Program Education Signs of Suicide Teach co in 3 Good Behavior Game and problem- solvmg Sklils Parenting skill and family relationship approaches Public Health The incredible Years Education Strengthening Families 10-14 Gatekeeper training Public Health Mental Health First Aid Healthcare Screening combined with care management Healthcare Identify and 51 support people alt-risk Henry Ford Perfect Depression Core {Pre- cursor to Zero Suicide) Best Available Evidence Social Services Crisis Intervention Public Health Active foiio w?up con toct approaches EST for Suicide Prevention Notionoi Suicide Prevention Lifeiine Social Services Appiied Suicide intervention Training Treatment for people at risk of suicide Health ca re improving Mood Promoting Access to v? Social Services Coiioborotive Treatment Justice Coiiohorotive Assessment and Management v? Suic?doii CAMS Intervene to I lessen harms Dioiecticoi Behovioroi Therapy and prevent future risk Attachment?Based Fomiiv Therapy Treatment to prevent re-attempts Health ca re ED Brief intervention with Foiiow-up Visits Social Services v? Postvention Heaithcare 52 Best Available Evidence StandBy Response Service Safe messaging following a suicide Media Guidelines 1/ Public Health Media 1This column refers to the lead sectors well positioned to bring leadership and resources to implementation efforts. For each strategy, there are many other sectors such as non-governmental organizations that are instrumental to prevention planning and implementing the specific programmatic activities. Preventing Suicide: A Technical Package of Policy, Programs, and Practices Prepared by: Deb Stone, MSW, MPH Kristin Holland, MPH Brad Bartholow, Alex Crosby, MD, MPH Shane Davis, Natalie Wilkins, Division of Violence Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention 2016 Policies, Programs, and Practices to Support individuals, Families, Communities: A Technical Package to Prevent Suicide is a publication of the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention. Centers for Disease Control and Prevention Thomas R. Frieden, MD, MPH, Director National Center for injury Prevention and Control Debra E. Houry, MD, MPH, Director Division of Violence Prevention James A. Mercy, Director Suggested Citation: Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, 5., and Wilkins, N. Policies, Programs, and Practices to Support Individuals, Families, and Communities: A Technicai Package to Prevent Suicide. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2016. Contents Acknowledgements 4 External Reviewers 5 Overview of Technical Package 6 Strengthen Economic Strengthen Access to Mental Health Care 16 Create Protective Environments 18 Promote Connectedness 22 Teach Coping and Problem-Solving Skills 24 Identity and Support People At-Risk 28 Intervene to Lessen Harms and Prevent Future Risk 32 Sector Involvement 37 Monitoring and Evaluation 39 Conclusion 40 References 42 Appendix A 50 Acknowledgments [to be inserted later] External Reviewers [to be inserted later] Overview This technical package represents a select group of strategies based on the best available evidence to help communities and states sharpen their focus on prevention activities with the greatest potential to prevent suicide. These strategies include strengthening economic supports; strengthening access to mental health care; creating protective environments; promoting connectedness; teaching coping and problem-solving skills; identifying and supporting people at-risk; and intervening to lessen harms and prevent future risk. The strategies represented in this package include those with a focus on preventing suicide from happening in the first place as well as approaches to lessen the immediate and long-term harms of suicidal behavior for individuals, families, communities, and society. The strategies in the technical package support the goals and objectives of the National Strategy for Suicide Prevention and the National Action Alliance for Suicide Prevention?s priority to strengthen community-based prevention. Commitment, cooperation, and leadership from numerous sectors, including public health, education, justice, health care, social services, business, labor, and government can bring about the successful implementation of this package. What is a Technical Package? A technical package is a compilation of a core set of strategies to achieve and sustain substantial reductions in a specific risk factor or outcome {Friedem 2014). Technical packages help communities and states prioritize prevention activities based on the best available evidence. This technical package has three components. The first component is the strategy or the preventive direction or actions to achieve the goal of preventing suicide. The second component is the approach. The approach includes the specific ways to advance the strategy. This can be accomplished through programs, policies, and practices. The approaches included come primarily from studies based in the United States. The evidence for each of the approaches in preventing suicide or its associated risk factors is included as the third component. This package is intended as a resource to guide and inform prevention decision-making in communities and states. Preventing Suicide is a Priority Suicide, as defined by the Centers for Disease Control and Prevention (CDC), is part of a broader class of behavior called seif?directeo? vioience. Self-directed violence refers to behavior directed at oneself that deliberately results in injury or the potentiai for injury (A.E. Crosby, Ortega, 81 Melanson, 2011). Self- directed violence may be suicide! or non-suicidal in nature. For the purposes of this document, we refer only to behavior where suicide is intended: - Suicide is a death caused by self-directed injurious behavior with any intent to die as a result of the behavior. - Suicide attempt is defined as a non-fatal self-directed and potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury. Suicide is highly prevalent. Suicide presents a major challenge to public health in the United States and worldwide. It contributes to premature death, morbidity, lost productivity, and health care costs (U.S. Office of the Surgeon General 8: National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014}. in 2014 (the most recent year of available death data), suicide was responsible for 42,773 deaths in the U.S., which is approximately one suicide every 12 minutes (Centers for Disease Control and Prevention, 2016d). In 2014, suicide ranked as the 10th leading cause of death and has been among the top 12 leading causes of death since 1975 in the U5 (Centers for Disease Control and Prevention, 2016d). Overall suicide rates have increased 24% from 1999 to 2014 (Curtin, Warner, 8; Hedegaard, 2016). Suicide is a problem throughout the life span; it is the second leading cause of death among those aged 10?34 years; it is the fourth leading cause among persons in their 405 and seventh among persons in their 505. Suicide rates vary by raceiethnicity with the highest rates, across the lifespan, occurring among non-Hispanic American lndiaanlaska Native (rate: Among young people are disproportionately at increased risk of suicide with young males aged 25-29 experiencing the highest rates (rate: 5697100000}. Moreover, suicide rates among non-Hispanic AIIAN have increased by 48.7% since 1999 (Centers for Disease Control and Prevention, 2016d). Suicides reflect only a portion of the problem (A.E. Crosby, Han, Ortega, Parks, 8t Gfroerer, 2011). Substantially more people are hospitalized as a result of nonfatal suicidal behavior (Le. suicide attempts) than are fatally injured, and an even greater number are either treated in ambulatory settings emergency departments) or not treated at all (A.E. Crosby, Han, et al., 2011). For example, during 2014, among adults aged 18 years and older, for every one suicide there were 9 adults treated in hospital emergency departments for self-harm injuries, 27 who reported making a suicide attempt, and over 227 who reported seriously considering suicide ideation) (Ferdon et al., In press}. Suicide is associated with several risk and protective factors. Suicide, like other human behaviors, has no single determining cause. Instead, suicide occurs in response to multiple biological, interpersonal, environmental and societal influences that interact with one another, often over time. The social-ecological mode ?- encompassing multiple levels of focus from the individual, relationship, community, and societal-- is a useful framework for viewing and understanding suicide risk factors identified in the literature (Dahlberg Krug, 2002}. Risk and protective factors for suicide exist at each level. For example, risk factors include: individual level: History of depression and other mental illnesses, hopelessness, substance abuse, certain health conditions, previous suicide attempt, violence victimization?d perpetration, and genetic and biological determinants Relationship level: High conflict or violent relationships, sense of isolation and lack of social support, family/loved one?s history of suicide, financial and work stress 0 Community level: inadequate community connectedness, barriers to health care lack of access to providers and medications) Societal level: Availability of lethal means of suicide, unsafe media portrayals of suicide, stigma associated with help-seeking and mental illness (U.S. Office of the Surgeon General at National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). It is important to recognize that the vast majority of individuals who are depressed or who have other risk factors noted, do not die by suicide. Furthermore, the relevance of each risk factor can vary by age, race, gender, sexual orientation, residential geography, and socio-cultural and economic status (US. Office of the Surgeon General 8: National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). Protective factors, or those influences that guard against the risk for suicide, can also be found across the different levels of the social-ecological model. Protective factors identified in the literature include: effective coping and problem solving skills, moral objections to suicide, strong and supportive relationships with partners, friends, and family; connectedness to school, community and other social institutions; availability of quality and ongoing physical and mental health care, and reduced access to lethal means (US. Office of the Surgeon General 8: National Action Alliance for Suicide Prevention, 2012; World Health Organization, 2014). These protective factors can either counter a specific risk factor or guard against a number of risks associated with suicide. Suicide is connected to other forms of violence. Suicide and other forms of violence often share some of the same root causes (Butchart, Phinney, Check, 8; Villaveces, 2004; Klevens, Simon, 8: Chen, 2012). For example, in neighborhoods where there is low social cohesion, or where residents don?t support and trust each other, people are at higher risk for suicide (Desai, Dausey, 8L Rosenheck, 2005) as well as perpetration of child maltreatment (Coulton, Crampton, Irwin, Spilsbury, 8i. Korbin, 2007; Freisthler, Merritt, 8: LaScala, 2006), teen dating violence (Capaldi, Knoble, Shortt, 8: Kim, 2012), intimate partner violence (Pinchevsky 8: Wright, 2012), and youth violence (Sampson, Morenoff, 8: Gannon-Rowley, 2002). Additionally, a lack of economic opportunities and unemployment are associated with suicide (Luo, Florence, Quispe-Agnoli, Ouyang, 8-: Crosby, 2011; Reeves et al., 2012), as well as perpetration of child maltreatment (D. Runyan, Wattam, lkeda, Hassan, 81 Ramiro, 2002), intimate partner violence (Heise 8: Garcia-Moreno, 2002; Pinchevsky Wright, 2012), sexual violence (Centers for Disease Control and Prevention, 2016c) and youth violence (Wilson, 2011). Other shared risk factors for suicide and violence occur at the individual level and include substance abuse, mental health problems, witnessing violence, and a lack of problem-solving skills (Centers for Disease Control and Prevention, 2016a, 2016c, 2016e; U.S. Office of the Surgeon General National Action Alliance for Suicide Prevention, 2012). Just as risk factors may be shared across suicide and violence, so too may protective factors overlap. For example, 8 emmcomeesdnee to err-?5 Borowsky, Hogan, 8: Ireland, 199?; Centers for Disease Control and Prevention, 2016b; Coulton et al., 2007; Kleiman, Riskind, Schaefer, 8t Weingarden, 2012; Pinchevsky Wright, 2012; Widome, Sieving, Harpin, 8t Hearst, 2003), school (Basile, Espelage, Rivers, McMahon, 8a. Simon, 2009; Capaldi et al., 2012; Carter, McGee, Taylor, 0 Williams, 2007; DeGue et al., 2013; Hong, Kral, Espelage, SLAIIen?Meares, 2012; Losel Fa rrington, 2012), family [Ca paldi et al., 2012; Centers for Disease Control and Prevention, 2016a; Elgar, Craig, Boyce, Morgan, 8; ?v'ellavZarb, 2009; Maimon, Browning, 81 Brooks-Gunn, 2010; Resnick, Ireland, at Borowsky, 2004), caring adults (Capaldi et al., 2012; Losel 8: Farrington, 2012; Maimon et al., 2010), and pro-social peers (Capaldi et al., 2012; Losel 8: Farrington, 2012) enhances resilience to suicide and other forms of violence. .- Comment IAI: From TS: lfound this wording somewhat awkward. Comment IA): From LLD: The Crosby 8: Sacks reference is missing from the reference list. i looked it up onllne and noticed that the 13 million estimate is based on knowing a suicide decedent in the past year. Knowing someone who died by suicide seems potentially broader to me than being directly impacted. Comment IA): From TS: Has anyone updated this?I It would be good to check. 1 Comment IAI: From LLD: they may also be impacted in other ways loss of The health and economic consequences of suicide are substantial. Suicide and suicide attempts have far-reaching consequences for individuals, families, and communities (Dunne, El. Dunne- Maxim, 1987; Mishara, 1995; National Action Alliance for Suicide Prevention: Suicide Attempt Survivors Task Force, 2014; National Action Alliance for Suicide Prevention: Survivors of Suicide Loss Task Force, 2015]. age .lnanearly II I I study, Crosby and Sacks l2002) estimated that 2% of the U.S. adult population, or 13.2 million adults, knew someone in the prior 12 months who had died by suicide. They also estimated that for each suicide, 425 adults were exposed, or knew about the death. In a more recent study, in one state, Cerel et. al {2016) found that 48% of the weighted survey population knew at least one person who died by suicide in their lifetimes. Research indicates that the impact of knowing someone who died by suicide andlor having lived experience li.e. having attempted suicide oneself) is much more extensive than injury and death. Peopliwith lived experience may suffer long?term health and mental health consequences ranging from anger, guilt, and physical impairment, depending on the means and severity of the attempt {Chapman Dixon?Gordon, 200?). Similarly, survivors of a loved one?s suicide may EaxperiencelongoIn-g?i pain and suffering including complicated grief (Mitchell, Kim, Prigerson, El. Mortimer-Stephens, 2004), stigma, depression, anxiety, post?traumatic stress disorder, and increased risk of suicidal ideation and suicide Ilulie Cerel, McIntosh, Neimeyer, Maple, 8f. Marshall, 2014; Sudak, Maxim, 8: Carpenter, 2008). L_ess discussed but no less important, are the financial and occggational effects for those left behind (Florence, Simon, Haegerich, Luo, a Zhou, 2015). The economic toll of suicide is immense as well. According to conservative estimates, in 2013, suicide cost $50.8 billion in estimated lifetime medical and work-loss costs ?orence et al., 2015). By another stimate flihe total lifetime costs associated with nonfatal injuries and deaths caused by self-directed violence in 2013 were approximately $93.5 billion after adjusting for undersreporting of suicide {Shepard, Gurewich, Lwin, Reed, 8t Silverman, 2015)] The overwhelming burden of these costs results Lfamily income, etc.) Comment From TS: it seems like it would be appropriate to acknowledge the CDC estimate too. Consider using that as a minimum and then say that others have estimated that the costs could be considerably higher after adjusting for ?nder-reporting ofsuicide. from lost productivityr over the life course, with the average cost per suicide being over $1.3 million {Shepard et al., 2016}. Suicide can be prevented. Despite the surrounding suicide, like most public health problems, suicide is preventable Public Health Service, 1999). And while progress will continue to be made into the future, evidence for numerous programs, practices, and policies exists, and manv programs are readv to be implemented now. Just as suicide is not caused bv a single factor, research suggests that suicide will not be prevented by any single intervention taking place in any single setting {Silverman 8i Maris, 1995; U.S. Office of the Surgeon General 8: National Action Alliance for Suicide Prevention, 2012). Rather, suicide prevention is best achieved by a focus across the individual, relationship, familv, communitv, and societal-levels and across all sectors, private and public business, public health, physical and behavioral healthcare, justice, education, labor] {National Action Alliance for Suicide Prevention, 2014; World Health Organization, 2014]. Assessing the Evidence This technical package includes programs, practices, and policies with evidence of impact on suicide or program, practice, or policv selected had to meet at least one of these criteria: a] meta-analvses or svstematic reviews showing impact on suicide; b} evidence from at least one rigorous le.g., randomized controlled trial or quasi-experimental design) evaluation studv that found significant preventive effects on suicide; cl meta~analvses or svstematic reviews showing impact on risk or protective factors for suicide, or cl] evidence from at least one rigorous RCT or quasi-experimental design) evaluation studv that found significant impacts on risk or protective factors for suicide. Finallv, consideration was also given to the likelihood of achieving bene?cial effects on multiple forms of violence; no evidence of harmful effects on specific outcomes or with particular subgroups; and feasibilltv of implementation in a U.S. context if the program, policy, or practice has been evaluated in another countrv. Within this technical package, some approaches do not vet have research evidence demonstrating impact on rates of suicide but instead are supported by evidence indicating impacts on risk or protective factors for suicide helpnseeking, stigma reduction, depression, connectedness). In terms of the strength ofthe evidence, programs that have demonstrated effects on suicidal behavior reductions in deaths, attempts) provide a higher-level of evidence, but the evidence base is not that strong in all areas. For instance, there has been less evaluation of communitv engagement and familv programs on suicidal behavior. Thus, approaches in this package that have effects on risk or protective factors reflect i theEdeveloangmenta-lnature of the evidence base and the use of the best available evidence at a givenl time. It is also important to note that there is often significant heterogeneitv among the programs, policies, or practices that fall within one approach or strategv area in terms of the nature and qualitv ofthe available risk or protective factors for suicide. To be considered for inclusion in the technical packageComment IAI: From TS: ?developmental nature"I doesn't seem correct. Do vou I mean the ?current status? evidence. Not all programs, policies, or practices that utilize the same approach gatekeeper training) are equally effective, and even those that are effective may not work across all populations. Tailoring programs and more evaluation may be necessary to address different population groups. The examples provided are not intended to be a comprehensive list of evidence-based programs, policies, or practices for each approach, but rather illustrate models that have been shown to impact suicide or have beneficial effects on risk or protective factors for suicide. In practice, the effectiveness of the programs, policies and practices identified in this package will be strongly dependent on the quality of their implementation and the communities in which they are implemented. Implementation guidance to assist practitioners, organizations and communities will be developed separately. Context and Cross-Cutting Themes The strategies and approaches that have been included in this technical package represent different levels of the social ecology, with efforts intended to impact the community and societal levels, as well individual and relationship levels. The strategies and approaches are intended to work in combination and reinforce each other to prevent suicide (see box below). The strategies are arranged in order such that those strategies hypothesized to have the greatest potential for broad public health impact on suicide are included first, followed by those that might impact more select populations persons who have already made a suicide attempt}. Preventing Suicide Strategy Approach Strengthen economic supports u. Strengthen household financial security I Housing stabilization policies Strengthen access to mental health care i Coverage of mental health conditions in health insurance policies Create protective environments - Reducing access to lethal means among persons at-risk of suicide - Organizational policies and culture I Community-based policies to reduce excessive alcohol use Promote connectedness I Peer norm approaches I Community engagement activities Teach coping and problem?solving skills - Socialvemotional learning - Parenting skill and family relationship approaches Identify and support people at risk Iv Gatekeeper training I Screening combined with care management 11 Crisis intervention Treatment for people at?risk of suicide Treatment to prevent re-attempts Postvention Safe messaging following a suicide 0 Intervene to lessen harms and prevent future risk Oil! The example programs, policies, and practices have been implemented within particular contexts. The social and cultural context of communities is critically important to take into account when selecting strategies and approaches. Practitioners in the field may be in the best position to assess the needs and of their communities and work with community members to make decisions about the combination of approaches included here that are best suited to their context. Suicide ideation, attempts, morbidity and mortality vary by gender, race/ethnicity, age, occupation, and other important population characteristics. Barriers to disclosure, help seeking, timely access to quality care, and ongoing support may also vary by population and community characteristics. ideally, the availability of multiple approaches tailored to the economic, cultural, and environmental context of individuals and communities are desirable as they may increase the likelihood of removing barriers to supportive and effective care and provide opportunities to develop individual and community resilience. These culturally appropriate approaches can then be included in comprehensive strategies to maximize the public health impact on reducing suicide-related morbidity and mortality among individuals and within communities. This package includes strategies where public health agencies are well positioned to bring leadership and resources to implementation efforts. it also includes strategies where public health can serve as an important collaborator le.g., strategies addressing community and societal level risks], but where leadership and commitment from other sectors such as business, labor or health care is critical to implement a particular policy or program workplace policies; screening combined with care management). The role of various sectors in the implementation of a strategy or approach in preventing suicide is described further in the section on Sector involvement. In the sections that follow, the strategies and approaches with the best available evidence for preventing suicide are described. 12 ?5 Strengthen Economic Supports -n Rationale Studies from the U.S. examining historical trends indicate that suicide rates increase during economic recessions marked by high unemployment rates, job losses, and economic instability and decrease during economic expansions and periods marked by low unemployment rates, particularly for working- age individuals 25 to 64 years old (Luo et al., 2011; Fowler et al., 2015). Economic and ?nancial strain, such as job loss, long periods of unemployment, reduced income, difficulty covering medical, food, and housing expenses, and even the anticipation of such financial stress, can directly increase I an individual?s risk for suicide or indirectly increase risk by exacerbating related physical and mental hiajth groblems; buffering these risks can therefore, potentially protect against suicide (Stack 8i. Wasserman, 200?}. For example, strengthening economic support systems can help people stay in their homes or obtain affordable housing while also paying for necessities such as food and medical care, job training, child care, among other expenses required for daily living. In providing this support, stress and anxiety and the potential for a crisis situation may be reduced, thereby preventing suicide. Approaches Economic supports for individuals and families can be strengthened by targeting household financial security and ensuring stability in housing during periods of economic stress. - Strengthening household ?nancial security can potentially bufferthe risk ofsuicide by providing individuals with the financial means to lessen the stress and hardship associated with a job loss or other unanticipated financial problems. The provision of unemployment benefits and other forms of temporary assistance, livable wages, medical benefits, and retirement and disability insurance to help cover the cost of necessities or to offset costs in the event of disability, are examples ofways to strengthen household financial security. I Housing stabilization policies aim to keep people in their homes and provide housing options for those in need during times of financial insecurity. This may occur through programs that provide affordable housing such as through government subsidies or through other options available to potential homebuyers such as loan modification programs, move-out planning, or financial counseling services that help minimize the risk or impact of foreclosures and eviction. 1 Comment IAI: From TS: was thinking that it might be good to work in a point about how these risks can be directly or indirectly associated with suicide risk because these stressors can exacerbate relationship as well physical and mental health problems. '93 .1 1 {Comment From Consistent tense reduced vs. reduce Comment IM: From LLD: the other packages Use ?RedIJctions you may want to consider Using similar language 2 for your potential outcomes. consistent throughblit. =lcze: -q nun?uh.- Int-AI-uun-Inq-nnunnut Ill-Ill.- a] Potential LutcomeJ Headsets-Reductions in suicide rates I Lower?Reductions in foreclosure rates - Reductions intewer eviction rates Red-aeed?Reductions in emotional distress 13 Evidence There is evidence suggesting that strengthening household financial security and stabilizing housing can reduce suicide risk. Strengthen household ?nancial security. An examination of variations in U.S. unemployment benefit programs across states demonstrated that the impact of unemployment on suicide was offset in those states that provided greater than average unemployment benefits (Cylus. Glymour, Er Avendano, 2014]. Another U.S. study examining the link between unemployment and suicide risk using suicide data, length of unemployment, and job losses found that the duration of unemployment, as opposed tojuat the loss of job, predicted suicide risk {Classen 3.: Dunn, 2012]. Together, these results suggest that not only should state unemployment benefit programs be generous in their ?nancial allocations, but also in their duration. Other measures to strengthen hOUSehold financial security transfer payments related to retirement and disability insurance, unemployment insurance compensation, medical benefits, and other forms of family assistance] have also shown an impact on suicide. A study by Flavin and Radcliff [2009) examined the impact of states? per capita spending on transfer payments, medical benefits, and family assistance {Temporary Assistance to Needy Families and total state spending on suicide rates between 19902000, controlling for a number of suicide risk factors leg, residential mobility, divorce rate, unemployment rate} at the state level. As per capita spending on total transfer payments, medical bene?ts, and family assistance increased there was an associated decrease in state suicide rates. Moreover, it wasn't spending in general that was associated with the reduction but spending on these types of assistance. in terms of lives saved, Flavin 8t Radcliff calculated the cost of reducing a state?s suicide rate by a full point for the years studied. At the national level, they estimated that 3,000 fewer suicides would occur per year nationwide if every state increased theirit_s per capita spending on these types ofare needed to further understand the outcomes impacted by programs such as these. 0 Housing stabilization policies. The Notional Neighborhood Stabilization Program was designed to help neighborhoods suffering from high rates of foreclosure and abandonment by slowing the deterioration ofthe neighborhoods and providing affordable housing options for low, moderate, and middle?income homebuyers. This program also offers financial assistance to eligible individuals for the purchase of a new home. Although this program has not been rigorously evaluated for its impact on suicide outcomes, it addresses foreclosure and eviction, which are 14 Comment IAI: From TS: Consider including a point about this being a correlational study and more evaluation work is needed but it suggests the potential benefits of policies that reach those who are particularly Vulnerable at the times when thEy are in greatest need. Needed. lea as: sets indicate Ibis risk factors for suicide. A longitudinal analysis of annual data on suicides and foreclosures demonstrated that as the proportion of foreclosed properties increased in U.S. states, so did the state suicide rate, particularly among working-aged adults (Houle Light, 2014}. Another study of data from 16 US. states participating in the National Violent Death Reporting System found that suicides precipitated by home foreclosures and evictions increased more than 100% from 2005 (before the housing crisis began) to 2010 (after it had peaked; Fowler, Gladden, Vagi, Barnes, and Frazier (2015)). Most of these suicides occurred prior to the actual loss of the decedent?s home. These findings suggest that integrating suicide prevention resources, messaging, and referrals into financial, foreclosure, and move-out planning and counseling services may help to prevent suicide. 15 Strengthen Access to Mental Health Care 'c Rationale While most people with mental health problems do not attempt or die by suicide (Olfson, Gerhard, Jf I arias [ArsenauIt?Lapierre, Kim, &Turecki, 2004; E. C. Harris 81 Barraclough, 1997; mental illnesses diffeek Tvrer, Reed, 8: Crawford, 2015], previous research indicates that mental illness is an important risk factor for suicide (E. C. Harris 8: Barraclough, 1993; World Health Organization, 2014]. Studies suggest that up i I 1 time of their deaths (Arsenault?Lapierre et al., 2004; Cavanagh, Carson, Sharpe, 3: Lawrie, 2003; Isometsa, 2001}. State-level suicide rates have also been found to be correlated with general mental health measures such as depression (Lang, 2013; Mark, Sherri, Bagalman, 8: Cao, 200?]. Findings from the National Comorbiditv Survev indicate that relatively few people in the 0.5. with mental health disorders receive treatment for those conditions (Kessler et al., 2005). Lack of access to mental health care is one of the contributing factors related to the underuse of mental health services [Cunningham 2009}. identifying wavs to improve access to timely, affordable, and qualitv mental health ca re for people I means that different tvpes of mental health problems pose different risks for suicide, but wasn't sure? Mav want to make the point more explicit Huang, 8: Stroup, 2015; Owens, 2002), End the level of riskeisk conferred bv different types of ?Hep added somelanguage than sweepers 1 Comment From TS: Isn't this to 90% of people who die by suicide mav have had a mental illnessior substance abuse problems at the ,res - Added. 1 omment IAI: From JM: assume this including substance abuse disorder? lt would be good to state this explicitlv. In. Comment IAI: From T5: lfound this sentence confusing. Can vou reword to this. From LLD: could sav: "if a state has a weaker paritv law than the federal paritv law leg, includes coverage for some mental health conditions but not others], then the federal paritv law will replace the state law.? in need is a critical component to suicide prevention {World Health Organization, 2014}. Apart from the treatment benefits, it can also serve to normalize help?seeking behavior and increase the use of such services. Approaches One approach to strengthening access to mental health care is through the provision of mental health coverage in health insurance policies. I Coverage of mental health conditions in health insurance policies. Federal and state laws include provisions for equal coverage of mental health services in health insurance plans that is on par with coverage for other health concerns li.e., mental health paritv}. Benefits and services covered include such things as the number of visits, co-pavs, deductibles, inpatient/outpatient services, prescription drugs. and hospitalizations. If a state has a stronger mental health paritv law than the federal parit?,r law, then insurance plans regulated bv the state must follow the state pa ritv law. If a state has a weaker paritv law than the federal paritv law ie.g.,i includes coverage for some mental health conditions but not others], then the federal paritv law will replace the state law. Equal coverage does not necessarily implv good coverage as health insurance plans vars,r in the extent to which bene?ts and services are offered to address various health conditions. Rather it helps to ensure that mental health services are covered on par with other health concerns. 15 Jhanks, Linda. Accepted your suggestion._, Potential Outcomes teeseased?lncreases in utilization of mental health services DecreasedReductions in of mental illnesses Deereased?Reductions in rates of suicide attempts Beereased-Reductions in rates of suicide Evidence There is evidence suggesting that coverage of mental health conditions in health insurance policies can reduce risk factors associated with suicide and may:F directlv impact suicide rates. I Coverage of mental health conditions in health insurance policies. The National Survev of Drug Use and Health is a nationallv representative survev of the U.S. population that provides data on substance use, mental health conditions, and services utilization. Using data from this survey, K. M. Harris, Carpenter, and See {2006) found that 12 months after states enacted mentoi health parity iows, self-reported use of mental healthcare services significantlv increased. Moreover, subsequent research by Lang {2013] examined state mental health laws and suicide rates between 1990 and 2004 and found that mental health paritv laws, specificallv, were associated with an approximate 5% reduction in suicide rates. This reduction, in the 29 states with parity laws, equated to the prevention of 592 suicides per vear._ Lang et. al (2013} estimated the cost of saving a life through such mandates as mental health paritv bv comparing the loss in wagg attributable to the policy, via increased premiums, to the number of lives saved. Based on these calculations, the cost ofsaving one life was between WEE-3.1 prevented. However, this calculation did not take into account the saving associated with improved mental health among non?suicidal individuals, increases in productivltv, or qualitv of life associated with increased mental health care. As such, this figure is considered the upper bounds on costs incurred and should be interpreted with caution (Lang, 2013}. 1 Comment IAI: From TS: i don?t think this is accurate. I was curious about this study and checked out the paper. I think they are saving that this is the cost incurred per suicide prevented. Thev go on to explain that this is the upper bound and does not reflect the benefits to non? suicidal individuals. Please con?rm this. If vou are going to include this then it will Lhe important to explain it further. 1? Create Protective Environments Rationale Prevention efforts that focus not only on Individual behavior change help?seeking, treatment interventions) but on changes to the environment can increase the likelihood of positive behavioral and health outcomes {Haddom 1980}. Creating environments that address risk and protective factors where individuals live, work, and play, can help prevent suicide {Dahlberg 81 Krug, 2002; U.S. Office of the Surgeon General 8: National Action Alliance for Suicide Prevention, 2012}. For example, rates of suicide and suicide attempts are elevated in certain occupational groups (Han et al., 2016; et al., 2016), therefore, changes to the organizational culture in these occupations, by way of implementation of supportive policies or even physical modifications to the workplace environment, can change social norms, encourage helprseeking, and demonstrate that good health and mental health are valued and Comment IAI: From lid: The word promising has certain connotations when using it around evidence. li?ou say later that the evidence around this strategy is some of the strongest for suicide. These two statements seem somewhat inconsistent. i would use a different word here then promising if you truly believe there is strong evidence. From JH: suggest deleting the word ?promising? From LLD: since we don't want to infer that these are the only approaches for creating protective environments, I might be inclined to change the word ?promising" to ?potential? or "poSsihle" or something along those lines. that stigma and other risk factors for suicide are not L. Knox et al., 2010; National Action Alliance for Suicide Prevention Workplace Task Force, 2015). Similarly, modifying the characteristics of the environment to prevent harmful behavior such as access to lethal means can reduce suicide rates, particularly in times of crisis (Beautrais, Gibb, Fergusson, Horwood, 31. Larkin, 2009,- A.E. Crosby, Espitia~ Hardeman, Ortega, 8t Lozano, 2013; Kaplan et al., 2013; Miller, Warren, Hemenway, 8i Azrael, 2015; C. W. Runyan et al., 2016Approaches The current evidence suggests three Wootential approaches for creating environments that; protect against suicide. Reducing access to lethal means among persons at-risk of suicide. Means of suicide such as firearms, hanging/suffocation, orjumping from heights provide little opportunity for rescue and, as such, have high case fatality rates about 85% of people who use a firearm in a suicide attempt will die from the injury). Research also indicates that 1) the interval between thinking about and attempting suicide can be as short as 5 or 10 minutes (Deisenhammer et al., 2009; Simon et al., 2001} and 2) that pe0ple tend not to substitute a different method when a highly lethal method is unavailable or difficult to access {Hawton, 200?; Yip et al., 2012]. Therefore, increasing the time interval between the thought and the suicide attempt, for example, by Thanliyou forthe suggestions. making it more difficult to access lethal means, can be lifesaving. The following are examples of approaches reducing access to lethal means for persons at-risk of suicide: 0 intervening otSuicide Hotspots. Suicide hotspots, or places where suicides may take place relatively easily, include tall structures leg, bridges and cliffs), railway tracks, and 18 isolated locations such as parks. Efforts to prevent suicide at these locations include erecting barriers to prevent jumping and installing signs and telephones to encourage individuals who are considering suicide, to seek help {Cox et al., 2013). 0 Safe Storage Practices. Safe storage of medications, firearms, and other household products can reduce the risk for suicide by separating individuals who may be vulnerable and/or impulsive from easy access to lethal means. Such practices may include education and counseling around storing firearms-- ocked in a secure place leg, in a gun safe or lock box], unloaded and separate from the ammunition-?and keeping medicines in a locked cabinet or other secure location awayfrom people who may be at risk or who have made prior attempts (Rowhani-Rahbar, Simonetti, Rivara, 2015; C. W. Runyan et al., 2015L Organizational policies and culture that promote protective environments may be implemented in places of employment. Such policies and cultural values may promote prosocial behavior asking for help}, skill building, changing social norms, referral and access to helping services leg. mental health, substance abuse treatment, financial counseling), and encourage leadership support from the top down. Such policies and cultural shifts can positively impact organizational climate and morale and help prevent suicide and its related risk factors depression, social isolation) (National Action Alliance for Suicide Prevention Workplace Task Force, 2015]. Community-based policies to reduce excessive alcohol use. Research studies in the United States have found that greater alcohol availability is positively associated with alcohol-involved suicides (Escobedo 8: Ortiz, 2002; Giesbrecht et al., 2015}. Policies to reduce excessive alcohol use broadly include zoning to limit alcohol outlet locations and density, taxes on alcohol, and bans on the sale of alcohol for individuals under the legal drinking age. These policies are important because acute alcohol use has been found to be associated with more than one-third of suicides and approximately 40% of suicide attempts {CherpiteL Borges, Wilcox, 2004). Potential Outcomes Increaseg in safe storage of means Reductions in suicide attempts Reductions in suicide deaths Increaseg in help-seeking Reductiong in alcohol-related suicide deaths Evidence The evidence for the effectiveness of preventing suicide by reducing access to lethal means feepersee at-eisk?ef?suieideand etheewaysrte otherwise establishi_ng protective environments for individuals at 19 5;ng suicide js_str9ng, particularly compared to existing evidence for other prevention strategies-is (Zalsman et al., 2016}. Reducing access to lethal means among persons at-risk of suicide. A meta-analysis examining the impact of suicide hotspot interventions implemented in combination or in isolation, both in the 0.5. and abroad, found associated reduced rates of suicide (Cox et al., 2013,- Pirkis et al., 2015). For example, after erecting a barrier on the Jacques?Cartier bridge in Canada, the suicide rate from jumping from the bridge decreased from about 10 suicide deaths per year to about 3 deaths per year {Perron, Burrows, Fournier, Perron, 8: lDuellet, 2013]. Moreover, the reduction in suicides by jumping was sustained even when all bridges and nearby jumping sites were considered, suggesting little to no displacement of suicides to otherjumping sites [Perron et al., 2013}. Further evidence for the effectiveness of bridge barriers was demonstrated by a study examining the impact of the removoi of safety barriers from the Grafton Bridge in Auckland, New Zealand. After removal of the barrier, both the number and rate of suicide increased fivefold [Beautrais, 2001; Beautrais et al., 2009]. Another form of means reduction involves implementation of safe storage practices. In a case- control study of firearm?related events identified from 37 counties in Washington, Oregon, and Missouri, and from 5 trauma centers, Grossman et al. [2005} found that storing firearms unloaded, separate from ammunition, in a locked place or secured with a safety device was protective of suicide attempts among adolescents. Further, a recent systematic review of clinic and community-based education and counseling interventions suggested that the provision of safety devices significantly increased safe firearm storage practices compared to counseling alone or compared to the provision of economic incentives to acquire safety devices on one?s own {Rowhani-Rahbar et al., 2016]. Another program, The Emergency Department Counseiing on Access to Lethai Means CALM), trained emergency clinicians in a large children?s hospital to provide lethal means counseling and safe storage boxes to parents of patients under age 13 receiving care for suicidal behavior. In a pre?post quality improvement project, Runyan et al (2016} found that at post?test (of the 55% of parents followed up, n=114] reported that all medications in the home were locked up as compared to fewer than 10% at the time of the initial emergency department visit. Among parents who indicated the presence of guns in the home at pre-test (Le. all (100%) reported guns were currently locked up at post?test (C. W. Runyan et al., 2016]. Organizational policies and culture. Togetherfor Life is a workplace program of the Montreal Police Force implemented to address suicide among of?cers. Policy and program components were designed to foster an organizational culture that promoted mutual support and solidarity among all members of the Force. The program included training of supervisors, managers and 20 Comment IAI: From .Il'v?l: Consistent with promising used earlier? Is it the strongest? I think it is consistent with promising, but We changed that to potential. The interpretation from the paper states no single strategy clearly stands above the others", so I would be hesitant to call it out as the strongest evidence. but it de?nitely may be for certain populations. Modified to simply $95.55!? 915% it is. Eli?En??a all units to improve competencies in identifying suicidal risk and to improve use and awareness of existing resources. The program also included an education campaign to improve awareness and help-seeking (Mishara 8: Martin, 2012). Police suicides were tracked over 12 years and compared to rates in the control city of Quebec. The suicide rate in the intervention group decreased significantly by 78.9% to a rate of 6.4 suicides per 100,000 population per year compared to an 11% increase in the control city (29.0 per 100,000) (Mishara 8: Martin, 2012}. Another example of this approach is the United States Air Force Suicide Prevention Program (AFSPP). AFSPP included 11 policy and education initiatives and was designed to change the culture ofthe Air Force surrounding suicide. The program uses leaders as role models and agents of change, establishes expectations for behavior related to awareness of suicide risk, develops population skills and knowledge education and training), and investigates every suicide outcomes measurement}. The program represents a fundamental shift from viewing suicide and mental illness solely as medical problem and instead sees them as larger service- wide problems impacting the whole community (K. L. Knox, Litts, Talcott, Feig, 3: Caine, 2003). Using a time-series design to examine the impact of the AFSPP program on various violence- related outcomes, researchers found that the program was associated with a 33% relative risk reduction in suicide (K. L. Knox et al., 2003).The program was also associated with relative risk reductions in related outcomes including moderate and severe family violence (30% and 54%, respectively}, homicide and accidental death (K. L. Knox et al., 2003). A longitudinal assessment of the program over the period 1981 to 2008 (16 years before the 1997' launch of the program and 11 years post-launch) found significantly lower rates of suicide after the program was launched than before (K. L. Knox et al., 2010). These effects were sustained over time, except in 2004, which the authors found was associated with less rigorous implementation in that year than in the other years (K. L. Knox et al., 2010}. - Community-based policies to reduce excessive alcohol use. While multiple policies to limit excessive use of alcohol exist, several studies on alcohol outlet density, specifically, suggest that measures to reduce alcohol outlet density can potentially reduce alcohol-involved suicides. Additionally, a longitudinal analysis of alcohol outlet density, suicide mortality, and hospitalizations for suicide attempts over 6 years in 531 California zip codes indicated that the density of bars, specifically, is related to suicide and suicide attempts, particularly in rural areas (Johnson, Gruenewald, 8: Remer, 2009}. Promote Connectedness 21 . Comment IAI: From JM: Seems like a nuance you can delete from this paragraph. You don?t really pick up on this later and it probably requires more Rationale Sociologist, Emile Durkheim theorized in 139? that weak social bonds, i.e. lack of connectedness, are . among the chief causes for suicidality (Durkheim, Connectedness is the degree to which an I individual or group of individuals are socially close, interrelated, or share resources with others (Centers Lexplanation for Disease Control and Prevention, 2009). ocial connections can be formed within and between 5? rCummentlAl: FromJH,Awkwarg multiple levels ofthe social ecology (Dahlberg Bi Krug, 2002}, for instance between individuals leg. peers, I, CONS-idem while the evidence limited, existing studies neighbors, co?workers], families, schools, neighborhoods, workplace, faith comm unities, cultural groups, ,r and society as a whole] Related to connectedness, social capital refers to a sense of trust in one?s ,l cumulul If?: . 1. that prosociai behavior is currently community and neighborhood, social integration, and also the availability and participation In somal abmmai_ Maybe promuteisabemr From JH: suggest deleting ?seek to organizations (Beyer, Layde, Hamberger, 8t Laud, 2015; Muennig, Cohen, Palmer, 8; Zhu, 2013). Many ecological cross?sectional and longitudinal studies have examined the impact of aspects of social capital i normalize? and say "Peer norm i approaches encourage prosocial JL. word? 1- i I on depression depressive disorder, mental health more generally, and suicide. While the evidence is still?beingbul-Itlimited, existing studies sygge_st]_the pattern is towards a?s?t?emveese association between social capital measured by social and improved mental health. Connectedness and social capital together can serve to protect against behaviors by decreasing isolation, encouraging adaptive coping behaviors, increasing belongingness, personal value and worth all of which helps individuals to build resilience in the face of Comment I prefer to keep it as normalize and took out prosocial behavior. We want to normalize help- seeking versus making it seem like a Lpersonal weakness. suicidal adversity. Connectedness can also provide individuals with better access to formal supports and resources, mobilize communities to meet the needs of its members and provide collective primary prevention activities to the community as a whole [Centers for Disease Control and Prevention, 2009]. Approaches Promoting connectedness among individuals and within communities through modeling peer norms and enhancing community engagement can protect against suicide. Peer norm approaches seek?o factors for suicide such as help?seeking, reaching out and talking to trusted adults, and promote peer connectedness. These approaches typically target youth and are delivered in school settings but can also be implemented in community settings. 22 AL reducing risk ofsuicide. Potential Outcomes Reductions in maladaptive coping attitudes and behaviors Increases in healthy coping attitudes and behaviors lncreaseg in referrals for youth in distressed Evidence Current evidence suggests that peer norm approaches and community engagement can reduce risk factors associated with suicidal behaviors. Peer norm bpproache Evaluations show that programs such as Sources of Strength can- 5 Community engagement activities. Community engagement is an aspect of sooal capital Community engagement approaches may involve residents participating in a range of activities, including religious activities community clean-up and greening activities, and physical exercise. These activities provide opportunities for residents to become more involved in the community and to connect with other community members, organizations, and resources, resulting in enhanced overall phySical health, reduced stress, and decreased depressive thereby lncreas Increases in pPositive perception; of adult support help?seeking behaviors Comment IAI: From JH: Cite findings from Let?s Connect intervention program? While the intervention didn?t signi?cantly reduce suicidal behavior, there were signi?cant improvements in connectedness (a protective factor for suicide]- is a great thought. We have quite a few programs that didn?t reduce suicidal behavior, but do impact related RFs, so we?re trying to stray from them and focus on those that impacted suicide and attempts or have a greater amount of >evidencefmore evaluations behind them. Comment From T5: Is there any evidence on outcomes more proximal to suicide? Did they look for any and not find them? It is important to describe relevant null effects when they were found. KH: They did not look at more proximal outcomes, but 505 is currently undergoing a 6-year evaluation funded by NIMH to examine impact, hopefully with suicidal behaviors being one of the houtcomes they? re measuring. Improve school norms and beliefs about suicide that are created and disseminated by student peers. In a randomized controlled trial of Sources ofStrength conducted With 18 high schools (6 metropolitan, 12 rural} Wyman et al. (2010] found that the program improved .I adaptive norms regarding suicidegmonggeer leaders, theteconnectedness to adults and school engagement Peer leaders were also more likely than controls to refer a suicidal friend to an adult students, the program resulted in increased perceptions of adult support for suicidal youths, particularly among those With a history of suicidal ideation, and the acceptability of help? seeking behaviors- Iseel?i-hg?help. PeceeptierFi?ef these improvements in factors that protect against suicidal behavior translate into reduced suicidal behavior and suicide. Community engagement activities. A vacant lot greening initiative was undertaken in Philadelphia between 1999 and 2008. Local residents and community members worked together to green 4 436 lots [or 7 8 million square feet} in 4 areas ofthe city. Researchers found significant associated reductions in community residents? self?reported level of stress which is a risk factor 23 for and engagement in more physical exercise, a protective factor for suicide, han residents in control vacant lot areas. Other bene?ts included reductions in firearm assaults and vandalism EBranas et al., 2011} Teach Coping and Problem-Solving Skills Rationale Building life skills prepares individuals to successfully tackle every day challenges and adapt to stress and adversity. Life skills encompasses many concepts, but most often include coping and problem?solving skills, conflict resolution, and critical thinking. Life skills are important in shielding individuals from suicidal behaviors {World Health Organization, 2014}. Suicide prevention programs thatfocus on life and social skills training are drawn from social cognitive theories (Bandura, 1986), surmising that suicidal behavior is attributed to [either]direct learning, modeling, andggenvironmental and individual hopelessness} characteristics. The literature linking life skills and suicide is robust. The inability to employ adequate strategies to cope with immediate stressors or identify and find solutions for problems has been characterized among suicide attempters [Pollock Williams, 2004}. Treatments that include bolstering skills (Goldsmith, Pellmar, Kleinman, St Bunney, 2002iand include problem?solving techniques {Ghahramanlou-Holloway, Bhar, Brown, Olsen, Beck, 2012; Townsend et al., 2001) appear to redUce suicidal ideation and attempts more effectively. Prevention programs focused on teaching these skills target youth, parents and families and have been used with both universal and at-risk populations. While many do not target suicidal behaviors directly, these programs strive to train youth and parents Comment IAI: From JM: Not seeing strong evidence here. Are you suggesting that this affects documented risk factors for suicide by reducing stress and increasing physical exercise? iwould like to see a stronger evidence statement here. From LLD: you might want to incorporate a phrase in the statement along the lines of "which are risk factors for suicide" KH:Added the qualifier you suggested, kLinda. 4.. Comment From T5: They had a follow Up paper in 2013 that showed intervention sites felt significantly safer. The effects on crimes was encouraging but not significant. it seems important to mention this too. From LLD: not sure i agree with Tom?s last point about mentioning the nonsignificant effect on crime. "l Comment From LLD: the word ?either" here implies another comparative clause; should the word ?or" be inserted before the word ?modeling"? May want to just delete the word "either? important life skills to offset the underlying vulnerabilities that contribute to engaging in high-risk behaviors early in life. Approach es Current evidence provides support for the following two approaches: Social emotional learning programs focus on developing and strengthening communication and problemesolving skills, emotion regulation, conflict resolution, help seeking and coping skills. These approaches address a range of risk and protective factors for suicidal behavior. They provide children and youth with skills to resolve problems in relationships, school, and with peers, and help youth to address other negative influences substance use} associated with suicide. These approaches are typically delivered to all students in a particular grade or school, although some programs also focus on groups of students considered to be at high risk for suicide. Opportunities to practice and reinforce skills are an important part of programs that work (Herman, Borden, Reinke, 8t Webster-Stratton, 2011i. 24 0 Parenting skill and family relationship programs are designed to strengthen parenting skills, enhance positive parent-child interactions, and improve children?s behavioral and emotional skills and abilities. Several parenting and familv relationship programs have been shown in rigorous evaluations to improve resilience and reduce risk factors for various behaviors, including ones closelv related to suicide, such as depression, internalizing behaviors, and substance abuse (ii/1.5. Knox, Burkhart, El. Hunter, 2010}. Potential Outcomes Reductions in suicide attempts and suicide ideation Improvements in of risk and protective factors associated with suicide Reductions in suicide risk behaviors depression, anxietv, conduct problems, substance abuse} Improvements in?anel noenaa?Iiee?help-seeking behavior ImprovementsEnhaec?e? social competence and emotional regulation skills problem-solving and conflict management skills Evidence There are several programs with evidence that support teaching social, emotional and parenting skills to reduce suicidal behaviors and associated risk factors. Comment [Ah lthink this should be this reference 2015: Comment IAI: From JH: Suggest translating OR and 95% CI for wider audience. wider audience. See Tom's suggestion below. HRevised accordinglv Comment From .IH: state if the control group received anv kind of intervention \Added Comment From JH: Report ages i {compare to 505 below} 1 ?1 From LLD: agree; this is too technical for a Jin. Social emotional learning programs. The Youth Aware of Mental Health Program (mm) is a program developed for teenagers that uses interactive dialogue and role-plaving to teach adolescents about the risk and protective factors associated with suicide [including knowledge about depression and anxiety} and enhances their problem-solving skills for dealing with adverse life events, stress, school and other problems. The program includes 3 hours of role-plav sessions and interactive workshops combined with a booklet that students can keep, educational posters displayed in classroom, and interactive lectures about mental health at the beginning and end of the program randomized controlled trial of YAM conducted across 10 European Union countries and 168 schools, Estudentiaged 14-15 participating in the YAM program were significantlv less likely to?haveani-neideet-suieideatte . . - . attempt suicide and ii ?have severe suicidal ideation . the 12-month follow-up compared it to the kernel youth suicide attempts among the YAM group was reduced bv over 50%; indieat?i-ngdemonstrating that out of 1000 students, five attempted suicide in the YAM group compared to 11 in the control group. Additionallv, related to severe suicide ideation, in the 25 v? YAM group absolute risk fell relative risk fell by 49.6% Wasserman et al., From JH: signi?cant? Signs ofSufcr'de {505} is another school-based prevention program for students aged 13-11 The program includes guided classroom discussions about suicide and depression. As part of the program, students are screened for depression and suicide risk and referred for professional help as indicated. The program is designed to increase knowledge about suicide and risk factors associated with suicidal behavior as well as improve and normalize help- seeking behavior (Schilling, Aseltine, 81 James, 2016). in a randomized controlled trial, $05 was shown to suicide attempts at 3-months post intervention among participating 1 students' knowledge of how to get help for themselves or friends for depression and/or suicidal thoughts, and favorable attitudes toward helprseeking. 505 participants with a lifetime history of suicide attempt were also less likely to report planning a suicide in the 3 months following the program compared to Eower?risk participants}5chi ling et al., 2016}. 11 It i\ 1 i Finally, the Good Behavior Game is a classroom?based program for elementary school children aged The program uses a team?based behavior management strategy that promotes goodjl?x,? behavior by setting clear expectations for good behavior and consequences for maladaptive behavior. The goal of the 636 is to create an integrated classroom social system that is supportive of all children being able to learn with little aggressive or disruptive behavior {Wilcox et al., 2008). Two cohorts of youths participated in the program in 1985?35 and 1986- 86 school years when they were in the first and second grades. A number of proximal and distal outcomes were assessed among the two cohorts over time. With respect to distal suicide-related outcomes, ?-aagn outcome evaluation of the GBGJ?indicated that assignedindividuals in the first cohort who were assigned to participate in when they were in the first grade reported half the adjusted odds of suicidal ideation and suicide later, between thejges Esttemptd when assessed approximately 15 years compared to peers who had been in a standard classroom setting. The beneficial effect ofthe program was consistent for suicidal ideation regardless of whether baseline covariates were included. The EEG effect on attempts was less robust in some adjusted models including caregiver mental health. in the?iecond students, neither suicidal idiotion nor suicide attempts were significantly different between 636 and the control interventions {Wilcox et al., 2008]: {FaisThe authors surmise this finding likely arose due to the lack of fl . implementation fidelitqand pointed to the need for 686 to be delivered with precision, y" consistency, and teacher support. 636 was also found to be associated with reduced risk of later substance abuse, a risk factor for suicide {Kellam et al., 2008}. 25 I. I I i (Comment From JH: signi?cant? 1 .i - kRevisedComment lAl: From JH: signi?cant? Comment IAI: From T5: The Lancet paper has a 2015 publication date. The authors provide the absolute and RH for suicide attempts too and they give a clear way ofthinking about this- for RR "Of 100D pupils, 11 attempted suicide in the control group vs five attempts in It might be worth using the attempt example so you can provide this explanation. JL. Comment From LLD: Jeff had Comment [Ah From .IH: is this the jffect size/magnitude of reductioniI Comment From JH: define control condition 3 Comment From JH: Lower-risk? Do you mean students with no prior reported history of suicide attempts? questions about what is meant by upstream. You are referring to primary prevention but some ofthe other Comment From JH: compared to? gridded. Comment Hi: From JH: Suggest stating clearly there are two separate cohorts of students receiving the intervention. How do these cohorts differ (time, location}? kn:- .1 Comment [Ah From TS: it is important to help the reader to understand that this study looked at the suicidal ideation when the ?rst graders were age 1941. This is .H authors? comment or your interpretation of the data? Please clarify. 'nnlu I Comment IAI: From signi?cant? Also please de?ne externalizing I Parenting skill and familvr relationship programs. Parenting and family skills training ibehaviors approaches have shown promising impacts in preventing key risk factors associated with 5 i kH Added Comment From T5: This transition suicide. For example, the incredibie Years is a comprehensive group training program for parents, teachers and children designed to reduce conduct and substance abuse problems, two important suicide risk factors, in youth bv improving protective factors such as responsive and positive parent-teacher?child interactions and relationships, emotion self~regulation and social competence (all protective factors for suicide] (Herman et al., 2011}. The program includes 9? 20 sessions offered in communitv~based settings religious, recreation centers, mental health treatment centers, and hospitals}. Several studies have demonstrated i Seems off. i i the effect of the 0? program on reducing internalizing such as anxietv and i i i i i 3 EH: edited. depression, and child conduct problems (C. H. Webster-Stratton, Reid, 8i. Beauchaine, 2011; Webster?Stratton, Jamila Reid, 8: Stoolmiller, 2008}. The program is also associated with improved problem-solving and conflict management; these skills were maintained at 1-year followvup [Reid, 8L Hammond, 2003,- C. Hammond, 199?; C. Webster-Stratton, Reid, 8i. Hammond, 2001). The program demonstrated greater benefits as the dosage ofthe intervention increased (Herman et al., 2011}. Additionally, Strengthening Families 1014 is a program that involves sessions between parents, youth, and family with the goal of improving parents? skills for disciplining, managing i emotions and conflict, and communicating with their children; promoting vouths? 'i interpersonal and problem-solving skills; and creating familv activities to build cohesion and i? positive parent?child interactions. The premise of the program is that developing these skills I for both parents and children will reduce internalizing behavior and adolescent substance ii abuse, two important risk factors for suicide (Spoth, Guvll, 8f. Dav, 2002}. Strengthening alcohol use, and drug use among participating families (Spoth et al., 2002). 2? Identify and Support People AtsRisk Rationale In order to decrease suicidegttention to people at increased example people with prior suicide attempts, is necessary, as these individuals tend to experience suicidal behavior at higher than I I average rateslThese vulnerable or disadvantaged populations include, but are not limited to, individuals with lower socio-economic status-of-who are living with a mental health problem; people who have attempted suicide previouslv; individuals who are institutionalized, have been victims of violence, or are homeless; and members of certain racial and ethnic minoritv groups. Supporting these vulnerable groups requires proactive case finding along with access to, and retention in, mental health services. Finding effective wavs of identifving at-risk or vulnerable groups, customizing services to make them accessible and engaged in care remain kev challenges. For example, simplv improving services does not guarantee that those services will be used bv those most in need of them, nor will it necessarilv increase the number of people who follow treatments that are recommended. People who are disadvantaged face social and economic issues that mav adverselv affect their abilitv to respond to the treatments or advice that are offered. Approaches The following three approaches focus on identifving and supporting people at increased risk. Gatekeeper training is designed to train teachers, coaches, providers and others in the communitv to identifv people who mav be at risk of suicide and to respond effectively, including facilitating treatment seeking and support services. Gatekeeper training is tvpicallv implemented in schools to identify at-risk youth and within health care settings to identifvf adults (and youth}. Screening combined with care management and overall continuitv of care has been used in primary care and behavioral health care settings to assure that people who may be at high?risk of suicide are identified and receive ongoing treatment as needed, particularlv after inpatient discharge and other transitions within the healthcare svstem so thev don?t 'slip through the cracks?. These approaches tvpicallv emplov screening for depression andlor suicide combined with collaborative treatment planning between patients and their providers and patient follow? up. Crisis intervention. These approaches provide support and referral services, tvpicallv bv connecting a person in crisis [or a friend or familv member of someone at?risk} to trained Volunteers or professional staff via telephone hotline, online chat, or text messaging. Crisis intervention approaches are intended to impact kev risk factors for suicide, including feelings of 28 Comment IAI: From TS: This seems i r' 1. awkward as written. it might be better to say to people with speci?c Comment Alz i?rn not sure about ?specific vulnerabili?ties? terminology. I think people are much more familiar with something like this. depression, hopelessness, and subsequent mental health care utilization. Like means reduction, crisis interventions can put space or time between an individual who may be considering suicide and harmful behavior. Potential Outcomes Reductions in suicide attempts Reductions: in suicide deaths in identification of individuals at?risk for suicidal behavior teereasedincreases in at-risk individuals in treatment i-neseased?lncreases in community members trained to identify at?risk individuals teeseased?Increases in referrals for health care Evidence Identifying people at risk of suicide can positively impact both suicide risk factors as well as suicide mortality, however sustained implementation of programs and practices appears critical. Among people who id entity themselves through calls to suicide hotlines, preliminary evidence finds reductions in suicide sweides-eu-t?thee?eets?mest?be u- - - wu- suicidal behavior is needed [Kitchener 8: Jorm, 2006}. II Gatekeeper training. One example of gatekeeper training is the Mental Heaith First Aid program. This program is designed for the lay public and consists of three weekly sessions of three hours each. Participants learn the of people in mental health crises andior in the early stages of mental health problems those experiencing suicidal thoughts and behavior, acute stress reaction, panic attacks and acute behavior, and depression, anxiety, and disorders], possible risk factors, and where and how to getEasdelenee?based ?ll effectivelhelp [Kitchener 3i Jorm, 2004}. In a randomized controlled trial of 301 participants of {ii MHFA, the. ii'? stars; [137.53% in}; 336?]? E?i'?'rii?iif? ?113 ?33? follow?up, significantly greater feelings of con?dence gc??ll, greater likelihood of encouraging people to seek professional help 29.4% vs. 16.8% i improved agreement with health professionals about treatments [9&036), and 5 decreased stigmatizing attitudes towards mental illness ip<.02l. Additionally, the intervention 1 Comment From LLD: suggest 5 shortening this introductory statement 'l about the evidence and making it i consistent with the other sections. if you need to provide caveats, then you might want to take a look at the TP for Lexample wording. Comment From TS: Add cites here. i Also this wording is awkward because it could be read as suggesting that those who chose to use the hotline are different from others at risk who did not. Maybe you could add the follow up period to the end -they have decrease suicidal Lthoughts and behavior at Kit {awkward here i possible to report magnitude of if "f intervention effects? I JL 1 Comment IAE: From LLD: wording is a bit Comment From .IH: signi?cant? Is it Comment From JH: Overall mental etc]? Please clarify .1 I i ?if percent who provided some or a lot of help did not differ between groups (Kitchener 81 Jorm, 2004]. Additional research rigorously evaluating MHFA for its impact on intervention recipients? 29 I I health or specific facets depression. Comment IAI: From JM: I think you need to provide a little more context on i Henry Ford so the readers understands in . what kind of population the reductions were experienced. I assume from the end . that Henry Ford is some sort of HMO, but just a little more information would help clarify this description to readers. r[Comment [Ah From JH: how much? Gatekeeper training has also been a primary part of all Garret Lee Smith (GL5) Suicide Prevention Program which is in place in 49 states and 43 tribes. i5. multi?site evaluation assessed the impact of community gatekeeper training on suicide attempts and deaths by comparing the change in suicide rates and nonfatal suicidal behavior among young people aged 10?24 in counties implementing GL5 trainings, with the trajectory observed in similar counties that did not implement these trainings. Counties that implemented GL5 trainings had significantly lower youth suicide rates one year following the training implementation [Walrath, Garraza, Field, Goldston, SI McKeon, 2015]. This finding equates to a decrease of 1 suicide death per 100,000 among youth ages 10 to 24, or the prevention of approximately 237I deaths in the age groUp, between 2007 and 2010. Counties implementing GL5 program activities, including gatekeeper training, also had significantly lower suicide attempt rates among youth ages 16 to 23 in the year following implementation of the GL5 program than did similar counties that did not implement GLS activities {4.9 fewer attempts per 1000 youths; [Godoy Garraza, Walrath, Goldston, Reid, 8: McKeon, 2015)}. More than 29,000 suicide attempts may have been prevented during the period examined, following implementation of the GL5 program. I Screening combined with care management and overall continuity of care. [The Henry Ford healthcare system is a large health maintenance organization (HMO) in the state of Michigan. Hang: Ford?s Perfect Depression Care program was the pre-cursor to what is now called Zero Suicide, and its overall goal was to eliminate suicide among its members. More broadly, the aim was to redesign delivery of depression care to achieve ?breakthrough improvement" in quality and safety by focusing on six aims: effectiveness, safety, patient centeredness, timeliness, efficiency, and equity among patients. The program screened and assessed each patient for suicide risk and implemented coordinated continuous follow-up care system wide (C. E. Coffey, 2006]. An examination of the impact of the program found that there was a dramatic and statistically significant decrease in the rate of suicide between the baseline years, 1999 and 2000, prior to the intervention to the intervention years, 2002-2009. During this time period, the suicide rate fell by 82%]50 E. Coffey, 2006; C. E. Coffey, Coffey, 8i. Ahmedani, 2013). Further?: among HMO members who received mental health specialty services, the suicide rate decreased from 110.3/100.000 in 1999 to 47.6f100,000 in 2010 with a mean of 362,000,000 over i the time period. Additionally, for those HMO members who accessed only general medical services as opposed to specialty mental health services, the suicide rate increased, from12/100,000 to 5.6f100,000 [p<.01l. Similarly, in the state of Michigan, rates of suicide in the general population increased over the period from 981100.000 to 12.5f100,000 [p<.001i (M. Coffey, Coffey, 8f. Ahmedani, 2015). 30 It Crisis intervention. Suicide prevention hotlines are one wav to provide crisis intervention. In an {Comment From JH: Report evaluation of the effectiveness of the National Suicide Prevention Lifeline to prevent [i magnitude 0* decrease? suicide, 1,085 suicidal individuals who called the hotline completed a standard risk assessment l: Comment This is bestl Fl can do. Not sure if vou want this level of detailhovvever. for suicide, and 380 of those completed a follow-up assessment between 1 and 52 days . (mean=13.5 davs] after the initial assessment. Researchers found that over half of the initial i; Comment To be consistent i above I added some measures of {r sample were seriouslv considering suicide when they called, and they had a plan fortheir suicide. Researchers also found that among follow?up participants, there was a signi?cant hecreasdinj pain p<.001l, hopelessness lF=47.8, p<.001l and intent to die lF:7.57, ps?ll between initiation of the call {time 1} to follow?up {time 3). Between time 2 lend of the to time 3, the effect remained for pain lF=14.1, and hopelessness association. I I I paDDll but was not significant for intent to die. (Gould, Kalafat, Harrismunfakh, 8: Kleinman, 2007]. i i in another study, this time employing a randomized controlled trial, Gould, Cross, Pisani, i Munfakh, and Kleinman (2013) assessed the impact of the Applied Suicide intervention Skills Training a widelvr implemented training program that helps hotline counselors, i emergency' workers, and other gatekeepers to identifv and connect with suicidal individuals, i understand their reasoning for living and diving, and assist with safelv connecting those in need i to available resources. The training was evaluated across the NSPL network of hotlines over the i period 2008-2009. Using data from 1,410 suicidal individuals who called 1? Lifeline centers, researchers found that compared to callers who spoke to counselors that received the usual care ithout training in were significantly more training, individuals who spoke with counselors likelv to feel depressed suicidai [1.39, more overwhelmed {1.18, 1.32}, and leg hopeful [1.351134 1.7?ll by the end of their call to the hotline compared to those with training in A5!5T.k3ounselors trained in were also: more skilled at keeping callers on the phone longer and establishing a connection with them. However, training in ASIST did not result in more comprehensive suicide risk assessments than usual care training {Gould et al., 2013}. 31 intervene to Lesseu Harms and Prevent Future Risk Rationale Comment IAI: From LLD: simplify statement and make it consistent with the other introductory statements about approaches. You may also want to take a look at the introductory statements to this section in the other TF5. J's. 5 Individuals who have experienced mental heaith challenges, suicidai ideation, who have made suicide i attempts or engaged in non-suicidal self-injury are at increased risk of suicide (US. Office of the Surgeon i General 84 National Action Alliance for Suicide Prevention, 2012]. Risk of suicide can also increase among those who have lost a friend, family member, co-worker, or other acquaintance to suicide lPitman, Osborn, King, St Erlangsen, 2014). Exposure to sensationalited or uninformed reporting regarding on i: suicide may heighten the risk of suicide among vulnerable individuals and can inadvertently contribute i to suicide contagion (Etzersdorfer 8: Sonneck, 1998; Niederkrotenthaler El Sonneck, 200?]. i i i Approaches EQ?beead-areay?ef-aThe four approaches included here to lesson harms and reduce future risk of suicide among those at increased risk focus on providing appropriate mental healthcare, continuity of care, caring for the bereaved, and providing safe messaging around suicide. I may want to mention how these are typically delivered leg, one on one or group formats; typical number of sessions, location, etc}. omment [Ah From Suggest eshing this description out a bit. You Included some ofthis info. Idon'tthink there's a "typical" number of sessions, as it seems to vary across treatment . . .- .. -. - a .--.-. n- - I- - - reatment for people at?risk of suicide ]typically includes various forms of delivered by licensed providers to help individuals with mental health problems and other risk factors for suicide with problem~solving, impulsivity and emotion regulation. Treatment usualiy takes place in a one on one or group format between patients and clinicians in mental healthcare settings and can vary in duration from several weeks to ongoing therapy for years in some cases. Treatment to prevent These approaches typically include follow-up contact and use diverse modalities leg, home visits, mail, teiephone, e?mail] to engage recent suicide attempt survivors in continued treatment to prevent re-attempts. Treatment may focus on improved coping skills, mindfulness, and other emotional regulation skills, and may include case management home visits to increase adherence to treatment and continuity of care; and one- on?one interpersonal therapy and/or group therapy. Approaches that engage and connect attempters to peers and providers are especially important because many attempters do not present to aftercare,- 12%?25% reattempt within a year, and 396?996 of attempt survivors die by suicide within 1 to 5 years of their initial attempt (lnagaki et al., 2015] - Postvention approaches are implemented after a suicide has taken place and may include debrie?ng sessions, counseling, and/or bereavement support groups for surviving friends and 32 ?settings. Comment IAI: From add something about contagion? family members/loved ones. These programs have not typically been evaluated for their impact KH: added on suicide or suicidal behavior but may reduce survivors' guilt, feelings of depression, and complicated grief (Saumilas 8i. Kutcher, 2011). Safe messaging following a suicide. The manner in which information on a recent suicide is i i communicated to the public leg. school assemblies, mass media, social media) can heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion. Therefore, responsible and safe reporting may help prevent suicide and suicide contagion. Potential Reductions in mental health-related sequrelae I Increasesiij connectedness Improvements in coping skills Improvements in messaging following suicide I Reductions in re-attempts I Reductions in contagion effects related to suicide Evidence The evidence addressing strategies to lesson harm and prevent future risk of suicide includes the evaluation of effects of specific approaches on risk and protective factors as well as suicide?related mortality. However, because the evaluation of suicide-related mortality requires large sample sizes and extended followrup, much ofthe evidence in this area primarily focuses on risk and protective factors. Treatment for people at?risk of suicide. There are a number of treatments with evidence of impact on risk and protective factors for suicide. One example is the improving Mood? Promoting Access to Coiioborotive Treatment program. JMPACT aims to prevent suicide among older primary care patients by reducing suicide ideation and depression in primary care settings. it facilitates the development of a therapeutic alliance, a personalized treatment plan that includes patient preferences, as well as proactive follow?up (biweekly during an acute phase and during continuation phase] by a depression care manager {Hunkeler et al.. 2006}. The program has been shown to significantly improve quality of life, and to reduce functional impairment, depression and suicidal ideation over 24-months of follow-up {Hunkeler et al., 2006; Unutzer et al., 2006) relative to patienE who received care as usual. 33 Another example is Coiiaborative Assessment andr Management ofSuicio?oiity which is a . lei: From 1-5: lthinka word is therapeutic approach for suicide-specific assessment and treatment of patient?s suicide risk. This ,1 "lizltl??'f flexible approach can be used across treatment settings and clinician theoretical orientations and Added. involves the clinician and patient working together in an interactive assessment process to develop patient-specific treatment plans. CAMS sessions are collaborative andiinvoive constant if patient input about what is and is not working with the ultimate goal of enhancing the i" i' a therapeutic alliance and increasing treatment motivation in the suicidal patient. CAMS been tested and supported in 5 correlational studies (lobes, 2012), in a varietv of inpatient and outpatient settings and in one RCT with several additional under wav. CAMS has been associated with significant improVEments in suicidal ideation, overall distress, and feelings of hopelessness at 12 month follow?up among a communitvbased sample of suicidal outpatients. (Comtois et al., 2011). Other examples include Diaiecticai Behaviorai' Ti?ierapjvr (DST) and Attachment-Based Familyr Therapy (ABFT). a multicomponent therapv for individuals at high risk for suicide and who may struggle with impulsivitv and emotional regulation. The components of include individual therapv, group skills training, between-session telephone coaching and a therapist consultation team. In a randomized controlled trial of women with recent suicidal or self- injurious behavior, those receiving DST were half as likely to make a suicide attempt at two?veer follow-up than women receiving communiti,r treatment [23% vs required less hospitalization for suicide ideation, and had lower medical risk across all suicide attempts and self-injurious acts combined [Linehan et al., 2006). a program for adolescents aged 12-18 and is designed to treat clinicallv diagnosed major depressive disorder, eliminate suicidal ideation, and reduce dispositional anxietv {Diamond et al., 2010]. A randomized controlled trial of ABFT found that suicidal adoIEscents assigned to ABFT experienced significantiv greater improvement in suicidal ideation over 24 weeks of follow?up than did adolescents assigned to enhanced usual care. Additionally, a higher percentage participants reported no suicidal ideatlon in the week prior to assessment at 12 weeks than did adolescents receiving enhanced Usual care [69.2% vs. 34.6%} and at 24 weeks (82.1% vs. 46.2%] (Diamond et al., 2010]. Treatment to prevent re-attempts. Several strategies that aim to prevent re-attempts have demonstrated impact on reducing suicidal behavior. For example, Emergency Department Brief intervention with Foliow-up Visits is a program that involves a one-hour discharge information session that addresses suicidal behavior, distress, risk and protective factors, alternatives to suicidal behavior, and referral options, combined with nine follow-up contacts over 13 months (at 1, 2, 4, 7, 11 weeks and 4, E, 12, 18 months]. Follow?up contacts are either conducted bv phone or through home visits according to a Specific time line for up to 13-months. A randomized 34 controlled trial that enrolled suicide attempters from eight hospital emergency departments in I, [five culturally different countries [BraziL India, 5ri Lanka, Iran, and China]sites]found that a brief intervention combined with 9 follow?up visits over Iii?months was fewer deaths from suicide relative to a treatment-as-usual group versus respectivelvl (Fleischmann et al., 2008]. Another example of treatment to prevent re~attempts involves octive foiiow?up contact approaches such as postcards, letters, and telephone calls intended to increase a patient's sense of connectedness with health care providers and decrease isolation. These approaches include expression of care and support and typicallv invite patients to reconnect with their provider. Contacts are made periodically or everv few months in the first 12 months post? discharge with some programs continuing contact for two or more veers]. In a meta-analvsis conducted by Inagaki et al. {2015], interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for suicide attempt were found to reduce reattempts by i approximatelv 17% for up to 12 months post?discharge; however, the these; approaches over periods of time longer than one vear on reattempts has not 1vet been demonstrated. Also. because the number of trials and associated sample sizes included in this meta-analysis were small, it was not possible to determine the effect of active contact and follow- up approaches on death bv suicide. In a randomized controlled trial of the post?crisis suicide ?d Comment IAI: From .IH: Unclear. to the article, this program was evaluated in five countries. Please state the countries. Tho I. Jidded. Comment From JH: De?ne [follow- _i ups greater than 1 veer] I kRevised. Comment IAI: From JH: De?ne "1 In. KH: Defined later in the sentence kcontact 4var, 2 vaars of followI up. prevention follow-up contact approach, Motto and Bostrom (2001} found that patients who refused ongoing care but who were randomized to be contacted bv letter four times per veer had a lower rate of suicide over two years of follow-up than did patients in the control group who received no further contact. Other studies have also shown post?crisis letters and coping cards to be protective against suicide ideation and attempts lHassanian-Moghaddam, Sarjami, Kolahi, Carter, 2011; Wang et al., 2015}. Finally, Cognitive Behavior Theropyfor Suicide Prevention is an example of a therapeutic approach to prevent re-attempts. It Uses a risk-reduction, relapse prevention approach that includes an analysis of proximal risk factors and stressors relationship problems, school or work-related dif?culties] leading up to and following the suicidal event; safety plan development; skill building; and also has familyr skill modules focused on familv s. A support and communication patterns as well as improving the familv?s problem solving skill randomized controlled trial of found that ill?session outpatient cognitive the designed to prevent repeat suicide attempts resulted in a 50% reduction in the likelihood suicide reattempt among adults who had been admitted to an emergency' department suicide attempt relative to treatment as usual [Brown et al., 2005I- 1 Postvention programs are implemented with the goal of providing support to survivors of others' Comment w: From Don?t you mean "Recommendations for Reporting on Suicide"? Please cite: suicide to reduce their own risk of suicide. One example of a postvention program, StondBy Response Service l5tondBy}, provides clients with face-torface outreach and telephone support through a professional crisis response team. Site coordinators develop customized case management plans, referring clients to other existing community services matched to their needs (Uisser, lComans, Scuffham, 2014). In a study by Visser et al. [2014), StondBy clients were i significantly less likely to be at high risk for suicidality than a suicide bereaved comparison group i who had not had contact with the Stond?y program (48% and 64% respectively}. Additionally, research suggests that active postvention approaches in which outreach to suicide survivors occurs at the scene of a suicide is associated with intake into treatment sooner, greater attendance at support group meetings, and attendance at more meetings compared to passive _i postvention [versus passive approaches where survivors self-refer for services] ll. Cerel 8i i Campbell, 2008}. Safe messaging following a suicide. Safe messaging after a suicide can help assure that reporting of the event is clone in such a way to reduce risk to consumers of news media and other messaging who may be particularly vulnerable. lElne way to ensure safe messaging following a suicide is to encourage that reporters adhere to Recommendations for ?eporting on inner Reports that are both inclusive of suicide prevention messages, stories of hope and resilience, risk and protective factors, and links to helping resources leg, hotline) and that avoid sensationalizing events or reducing suicide to one cause Ir Comment From T5: Are you sure The media did not want "guidelines" and they reacted negatively to the idea of external guidelines. KH: Edited accordingly. I didn?t realize they didn?t like the idea of "guidelines" - kinteresting. Comment itbink this is a better link.) 1 I that the 81 reduction wasjust on the subway system? lthought that was nationally. Please confirm. KH: it was nationally apologies for the koversight in the way this was written. Comment IAI: From T5: Thomas also had a 2010 report that suggested benefits of good reporting. KH: Added. can help reduce the likelihood of suicide contagion. The most compelling evidence supporting the effect of recommendations for reporting on suicide on reduction in suicides comes from Austria. After a sharp increase in suicides on the subway, media guidelines were introduced and an interrupted time series design was used to evaluate the national impact of the guidelines on subsequent suicides. Changes in the quality and quantity of media reporting resulted in a nationwide significant reduction of 81 suicides pnnualltl (Niederkrotenthaler 8i Sonnet: way leg, reporting on suicide and repetition} have harmful effects on suicide, but reporting on positive coping skills in the face of adversity can also demonstrate protective effects Reports of individual suicidal ideation not against suicide [Niederkrotenthaler et al., 2010]. accompanied by reports of suicide or suicide attempts, along with reports describing a "mastery" of a crisis situation where adversities were overcome, associated with significant decreases in suicide rates in the time period immediately following such reports {Niederkrotenthaler et al. 2010]. 35 Sector Involvement Public health can play an important and unique role in addressing suicide. Public health agencies, which typically place prevention at the forefront of efforts and work to create broad population-level impact, can bring critical leadership and resources to bear on this problem. For example, these agencies can serve as a convener, bringing together partners and stakeholders to plan, prioritize, and coordinate suicide prevention efforts. Public health agencies are also well positioned to collect and disseminate data, implement preventive measures, evaluate programs, and track progress. Although public health can play a leadership role in preventing suicide, the strategies and approaches outlined in this technical package cannot be accomplished by the public health sector alone. As noted in the National Strategy to Prevent Suicide, the integration and coordination of prevention activities across sectors and settings is critical for expanding the reach and impact of suicide prevention efforts. Other sectors vital to implementing this package include, but are not limited to, education, government (local, state, and federal], social services, health services, business, labor, justice, housing, media, and organizations that comprise the civil society sector such as faith-based organizations, youth-serving organizations, foundations, and other non-governmental organizations. Collectively, these sectors can make a difference in preventing suicide by impacting the various contexts and underlying risks that contribute to suicide. The strategies and approaches described in this technical package are summarized in Appendix A along with the relevant sectors that are well positioned to lead implementation efforts. For example, business and labor, health care insurers and providers, and government entities are in the best position to implement programs and policies that Strengthen Economic Supports and Access to Mental Health Cure. These types of supports go beyond individual behavior change and require commitment and support from those sectors that can directly address some of the underlying risks and the environmental contexts that increase the risk for suicide. Public health entities can play an important role by gathering and information to inform policy, raise awareness, and evaluate the effectiveness of various policies. Moreover, partnerships with non?governmental and community organizations can be instrumental in increasing awareness of and garnering support for policies affecting individuals and families. The public health sector has been at the forefront of many community-based prevention efforts, working collaboratively with schools and community-based organizations, to change social norms and positively impact health behavior. Public health is well suited to take on a similar leadership role in Promoting 37 Connectedness through peer norm and community engagement activities and supporting the development, evaluation, and adoption of effective programs that Teach Coping and Probiem-Soiving Skiils to prevent suicide from happening in the first place. These programs are often delivered in school and community settings, making education and non-governmental organizations vital partners in prevention. Businesses, workplaces, and local and state government entities, on the other hand, are in the best position to establish policies and support practices that Create Protective Environments where people live, work, and play. Public health entities can play an important role by gathering and information, working with other agencies within the executive branch of their state or local government in support of policy and other approaches, and evaluating the effectiveness of measures taken. in a similar fashion, public health entities can partner with schools, workplaces, and community organizations to implement and evaluate prevention programs, policies and practices geared toward creating safe, healthy, and supportive environments. Finally, this technical package includes a number of interventions delivered in hospital, primary care, behavioral health care, and community settings designed to identify and Support Peopie At?Risir and to Lessen Harms and Prevent Future Risk. The intensity and activities of these interventions require the expertise of professionals who are licensed and trained to deliver critical intervention support. The health care, social services, and justice sectors can work collaboratively to support individuals at high- risk for suicide and their families. These activities also require coordination of supports across various service providers and community organizations. Regardless of strategy, action by many sectors will be necessary for the successful implementation of this package. In this regard, all sectors can play an important and influential role in preventing suicide from happening in the first place and lessening the immediate and long-term harms of suicidal behavior by helping those in times of crisis get the services and support they need. 38 Monitoring and Evaluation Monitoring and evaluation are necessary components of the public health approach to prevention. It is important to have timely and reliable data to monitor the extent of the problem and to evaluate the impact of prevention efforts. Data are necessary for program implementation as planning, implementation, and assessment all rely on accurate measurement of the problem. Surveillance data helps researchers and practitioners track changes in the burden ofsuicide. Surveillance systems exist at the federal, state, and local levels. it is important to assess the availability of surveillance data and data systems across these levels to identify and address gaps in the systems. National Vital Statistics System and the National Violent Death Reporting System are examples of surveillance systems that provide data on deaths from suicide. for example, is a state-based surveillance system that combines data from death certi?cates, law enforcement reports, and coroner or medical examiner reports to provide detailed information on the circumstances of violent deaths, including suicide, which can assist communities in guiding prevention approaches [Blair, Fowler, Jack, Crosby, 2016}. The National Electronic Injury Surveillance System-All Injury Program provides nationally representative data about all types and causes of nonfatal injuries treated in U.S. hospital emergency departments, and can be used to assess national rates of, and trends in, self-harm injuries by cause falls, poisoning, etc), age, racefethnicity, sex, disposition (where the injured person goes when released from the Emergency Department). In addition to information on deaths and nonfatal injuries, there are also surveillance systems that provide national, state, and some local estimates of suicidal behavior. The Youth Risk Behavior Surveillance System collects information from a nationally representative sample of 9-12 grade students and is a key resource in monitoring health?risk behaviors among youth, including whether youth have seriously considered attempting suicide, attempted suicide, made a plan, or required treatment by a doctor or nurse for a suicide attempt that resulted in an injury, poisoning, or overdose (Brener et al., 2013}. The data are obtained from a national school-based survey conducted by CDC as well as from state, territorial, tribal, and large urban school district surveys conducted by education and health agencies. The National Survey on Drug Use and Health (NSDUH) is an annual survey of the civilian, non- institutionalized population aged 12 years and older. NSDUH provides Mnational and state?level estimates of substance use, including alcohol, tobacco, illicit drugs, and non-medical use of prescription d?gg; and mental health, including past year mental illness, Ito-occurring illnesses, service utilization, along with suicide ideation suicide plans, and suicide pttempts} NSDUH resource tohtrack trends}! in suicide?related risk factors in the population and to help identify groups at increased risk. It is also important at all levels (local, state, and federal] to address gaps in responses, track progress of prevention efforts and evaluate the impact of those efforts, including the impact of this technical package. Evaluation data, produced through program implementation and monitoring, is essential to provide information on what does and does not work to reduce rates of suicide and its associated risk Comment From TS: This description seems incomplete comparted to the description of YRBS ?1 Comment IAI: From TS: Should this be and protective factors. Theories of change and logic models that identify short, intermediate, and long- term outcomes are an important part of program evaluation. programs, and '50 be consistent? '3 The evidence-base for suicide prevention has advanced greatly over the last few decades. However, r: {comment FromJH;including additional research is needed to understand the impact of Earogram olicies and practices on Euicide ?amp?? 1 'l Comment [Ali .IH: redundant With I prior sentence. {and suicide attempts, at a minimum}, 5 opposed to merely examining thei_r effectiveness risk factors I: asseeiated?wish?sui-eide. More research is also needed to examine the effectiveness of upstream before risk occurs! and community-level strategies to prevent suicide at the population level. Lastly, it will be important for researchers to test the effectiveness of combinations of the strategies and approaches included in this package. Most existing evaluations focus on approaches implemented in isolation, but there is potential to understand the synergistic effects within a comprehensive Prevention approachConclusion Suicide is a serious public health problem whose rates have been on the rise for more than a decade and whose costs stretch well into the billions of dollars each year. While suicide is a rare outcome statistically, its human impact has a ripple effect that is far?reaching. Each of us likely interacts with suicide survivors, those with lived experience, and those with thoughts of suicide, on a daily basis-at home, at work, and in our communities. Suicide and suicide attempts are therefore public health issues of societal concern. Fortunately, like many public health problems, suicide is preventable, and fortunately more is being done to prevent suicide than ever before, as evidenced by the work of the National Action Alliance for Suicide Prevention, the release of the first world report on suicide, and more timely surveillance data, to name just a few examples. Unfortunately and unlike most other public health problems, suicide mating Mstill overcome sesaggiesagaiastm stigma, shame, and secrecy related to help-seeking, mental illness, being a survivor, or someone with lived experience; misplaced fear efrglatgd_t9_asking someone about their risk of suicide [versus the fear and consequence of not asking), and?fear of taking up strategies known to be effective but perhaps unpopular; misinformation about suicide preventability, misplaCed emphasis by the media and others on sensational aspECts of suicide, and disproportionate ,t_s public health burde?Wbeng??gW funding given effort to continue pushing the field and society further towards prevention, this technical package includes strategies and approaches that ideally would be used in a comprehensive fashionComment From TS: lfound this I somewhat awkward. The idea of suicide struggling seemed off and the point is not entirely clear. I think you can be more specific and reference an earlier point Comment From .IH: i is jargonComment prefer to keep this language in if it?s ok. The e.g. is meant to help define the terms and it's been mentioned previously and defined. It's also a continued topic of discussion in the field that we need to focus more upstream. Its-rating and re-iterating it is good I think. And Iastiy, there?s a lot of jargon and terms in here that we'd also i I ill I I Lthe media recommendations section. have to get rid of if we?re honest about Lthe use ofjargon and reading levelcombination-4n a multi-level, multi-sectoral way. This technical package includes strategies and- I approaches targeting preventiorilegu social emotional learning for children and youth), as. well as strategies focused more cognitive behavioral treatment to prevent re- 40 .J attempts}. It includes that range from a focus on the whole population regardless of risk to strategies designed lmportantly, this technical package extends the bounds of the typical prevention strategies to consider approaches go beyond individual behavior change to better address risk factors impacting communities and populations more broadly housing and community engagement initiatives. While the evidence base continues to emerge, the collection of programs, policies, and practices laid outlifxn, here are available for implementation now. And in keeping with good public health practice, the intent l?i is that monitoring and evaluation will play a key role in that implementation. Moreover, as new evidence becomes available, this technical package can be refined to reflect the current state ofthe science. In closing, and in keeping with a message of resilience as spoken by those with lived experience, 'hope, help, and healing is possible.? Comment From TS: Ithink you can drop this and just use the more Lcouid describe this as a range. Comment Hi: From JMLYES this is jargon, so the helps, but you might want to figure out a way to say this without referring to the outer levels of ,__the social ecology. Comment This sets you up for people to say oh yeah what transgendered people, prisoners etc. I. Comment lAl: l'm not exactly clear on how to take this comment and subsequently how to address it. Open to 41 Lideas. descriptive test. You don't need both. You 1 JL References Arsenault-Lapierre, G., Kim, C., Turecki, G. (2004). diagnoses in 3275 suicides: a meta-analysis. BMC 4, 37. Bandura, A. (1986}. Sociaifoundations of thought and action: A sociai cognitive theory: Prentice-Hall, Inc. Basile, K. C., Espelage, D. L., Rivers, McMahon, P. M., E: Simon, T. R. (2009). The theoretical and empirical links between bullying behavior and male sexual violence perpetration. Aggression and vioient behavior, 14(5), Basile, K. 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H., LoMurray, M., Schmeelkaone, K., Petrova, M., Yu, (1., . . . Wang, W. (2010). An outcome evaluation of the Sources of Strength suicide prevention program delivered by adolescent peer leaders in high schools. Am Public Health, 100(9), 1653?1661. doi: Yip, P., Caine, E., Yousuf, 5., Chang, Wu, K., 8L Chen, (2012). Means restriction for suicide prevention. Lancet, 379. 49 Appendix A: Summary of Strategies and Approaches to Prevent Suicide Strategy Approach/Program, Practice or Policy Strengthen household financial security Suicide Best Available Evidence Other Risk] Protective Factors for Suicide Suicide Attempts or ldeation Lead Sectors1 Government (local, Unemployment benefit programs state, Federal) Strengthen economic Other income supports Businessflabor . . . . . . Housmg pollcles Government {locaL The National Neighborhood Stabilization state, Federal) Program Coverage of mental health conditions in health insurance policies Health ca re Strengthen Mental Health Parity Laws 1/ access to Government (state, mental health Fadera? ca re Reducing access to lethal means among persons at-risk Government (local, intervening at suicide hot spots state) 1/ Safe storage practices Public Health Establish protective Organlzatlonal pollcles and culture Busmesstabor . Together for Life envnronments Government (local, US Air Force Suicide Prevention Program 1/ state, Fed eral) 50 Best Available Evidence Communitywbased policies to reduce excessive alcohol use Alcohol outlet density 1/ Government {local, state] Businessllabor Promote connectedness Peer norm approaches Public Health Sources of Strength Education Communitvrengagement activities Public Health Greening vacant urban spaces Government {local} Social emotional learning Public Health Youth Aware of Mental Health Program Education Signs of Suicide Teach co in 3 Good Behavior Game and problem- solvmg Sklils Parenting skill and family relationship approaches Public Health The incredible Years Education Strengthening Families 10-14 Gatekeeper training Public Health Mental Health First Aid Healthcare Screening combined with care management Healthcare Identify and 51 support people alt-risk Henry Ford Perfect Depression Core {Pre- cursor to Zero Suicide) Best Available Evidence Social Services Crisis Intervention Public Health Active foiio w?up con toct approaches EST for Suicide Prevention Notionoi Suicide Prevention Lifeiine Social Services Appiied Suicide intervention Training Treatment for people at risk of suicide Health ca re improving Mood Promoting Access to v? Social Services Coiioborotive Treatment Justice Coiiohorotive Assessment and Management v? Suic?doii CAMS Intervene to I lessen harms Dioiecticoi Behovioroi Therapy and prevent future risk Attachment?Based Fomiiv Therapy Treatment to prevent re-attempts Health ca re ED Brief intervention with Foiiow-up Visits Social Services v? Postvention Heaithcare 52 Best Available Evidence StandBy Response Service Safe messaging following a suicide Media Guidelines 1/ Public Health Media 1This column refers to the lead sectors well positioned to bring leadership and resources to implementation efforts. For each strategy, there are many other sectors such as non-governmental organizations that are instrumental to prevention planning and implementing the specific programmatic activities. From: LiKamWa, Wendy Sent: 5 Feb 2016 22:49:06 +0000 To: McIntosh, Wendy LiKamWa Deborah Subject: Conversation with LiKamWa, Wendy LiKamWa, Wendy 9:3? AM: aww, el jefe was really disappointed that HH was cancelled yesterday "Wendy - Sorry this didn't work out. I?m curious how many people ?yes". I was planning to attend, but didn't have a chance to respond to your email. Let's reschedule soon. Thanks. Jeff" Stone, Deborah (CDCIONDIEHINCIPC) 9:38 AM: that's too bad. i think people will always cancel at the last min so might be better to just keep the time and not cancel or you might have to reschedule lots of times. Just make sure you have someone you know who is going besides el LiKamWa, Wendy 9:39 AM: well, that was the point. no one was going I told him that after I sent the email yesterday morning, no one responded that they were definitely planning to attend, but I received emails from 1? people who said they weren't going to make it. And 2 maybes. LiKamWa. Wendy 10:16 AM: haha, guess who was the first person to RSVP to the new HH invite Stone. Deborah 10:16 AM: me? haha el jefe LiKamWa, Wendy 10:18 AM: yup. eI jefe Stone. Deborah 10:18 AM: poor guy. he does try hard and mean well. LiKamWa. Wendy 10:20 AM: yeah, i know it's like he desperately wants to be liked but he drives everyone crazy with his micro-management Stone. Deborah 10:21 AM: exactly. do you think i should tell him? LiKamWa. Wendy 10:21 AM: haha, go right ahead. maybe wait until we get the for SP Stone. Deborah (CDCIONDIEHINCIPC) 10:21 AM: haha! good point! btw. our proposal is with now! LiKamWa. Wendy 10:22 AM: I sent you a text about my plans for next week You'll be ok by yourself on the call with Yeates and Kim, right? Stone. Deborah (CDCIONDIEHINCIPC) 10:22 AM: oh ok. for some reason my phone is nowhere to be found. hold on.. ugh. yes. will be ok with yeates and kim. hope yeates is in a better mood this time. he seemed a bit cranky last time. LiKamWa, Wendy 10:24 AM: well, kim wasn't on the last call, right? or am i misremembering? LiKamWa, Wendy 10:39 AM: ok, I need to buckle down and finish revising this MMWR would you have a minute to look for any articles on females in the protective service? LiKamWa, Wendy 2:56 PM: haha, one of the police articles i saw listed "access to firearms," and was like, that would raise a few red flags! Stone. Deborah (CDCIDNDIEHINCIPC) 2:56 PM: it's ok. that's fair territory! that's a big reason why their rates are high we aren't saying take away their guns! at least not explicitly! LiKamWa, Wendy 2:5? PM: actually, the tiesman et al article NIOSH) talks about firearms and access to firearms a lot Stone, Deborah 2:59 PM: yeah, it's more of an issue if we are advocating for gun control. it's a fact that access is a risk factor. LiKamWa, Wendy 3:00 PM: still, "lethal means" is probably less likely to create issues compared to using the F-word Stone, Deborah (CDCIDNDIEHINCIPC) 3:00 PM: very true. LiKamWa, Wendy 3:03 PM: grr, none of the references we included talk about reasons for management occs to have higher risk i mean, i can speculate and make up my own reasons but in the colorado paper, the highest number of suicides was in management, and they didn't talk about it at all Stone, Deborah 3:14 PM: see if you can find anything in the database about job stress or job strain. i'm pretty sure i've seen that. you can search the enl forjob stress or job strain and see if articles pop up. LiKamWa, Wendy 3:15 PM: that's not what i meant I mean we're at our max of 10 references and none of our current references talk about reasons for management occupations having higher suicide rates Stone, Deborah 3:15 PM: oh sorry. i'm unclear why we can only have 10 esp if we need 11. i'd make a note to jaqueline. i'm sure they can make an exception LiKamWa, Wendy 3:21 PM: i can't find a good article quickly Stone, Deborah 3:22 PM: i can look if you want. LiKamWa, Wendy 3:22 PM: I'm just going to send it as is, and then if she asks for more information, we can add another reference Stone, Deborah 3:22 PM: ok LiKamWa, Wendy (CDCICCEHIPINCIPC) 3:26 PM: although, this sounds kinda stupid: "Of note, while management occupations had the tenth highest rate of suicide, they accounted for the second largest percentage of suicide deaths in the sample; therefore, it is important to target prevention strategies to managers as well. Suicide prevention strategies targeting these occupation subgroups should take into account these specific risk factors LiKamWa, Wendy 3:33 PM: help? the rest of the team has deserted me Stone. Deborah 3:40 PM: Of note, while management occupations had the tenth highest rate ofsuicide, they accounted for the second largest percentage of suicide deaths, OVE HALL, in the sample; therefore, it is important to target prevention strategies to managers as well. i'd delete the last sentence. suicide prevention strategies targeting these. and maybe delete 'in the sample LiKamWa, Wendy 3:40 PM: okies, that works! thank you Stone. Deborah 3:41 PM: :l i won't dessert you! or is it desert? haha hehe LiKamWa, Wendy 3:42 PM: dessert is that yummy sweet stuff after a meal. desert is the dry place filled with sand and scorpions, and is also a verb that means to abandon Stone, Deborah 3:43 PM: haha! awesome! oh and speaking of scorpions--that was so dumb for e! jefe to mention that to khyia! nobody knew what he was talking about! LiKamWa, Wendy 3:43 PM: i know! well, i did Stone, Deborah 3:44 PM: well you and brad and maybe one other khyia was like um yeah.. LiKamWa, Wendy 3:44 PM: hahaha Stone, Deborah 3:44 PM: or LiKamWa, Wendy 3:44 PM: "moving right Stone, Deborah 3:44 PM: haha! did you read that connects story!? about that woman who used to be in i were her i'd probably have done everything wrong {won?t give it away if you didn't read} LiKamWa, Wendy 3:52 PM: do you have a minute to look at what i just sent, and make sure I addressed everything, and didn't leave internal comments in there, etc.? and what should I say in my email response to doug {the lead MMWR editor}? he asked that i send the revisions to him, not jacqueline Stone, Deborah 3:55 PM: ok. will review now. Stone. Deborah 3:59 PM: why is there a parenthesis that says {reference} after we talk about the census? Is a reference needed there? LiKamWa. Wendy 4:00 PM: what page are you on ohisee that's language that NIOSH added, i think i think it means that the codes are the reference Stone. Deborah 4:02 PM: also, i'd respond to her second comment in the discussion section about rates and numbers of like we addressed the issue LillIamWa.I Wendy 4:02 PM: although i could have completely misinterpreted, but no one else has picked up on it Stone. Deborah (CDCIONDIEHINCIPC) 4:02 PM: ok. just leave it for now. LiKamWa. Wendy 4:03 PM: ok Stone. Deborah 4:03 PM: where it says. "The proportion of suicides for males to females was similar to the national proportion in 2012. which was 78.3% and 21.7%, respectively. I'd add the wisqars ref (1) LiKamWa. Wendy 4:03 PM: i mean. ok to responding to her comment good catch Stone. Deborah 4:05 PM: that's all i got! looksgood! LiKamWa, Wendy 4:07 PM: thanks ok. i'm guessing bradford isn't going to weigh in I already talked to aimee earlier she's on her flex day, so she said she didn't need to see it unless i wanted her to Stone. Deborah 4:08 PM: yeah. he's fine. i mean go ahead without him though he did just send me an email on something else so he may be working on it now. maybe email or im him and say you are going to send now unless he wants you to wait. LiKamWa. Wendy 4:0!7lI PM: haha. Ijust IMed him Stone. Deborah (CDCIDNDIEHINCIPC) 4:10 PM: cool LiKamWa, Wendy (CDCICCEHIPINCIPC) 4:10 PM: he says he trusts us all and to please send ok. how about this for an email response, "Dear Doug. Thank you. We have made the requested revisions. haha. i can't think of anything else to say I was going to add. "we'd be happy to discuss any remaining questions with jacoueline.? but then it sounds like we'd rather be communicating with her directly instead of him crap. sorry didn't mean to call i think "ctrl enter" starts a phone call? Stone, Deborah 4:15 PM: Ok, sorry, was getting a snack. lol. and i didn?t see that you called. Dear Dougie, LiKamWa, Wendy 4:16 PM: love, wendy wendie Stone, Deborah 4:16 PM: hahah! wendi hah! Dear Dougie, Please find the attached revised draft attached per your request. The research team has replied to all of Jaqueline's questionsfcomments in track changes. Please let me know if you have any further concerns.? oops don't say attached twice! LiKamWa, Wendy 4:13 PM: hahaha Stone, Deborah 4:18 PM: that would be funny Oh and you can always add that you appreciate the feedback. LiKamWa, Wendy 4:18 PM: and i probably want to spell jacqueline correctly Stone, Deborah (CDCIDNDIEHINCIPC) 4:18 PM: that's a lie but they like it oh and yes, spell all names correctly! just call herjackie LiKamWa, Wendy PM: yes, i?m sure they'll all love that ok, i like what you said not sure if "please let me know if you have any further concerns" is the best thing to include he already said that the report will then go back to the editor for another review Stone. Deborah 4:20 PM: oh ok LiKamWa, 4:21 PM: maybe just keep it short and sweet, and say, thanks, wendy Stone, Deborah (CDCIONDIEHINCIPC) 4:22 PM: yep that's fine. LiKamWa, Wendy 4:22 PM: just one more workday and one more hour until yacay! Stone, Deborah 4:22 PM: woo hoo! LiKamWa, Wendy 4:24 PM: haha he's out of the office until monday Stone, Deborah 4:26 PM: funny. figures! LiKamWa, Wendy PM: any plans for the weekend? Stone. Deborah 5:05 PM: sorry. i'm working on something that is annoying me so need to figure it out! LiKamWa. Wendy 5:05 PM: no worries Stone. Deborah 5:31 PM: ok. finished! was working on a revised codebook for a new paper i may have told you about on train suicides. amanda is heading it up and brad and kristin and i are working on it with doryn from action alliance, jerry reed. and a guy from dept of trans. LiKamWa. Wendy 5:32 PM: yeah cool don't want to hear the gory details though! Stone. Deborah 5:32 PM: right LiKamWa. Wendy (CDCICCEHIPINCIPCII 5:32 PM: (tmil Stone. Deborah 5:32 PM: haha! that's so funny! LiKamWa. Wendy (CDCICCEHIPINCIPQ 5:32 PM: Stone. Deborah 5:33 PM: puke. LiKamWa. Wendy 5:33 PM: i will if you tell me about the train videos! Stone. Deborah 5:34 PM: yeah i'm not into watching those! LiKamWa. Wendy 5:34 PM: that's cool that amanda is going to AAS natalie and brad and aimee aren't going Stone. Deborah 5:35 PM: oh. how did you find out? LiKamWa. Wendy 5:35 PM: kristin sent out that email earlier and i had asked natalie and brad and aimee separately in the past few weeks Stone. Deborah 5:35 PM: oh didn?t realize that's what it said. i feel bad for brad. i know he really wanted to go. i wonder why he's not going. because of travel issues? LiKamWa. Wendy (CDCICCEHIPINCIPQ 5:35 PM: YEP and he was mad that they wouldn't let aimee go on one of the site visits Stone. Deborah 5:36 PM: i feel like there should be a way to have him go thatahead to go right?I LiKarnWa. Wendy 5:37 PM: i haven't done my travel request yet but no one has told me i can't go Sterne. DebOrah (CDCIONDIEHINCIPC) 5:37 PM: ok LiKamWa. Wendy (CDCICCEHIPINCIPQ 5:40 PM: if i can't go you'll have to present for me! i agree that brad should be allowed to go Stone. Deborah 5:43 PM: i just wrote kendell and jeff an email advocating for brad and aimee but especially brad. i feel like he works so hard but gets no recognition or reward. and he's really excited by all the suicide prev stuff but can hardly participate in anything. i should have said some of that in my email! oh well. i think i got my point across. LiKamWa, Wendy 5:43 PM: yeah, poor guy oh boy. what did you write? Stone. Deborah 5:44 PM: well i said that i have two site visits that were in my travel projections but that might not take place until next fiscal year {the RSV is in April!) and i asked if aimee and brad could use those slots for MS. and i said what a great champion brad is and that our partners would like to see him etc.. i also mentioned we may get two free registrations like we did last year if we have a table there LiKamWa. Wendy 5:45 PM: were you site visits for this quarter? *your Stone. Deborah 5:45 PM: no i think quarter 4 LiKamWa. Wendy 5:45 PM: oh. are we doing that this year? ok, i seem to remember that they were trying to encourage people to take their trips later in the year if possible, but I'm not really sure how it works Stone. Deborah (CDCIONDIEHINCIPC) 5:46 PM: yeah i don't know how it works either but i figured i'd try. can't really hurt. i hope! ha! LiKamWa. Wendy 5:47 PM: let me know what they say! Stone. Deborah 5:4?r PM: ok. i'm going to get going. i hope you have a good weekend! i'm having brunch with michele on sunday and going to a superbowl party. LiKamWa. Wendy 5:47 PM: promise jetf that you'll go to the next happy hour, maybe that will help Stone. Deborah 5:4]Ir PM: oh yeah, that's a good idea! haha! LiKarnWa. Wendy 5:47!r PM: have a good weekend too! Stone. Deborah (CDCIONDIEHINCIPC) 5:48 PM: thanks! LiKamWa. Wendy 5:48 PM: today's my 8 hour day. so i'm signing off too Stone. Deborah 5:48 PM: (car) Lil-(amWa, Wendy 5:43 PM: i'll be teleworking on monday (ninja) Stone. Deborah (CDCIONDIEHINCIPC) 5:48 PM: ok. me too ha! LiKamWa. Wendy 5:43 PM: Stone. Deborah 5:43 PM: i thought that car was going to do (bike} From: Middlebrooks, Jennifer Sent: 30 Jan 2017 12:13:23 -0500 To: Mercy, James Joni Linda L. Thomas Erin Jeffrey Greta M. Gayle H. Alexander Cc: Dorigo, Leslie Courtney (CDCIONDIEHINCIPCJ Subject: DVP Media Report Media Coverage BULLYING Jan. 23, 2017 ?Special Needs Parent Hopeful First Lady Melanie Trump Will Help Curb Bullying? - Publicationfoutlet: Parent HeroidlUVM: I "First Lady Melania Trump has talked about setting an anti-bullying campaign when her husband was running for U.S. president. A special needs parent is hoping now that she has an important role in the White House, Trump will make good on her word for the sake of the parent's children with autism and other families.? GUN VIOLENCE Jan. 20, 2017 "Congress Gutted Researchers' Ability to Study Gun Violence. Now They're Fighting Back" - Publication/Outlet: Mother Jones (UVM: 0 "On November 14, six days after Donald Trump won the presidential election, more than 80 researchers from 42 schools of public health gathered for a closed-door meeting at the Boston University School of Public Health. Their agenda: how to get around the federal government's de facto ban on researching the health impact of gun violence and get it done anyway." "Public Health Advocates Push Gun Safety Over Gun Control" - Publication/Outlet: WGCU - Fort Meyers, Fla. (UVM: - ?Members of the public health community are calling for action on gun violence by shifting the conversation away from gun control. The group is focusing on gun safety in an effort to find common ground among gun rights activists and those looking for In 1995, Congress added language to a bill that said funding for the Centers for Disease Control and Prevention to research injury prevention could not be used to promote gun control. Congress later added the same language to bills funding the National institutes of Health." Jan. 23, 2017 ?Diversify Washington in More Ways Than One: Scientists Must Become More Involved in Political Processes" - Publication/Outlet: SalonlUVM: 0 ?Through 314 Action, we also advocate an end to the ban on research by the CDC on gun violence. The Dickey Amendment, passed in 1996 as a result of pressure from the powerful NRA lobby, prohibited funds made available for injury prevention and control at the Centers for Disease Jan. 24, 201? Jan. 25, 2017 Control and Prevention from being used to advocate or promote gun control. The effects of this amendment have reduced funding for firearm research by 96 percent, leaving meager resources for any researcher looking to investigate the epidemic of gun violence. As we enter a new year and a new administration, 314 Action will seek to not only abolish this amendment, but also to promote a common sense, data- driven approach to solving gun violence." "Outside Police Agencies to Help Wilmington Stop Crime" - Publication/'Outlet: DelawareOnline.com{UVM: 0 ?Wilmington Mayor Mike has called upon outside law enforcement agencies to help put an end to the spike in city crime that has led to 18 shootings this year, eight of which were fatal. The CDC identified the lack of intervention among youth at pivotal moments in their lifetimes as a cause of the violence cycle.? ?American Carnage' is Real? - PublicationIOutlets: Bloomberg, ?Bloomberg View? blog, Reodlng Eagle, Chlcogo Tribune, and Providence Business Journal (Total UVM: . "You've heard about the "American carnage." But how bad is it out there, really? Pretty horrible, actually. I am referring of course to what was probably the most memorable phrase in President Donald Trump's inaugural address.? ?Beyond Gun Violence: NC Churches Join Community for Preach-In Event" - Publication/Outlet: Public News Service and The Charlotte Post {Total UVM: - "Coming on the heels of the millions who participated in the Women's March on Washington and sister events, this weekend will bring another opportunity for civic engagement. Religious and community organizations are holding a preach-in event to educate people of faith on gun control and how it is supported by the teachings of their religion. The Reverend Richard Edens is one of the pastors at the United Church of Chapel Hill, the host site of Beyond Gun Violence Conference.? ?Chapel Hill-Carrboro churches to talk gun violence this weekend" i PublicationIOHtlet: The News St ObserverlUVM: - "We live in a nation with more than 300 million guns in circulation. We recoil at shootings in Sandy Hook or Virginia Tech and jointly lament this should not happen, but every week 30 to 35 children and young people die while another 180 are injured. Every week. It is time to pay attention." "An Unusual Anti-Suicide Partnership Targeting Gun Shops ls Ramping Up? I Publicationlt'Jutlet: New i?ork MoguzlnelU?v'M: - ?You probably wouldn?t expect a delegation from the American Foundation for Suicide Prevention to show up to the largest annual trade event for firearms sellers. And yet that?s what happened at the 2017 SHOT Show, which was held last week in Las Vegas. As Maura Ewing writes in the Trace, the delegation, perhaps a bit out-ofeplaceseeming "among the rows of retailers hawking the latest models of firearms and tactical gear had come to promote a unique partnership with the show?s organizers on a nationwide suicide prevention program with the ambitious goal of stopping nearly 10,000 deaths in the next decade.? ?Obama CDC Study: Silencers Best Option for Noise Reduction at Gun Ranges" I PublicationICIutlet: TheTruthAboutGuns.com(UVM: I "With the introduction of the Hearing Protection Act, Congress is closer than ever to removing silencers from the purview of the National Firearms Act and ensuring that every American gun owner can easily make their firearm much quieter. Suppressed firearms are not only more enjoyable to shoot, but, according to a report by the Obama administration report on noise and lead at outdoor firing ranges, they're the only effective way to reduce the harmful noise levels." Jan. 26, 2017 "Gun Rights Activists Sue Over Massachusetts Firearms Laws" I Publication/Outlet: I ?Gun rights activists aided by the National Rifle Association are suing Massachusetts over its firearms laws, saying the state's assault weapons ban is preventing law?abiding residents from buying and possessing some of the most popular rifles in the country, as well as most standard capacity magazines." SEXUAL VIOLENCE Jan. 21, 201? "How Will President Trump Handle Violence Against Women in the I PublicationfOutlet: The Hill(U?v?M: 409*} I "This week, The Hill reported that the incoming Trump administration is looking to dramatically reduce federal spending. Of these spending cuts, funding for Violence Against Women Act grants was highlighted to be on the chopping block. This action is a grave mistake it will likely put the lives of those experiencing domestic violence in danger because they will have fewer resources to escape." Jan. 24, 2017 "Sexual Assault in the Time of Trump" I Publication/Outlet: AlJozeemlUVM: I "Affirmative consent, for those who don't know, is the idea that if you don't consent at every stage of a sexual encounter, it's rape. That means asking for every kiss and asking for every boob squeeze. It's almost as if feminists want everyone to remain celibate." These words were spoken last autumn to a packed auditorium of students at Auburn University in Alabama during a speech called How Feminism Hurts Women by Milo Yiannopoulos.? Jan. 25, 2017r "Anti-Domestic Violence Groups Concerned About Threatened Budget Cuts" I PublicationIOutlet: MetrolUVM: I "Police can respond to a variety of calls, but according to Milton Police Chief John King, the most common violent crime his department deals with is domestic violence. King is pretty confident it?s a common call in most communities. In Massachusetts, nearly one in three women and one in five men have experienced physical violence, rape or stalking by an intimate partner, according to a Centers for Disease Control and Prevention survey and those numbers are likely to be underreported, King said." SUICIDE Jan. 23, 201? ?Mind Your Mental Health" I PublicationIOUtlet: "The Green Sheet" bloglUVM: I ?Jokingly, my closest friends refer to me as "bipolar" because my mood is seemingly always on a roller coaster ride of feeling on top of the world one minute, and then feeling as if the world is coming to an end the next. But these emotional swings are mainly due to the fact that I am ?nancially and invested in my merchant account and merchant cash advance deals. 'Among the professions with suicide rates 1.5 times or more than the rest of the population are doctors, dentists, veterinarians, financial workers, lawyers, and engineers, according to the CDC National Occupational Mortality Surveillance Database.? Jan. 25, 2017 ?Gun Stores Hear 3 Bold Pitch at Top Firearms Trade Show: Suicide Prevention" I PublicationICJutlet: The TrocelU'v'M: 0 "New offerings abounded at the 2017 SHOT Show, the industry?s largest annual trade event, hosted last week by the National Shooting Sports Foundation in Las Vegas. But among the rows of retailers hawking the latest models of firearms and tactical gear, there was one surprising addition to this year?s convention: a delegation from the American Foundation for Suicide Prevention. They had come to promote a unique partnership with the show?s organizers on a nationwide suicide prevention program with the ambitious goal of stopping nearly 10,000 deaths in the next decade.? Jan. 26, 2017 ?Suicide Rates in the United States tncreasi?g, Black Youth Hit Hardest? I PublicationIOHtlet: Rolling - ?Recent events in the news have exposed the hidden tragedy of suicide in America. Most recently, Nakia Venant, 14, of Miami Gardens, Florida was found hanging, Sunday, Jan. 23. She posted her final goodbye on Facebook Live. Nearly a month ago, a Georgia teen committed suicide on Facebook. On December 30, Katelyn Nicole Davis filmed her death by hanging from a tree in front of her Cedartown, Georgia home, reports say. In a video taken prior to her suicide, Davis alleged she had been physically and sexually abused by her stepfather. In Los Angeles, actor Frederick Jay Bowdy, 33, used Facebook Live to show his suicide to horrified family and friends. These well-publicized cases echo recent CDC findings that in 2016 the suicide rate in America reached a 30-year high. The CDC study titled ?Increase in Suicide in the United States, 1999? 2014" also found a continued increase in suicide rates for young Black males." MULTIPLE TOPICS (Bullying, Sexual Violence, and Suicide] Jan. 25, 2017 ?Candidates Talk Money, Mental Health, Start Times" 1: Publicationloutlet: The Los Alomos MonitoriUVM: - "Ca ndidates running for seats on the Los Alamos School Board shared their views with the public Wednesday night during a forum organized by the League of Women Voters of Los A recent Centers For Disease Control Survey revealed that Los Alamos youth rank above the 9.2 percent state average when it comes to sexual dating violence, suicide ideation and bullying." Total unique visits per month of publication?s website (within one month prior to date reported) From: Middlebrooks, Jennifer Sent: 24 Feb 2017 15:05:43 43500 To: Mercy, James Joni Thomas Linda L. Erin Jeffrey Gayle H. Greta M. Alexander Subject: DVP Weekly Media Report Summary The national media covered a variety of violence?related topics with CDC mentions during the week of February 17?23. The release of a study published in the Journal of the American MedicalAssociotian (JAMA), which found conducted found that suicide rates for teens have gone down 7 percent after the legalization of same?sex marriage, resulted in a predominant focus on teen suicide. Media Coverage CHILD ABUSE 8. NEGLECT Feb. 17, 2017' ?Developing Resilience in Children? a Publication: Centre Daily Times - ?How can we impact the troubling ubiquitous human issues that characterize our society, or at least know to process the daily bombardment? From children being bullied in schools because of ethnic or social status, to increased heroin abuse because of posttraumatic stress to increased levels of adolescent depression and suicide due to increased stressors, to increased incidences of sexual assault and cutting on college campuses, to record levels of being overweight and obesity, just to name a few, I think we can agree that something is not quite right in our modern society. The statistics from recent studies are alarming and have reached crisis levels. A 2016 study published in the Journal of Abnormal found that 83 percent of participants experienced depression, anxiety or other mental health disorder. The study was conducted over the lifetimes of 988 individuals, with a total of 13 assessments taking place between their birth and when they hit age 38. A recent American Academy of Pediatrics study found a significant increase in major depressive episodes over the past 10 years, especially among adolescent girls and young adult women.? Feb. 20, 2017 ?Effects of Adverse Childhood Experiences Focus of Summit" 0 Publication: The News StarlUVM: - Wednesday summit and documentary screening held at the University of Louisiana Monroe will focus on adverse childhood experiences and the long?term ramifications these experiences can have on physical and mental wellbeing. An ongoing study between the Centers for Disease Control and Prevention and the Kaiser Permanente health system launched in 1998 and has tracked the number of ACES each of the 17,000 respondents experienced and their responses on subsequent mental and physical evaluations.? GUN Feb. 17, 201? "Court tosses Florida 'Docs vs. Glocks' Law? IPublication: UPl.com I federal appeals court tossed out a Florida law restricting doctors from discussing guns and gun safety with their patients, on grounds that such restrictions are a violation of the First Amendment." "American Council on Science and Health" I Publication: American Council on Science and Health I recent ruling by the 11th U.S. Circuit Court of Appeals in Atlanta, Georgia, found the Firearm Owners Privacy Act enacted in 2011 in Florida? impeded the First Amendment free speech rights of medical professionals. The law sought to preserve Second Amendment rights but thought forbidding physicians to discuss gun ownership with patients was the way to do so. Fines and censure by the state medical board were threatened if doctors were found to be in violation. Ambiguous language did n?t help." "NRA-Backed Law Limiting Doctors? Gun Speech Struck Down" I Publication: NewsweeklUVM: I federal appeals court has struck down a Florida gag rule that barred doctors from talking with their patients about guns, an outcome that gun-safety advocates view as a victory for public safety. The National Rifle Association and the Republican-controlled Florida legislature have long supported the measure. The Atlanta-based 11th US. Circuit Court of Appeals on Thursday afternoon found that the measure, formally called the Firearms Owners? Privacy Act, violates doctors? free speech rights and denies patients medical information. Critics of the measure said the law unjustly punishes medical professionals for discussing responsible gun ownership and firearms safety with patients, especially if individuals have children who might come across loaded, unsecured guns at home. Supporters of the law argued such medical discussions would infringe upon an individual?s right to bear arms and push an anti- gun agenda.? "Money for Firearms Research Lacking, Harvard Professor Tells Scientists? I Publication: The Boston GlobelUVM: I "An average of about 100 people nationwide die every day from gun injuries, but funding for firearms research is virtually nonexistent, a Harvard University professor said Friday. David Hemenway, who teaches at Harvard?s School of Public Health, described a grim research landscape during the annual meeting of the American Association for the Advancement of Science in Boston. The Centers for Disease Control and Prevention had once set aside $2.6 million annually to study firearm injuries, but that was wiped out in the 19905 under pressure from the gun lobby and congressional Republicans, Hemenway said." "Gauging Gun Violence in Miami-Dade Complicated by Jumble of Records" I Publication: Miami HeroldlUVM: I ?Gauging the scope of gun violence in Miami?Dade particularly involving young people is difficult because a jumble of statistics kept by dozens of different police and state agencies can sometimes take months to be compiled or released to the public. The difficulty in obtaining shooting data echoes broader concerns over researching the effects of gun violence. Decades ago, the US. Centers for Disease Control and Prevention used to support research into gun-related injuries, even completing one study in 1993 that found a correlation between having a gun in the house and an increased risk of homicide.? Feb. 18, 2017 Megiial Society Launch Effort to Help Docs Discuss ng Safety" IPublication: The Teiegram (UVM: I "The Massachusetts Medical Society and the state attorney general's office, with endorsement from chiefs of police associations, have released pamphlets and online educational material to help doctors talk voluntarily to patients about another touchy subject; guns in the home and how to keep themselves and family members safe. Health professionals and those familiar with statistics about the more than 33,000 people killed by guns and nearly 79,000 people who survive gunshots each year in the United States, according to the federal Centers for Disease Control and Prevention, applauded the announcement at Boston Medical Center last week as a way to further protect public health." Feb. 22, 201? "The Conversation We Should all be Havin?out Gun Violence and Firearm Safety" I Publication: Charieston City PaperlUVM: 279.9K*l - "As with most things, managing gun violence and the flow of firearms in America comes down to money. The Bureau of Alcohol, Tobacco, Firearms and Explosives the lead federal agency charged with enforcing federal laws related to firearms is woefully understaffed. For example, a 2016 Congressional report states that the has maintained that the agency cannot meet its goal of inspecting every federal firearm licensee for compliance on a three-year cycle." In 2015, ATF agents were only able to complete 6 percent of inspections of the nation's federal firearm licensees. Add that to the rising number of firearms being pumped to the civilian gun stock each year, peaking in 2013 with 16 million firearms introduced to the 0.5., and the need for funding the ATF becomes even more obvious. The same can be said for supporting research organizations such as the CDC and National Institutes of Health, which have both struggled to find the necessary financial support to combat gun violence." "In Harm?s Way: Gun Injuries and Deaths Amo?g Florida Kids Have SM'Lked" I Publication: Tampa Bay TimeslUVM: - ?Gun injuries are a growing problem for Florida?s children, rising along with the increasing availability of firearms across the state, the Tampa Bay Times has found. When asked why the focus was not on gun injuries and deaths, spokeswoman Mara Gambineri pointed out that the federal Centers for Disease Control and Prevention have funded much of the state?s injury prevention efforts. Since 1996, Congressional Republicans have pressured the agency not to fund gun research and safety measures.? Feb. 23, 2017 SEXUAL VIOLENCE Feb. 17", 201? Feb. 19, 2017 Feb. 20, 2017 "Hypocrites at NRA Aren't Fooling Anyone" IPublication: The I "In his recent op-ed, ?The mentally ill have gun rights, too National Rifle Association Executive Director Chris Cox defends the reversal of an Obama?era rule that prohibited those who have been diagnosed with certain mental illnesses and assigned a representative payee by the Social Security Administration from owning a firearm. It is also amusing to note the sudden commitment to data and evidence based solutions, as they have held researchers hostage for decades. Through the 1996 Dickey Amendment, the NRA has actively prevented the Center for Disease Control (CDC) from studying gun violence and disseminating data about the best methods to prevent it." "Bill Would Require High Schoolers to Learn About Legal Consent" I Publication: WAW Nexstar Media Group Affiliate: Portsmouth, Va. - bill that would require high schoolers to learn the meaning of legal consent is heading to the governor?s desk. Advocates say the goal of early education is to hopefully cut down on troubling numbers when it comes to sexual assaults. The CDC says nearly one in five women have been raped at some time in their lives." ?Let?s Stop Treating the Divorce Rate Like the Crime Rate" - Publication: New York MogazinelUVM: - "In honor of Valentine?s Day, Science of Us is spending this week talking about love specifically, what happens when it goes wrong. if you ever wondered about the of breakups, we?ve got you covered. Certain statistics are treated as assurances that America is getting more civilized, like the crime rate (mostly) going down, infant mortality decreasing, and life expectancy (mostly) going up. Then there's divorce: The topic is hotly debated, and so is the rate itself." ?Nine Years after His Daughter Was Killed in His Home by Her Ex, Dad Has a Strong Warning for Parents? 0 Publication: l'ndependentjournol Review 1- "Demi Brae Cuccia was a cheerleader at Gateway High School in an honor roll student, and an engaged member of her church. According to CBS Pittsburg, Demi and John Mullarkey Jr. had recently ended a tumultuous two-year relationship. In an interview with Independent Journal Review, her father Dr. Gary Cuccia said he knew the couple had broken up but didn't think anything of it at the time. Less than 15 minutes after Mullarkey entered the house, reported the Post-Gazette, the two got into a verbal fight. During the argument, Mullarkey pulled out his 3.5 inch pocketknife and stabbed Demi 15 times. According to the Centers for Disease Control and Prevention (CDC), 21 percent of females and 10 percent of males experienced physical or sexual violence between the ages of 11 and 17. But many instances of teenage violence goes unreported.? Researchers Say Funding for Gun Research is Non-Existent But it Would Save Lives" 0 Publication: Deutsche Weiie . ?More people die due to guns in America than in any other high-income country. But the US congress has restricted funding for gun violence research. Researchers say it's impossible to generate lifesaving data.? "Church Response to Domestic Violence Focus of Study? - Publication: Baptist PressiUVM: - ?When it comes to domestic violence, Protestant pastors want to be helpful but often don't know where to start, a new study According to the Centers for Disease Control and Prevention, nearly a quarter of American women (24.3 percent) and 1 in 7 men {13.8 percent} have 'experienced severe physical violence by an intimate partner.? Feb. 21, 2017 "Tips for Protecting Your Teen from an Abusive Relationship? I Publication: Miami HeraidlUVM: Iv "Parents often dread the first time their child heads out on a date, worrying about emerging hormones and the emotions in play. However, there is a greater threat to your teen's well-being than a broken heart. According to a 2013 Centers for Disease Control and Prevention survey, one in five girls between 12 and 18 years old experienced teen dating violence. Teen dating violence is physical, emotional or sexual abuse between two teenagers in a relationship. Dating violence can include being hit, kicked or shoved by a partner; being shamed, bullied or verbally demeaned; or being forced into sexual encounters. This abuse often takes place face-to-face, but can occur over the telephone, through text messaging, via social media platforms or online." "Freedom 180, AMlKicls Raise Awareness of Teen Dating Abuse" I Publication: Panama City News HeraldiUVM: II ?One in three teenagers has experienced dating violence, according to a 2013 statistic from the Centers of Disease Control (CDC). But Chris Cobb, a student at Panama City Marine Institute is surprised that number isn't higher. He has had a number of friends come to him saying they were in abusive relationships and needed advice. Healthy relationships and what a healthy relationship looks like just isn't talked about, he said, and teens don't always feel comfortable going to their parents for advice." ?Letters: Hiring Legal Immigrants Best; More on Presidency? - Publication: The GazettelUVM: I "Reduce all relationship violence: February is Teen Dating Violence Awareness Month. While many adults are unaware of the prevalence of teen dating violence, the U.S. Centers for Disease Control report that 1 in 4 teens report being hit, slapped, stalked, sexually assaulted or emotionally abused by a dating partner. About 1 in 5 women and nearly 1 in 7' men who ever experienced rape, physical violence, and/or stalking by an intimate partner, first experienced this violence between the ages of 11 and Feb. 22, 2017 "Groups Work Against Dating Violence: Datin_g_Abuse and Teen Dating Violence Continue to increase for Girls and Young Women Aged 16-24. I Publication: The Daily lowonlUVM: "Most would agree that everyone deserves to be in a relationship founded on mutual respect and communication, and free from verbal, emotional, and physical abuse. Unfortunately, according to the Centers for Disease Control and Prevention's Division of Violence Prevention, this is not the reality for millions of Americans. This month, the Women?s Resource and Action Center, the Domestic Violence Intervention Program, the Office of the Sexual Misconduct Response Coordinator, and the Rape Victim Advocacy Program have successfully used Teen Dating Violence Awareness and Prevention Month to celebrate and advocate for healthy relationships.? ?Recognise Stalking as Domestic Violence? I Publication: Moldy MoiilUVM: - "How many have experienced stalking? A 2013 report by Women?s Aid Organisation Malaysia?s largest service provider for domestic violence survivors documented 34 domestic violence cases, of which nine women had been stalked by their abusers. in the United States, approximately a third of women domestic violence survivors were stalked by their abusers, according to a 2011 Centers for Disease Control and Prevention (CDC) report." "Teen Dating Violence: More Than Teenage Drama" . Publication: WRAL Raleigh, N.C. - ?February is Teen Dating Violence Awareness month. Teen dating violence is reported as extremely common and starts as early as 11 years old. The question is how parents should recognize the signs and not just dismiss it as teen drama. According to LoveisRespect.org, 1 in 3 teens will experience dating violence. According to the CDC, 23 percent of girls and 14 percent of boys will experience dating violence for the first time between 11 and 17 years old.? Domestic Violence Center Honored by LA. County" 0 Publication: KHTS - Santa Clarita, Calif. 99.5K*l v- Domestic Violence Center staff and leadership were honored Tuesday by the county for their work preventing teen dating abuse. February is Teen Dating Violence Awareness Month. Every year, approximately 1.5 million high school students nationwide experience physical abuse from a dating partner, according to the Feb. 23, 2017 ?Parents: Survey Sex Abuse Questions Went Too Far? - Publication: MagicValley.com I ?Brandy Ramos? 9-year?old daughter has spent the school year learning about adding decimals and the difference between cold?blooded and warm?blooded animals. So earlier this month, Ramos was shocked when she picked up her daughter from school and the third-grader asked her to explain a sex act. The original Adverse Childhood Experiences Study organized by Kaiser Permanente and the 1.1.5. Centers for Disease Control and Prevention .1 was given in the mid- SUICIDE Feb. 17, 2017 Feb. 20. 201? Feb.21,2017 1990s to more than 17,000 southern California adults. It's ?one of the largest investigations of childhood abuse and neglect and later-life health and well-being,? the website says." ?Legislators Designate Suicide Prevention Week? I Publication: I ?Legislators have passed resolutions to designate the week of Sept. 10 as National Suicide Prevention Week in Virginia. According to the Centers for Disease Control and Prevention, suicide is the 10th leading cause of death in the United States, taking more than 43,000 lives each year. The CDC estimates that more than 1 million Americans attempt suicide annually.? ?Gay Marriage Legalization Linked to Drop in Teenage Suicide Attempts? I Publication: Medical News TodaleVM: 10.9M*l I ?In June 2015, the United States Supreme Court ruled that same?sex marriage bans were unconstitutional, enabling homosexual couples across America to marry. A new nationwide analysis suggests the legalization of gay marriage in the 0.5. may have led to a drop in suicide attempts among students. According to the Centers for Disease Control and Prevention (CDC), suicide is the third leading cause of death among 10+24-yearrolds in the U.S., accounting for 4,600 deaths each year.? ?Drop in Teenage Suicide Attempts Linked to Legalisation of Same-Sex I Publication: News GriolUVM! 104-0K*l I "Legalisation of same-sex marriage in US states has been linked to a drop in suicide attempts among teenagers. Researchers say suicide attempts among high school students fell by an average of 7% following the implementation of the legislation. The impact was especially significant among gay, lesbian and bisexual teenagers, for whom the passing of same-sex marriage laws was linked to a 14% drop in suicide attempts." ?Marriage Equality Means Fewer Teens are Dying by Suicide" I Publication: Dazed MogazinelUVM: I ?The legalisation of same-sex marriage in the U.S has been linked to fewer teenagers attempting to take their own lives. Suicide attempts among high school students dropped by 7 percent following the change in marriage laws, according to researchers from John Hopkins University, Harvard and Boston Children?s Hospital. The study, carried out across 17 years over 47 U.S states, saw the biggest drop among gay, lesbian and bisexual young people, with 14 percent less suicide attempts. It translates to roughly 134,000 fewer teens. As Forbes reports, it?s halfway to the government's federal goal of reducing teen suicide by 10 percent in 2020. Suicide is the second leading cause of death among 15 to 24-year-olds, according to the US Centres for Disease Control and Prevention, with numbers rising significantly among people." "Teen Suicide Attempts Fell as Same-Sex Marriage Became Legal" I Publication: Brodenton HeroldlUVM: In ?Teen suicide attempts in the U.S. declined after same-sex marriage became legal and the biggest impact was among gay, lesbian and bisexual kids, a study found. The research found declines in states that passed laws allowing gays to marry before the Supreme Court made it legal nationwide. The results don't prove there?s a connection, but researchers said policymakers should be aware of the measures? potential benefits for youth mental health. Suicide is the second~leading cause of death for all U.S. teens. Suicidal behavior is much more common among gay, lesbian and bisexual kids and adults; about 29 percent of these teens in the study reported attempting suicide, compared with just 6 percent of straight teens.? ?Same-Sex Marriage Laws May Reduce Teen Suicide Attempts 0 Publication: SeekerlUVM: - ?Researchers at Johns Hopkins University found that suicide attempts among gay, lesbian and bisexual teenagers dropped by 14 percent following the legalization of gay marriage on the state level.? ?Same Sex Marriage Legalization May Have Cut Teen Suicide Attempts" - Publication: FortunelUVM: - "Policies legalizing same sex marriage are correlated with fewer youth suicide attempts, especially among teenagers who are sexual minorities, according to a new study. Researchers from Johns Hopkins' Bloomberg School of Public Health analyzed data from both states that had and hadn't legalized same sex marriage prior to 2015, when the Supreme Court issued a decision legalizing it across the country. "After same?sex marriage laws were implemented, the proportion of high school students reporting suicide attempts in the past year decreased by 0.6 percentage points, equivalent to a 7% decline," wrote the authors. States that had not legalized same sex marriage did not see these declines." "Teen Suicide Rates Dropped After Same-Sex Marriage Was Legalized, Study Finds" a Publication: I "Policies legalizing same sex marriage are correlated with fewer youth suicide attempts, especially among teenagers who are sexual minorities, according to a new study. Researchers from Johns Hopkins' Bloomberg School of Public Health analyzed data from both states that had and hadn't legalized same sex marriage prior to 2015, when the Supreme Court issued a decision legalizing it across the country. "After same-sex marriage laws were implemented, the proportion of high school students reporting suicide attempts in the past year decreased by 0.6 percentage points, equivalent to a 7% decline," wrote the authors. States that had not legalized same sex marriage did not see these declines." ?Why Teen Suicide Rate Has Dropped Since Same-Sex Marriage Was Legalized" a Publication: I study published in The Journal of the American Medical Association found that suicide rates for teens have gone down 7 percent after the legalization of same-sex marriage. The study looked at suicide rates in teenager between 1999 and 2015, which was the year that the Supreme Court legalized same-sex marriage across the nation.? ?Teen Suicide Attempts Declined After Same-Sex Marriage Became Legal, Study Finds" I Publication: KDVR - Fox Affiliate: Denver, Colo. (UVM: ?Suicides have become the second~leading cause of death among people aged 15 to 24 in the United States. But researchers say the legalization of same-sex marriage may be a source of hope for some teens. According to the Centers for Disease Control and Prevention, almost 30 percent of gay, lesbian and bisexual high school students reported attempting suicide, compared to 6 percent of heterosexual students." ?Springand Summer Months More Common for Suicide" - Publication: KCRG ABC Affiliate: Cedar Rapids, Iowa (UVM: - "According to the CDC, more people in the United States complete suicide in the spring and summer months, than during the rest of the year. Crisis agency Foundation 2 experiences that first hand. 'As spring comes and things are starting to be reborn, the flowers are coming out, and the weather is warming up, people feel better. if you?re depressed, you feel that much more of a distance between yourself, and your world around you, and the people around you,? counseling supervisor Nancy Oehlert said.? Feb. 22, 2017 ?Marriage Equality Laws Associated With Drop in Teen Suicide Rate? a Publication: She KnowslUVM: 13.0M*l - new study published in JAMA Pediatrics found that across 4? states, same-sex marriage policies were associated with a 7 percent reduction in high school students who reported a suicide attempt in the past year particularly among adolescents who were sexual minorities. Suicide is the second-leading cause of death for people ages 15 to 24 {the first is unintentional injury). According to the CDC, the attempted suicide rate is four times higher among lesbian, gay and bisexual adolescents, so the potential impact of marriage equality laws on this population is especially significant.? Teen Suicide Attempts Fell with the Rise of Marriage Equality: 0 Publication: Towlerood(UVM: 2.3M*l I link has been found between the legalization of gay marriage and a drop in the suicide rates of LGBT teenagers. A study compiled by researchers from John Hopkins University, Harvard University and Boston Children's Hospital and published this week in the journal lama Pediatrics has determined that in US states where marriage equality was passed, the suicide rate among LGBT teenagers fell around ?Legal Same-Sex Marriage Reduces Youth LGBT Suicide Rates" 0 Publication: Elle I ?In a world of bad news and fake news, isn't it good to hear some good news? Since 2015 the US called State-level bans on same?sex marriage unconstitutional, meaning that the slow and hard-fought battle of marriage equality was finally won. Though many LGBT people may not have even wanted to exercise this potential freedom, many argued it was important to be seen equally in the law and thus, society en- masse.? "Legalized Same-Sex Marriage Linked to Lower Rates of Suicide Attempts Among Teens" I Publication: Nature World NewslUVM: I new study revealed that teens living in states that have legalized same? sex marriage were less likely to attempt suicide. The study, published in the journal JAMA Pediatrics showed a link between the legalization of same-sex marriage in some states and the drop of suicide rates among teens in the same area." "Same Sex Marriage Laws Associated with Drop in Suicide Rates Among High School Students" I Publication: Axis of LogiclUVM: - ?States that legalized same?sex marriage before it became federal law two years ago saw a sharp decline in suicide attempts by high school students, according to an analysis by researchers at the Johns Hopkins Bloomberg School of Public Health.? Study Shows That Legalization of Same Sex Marriages is Linked to a Lower Teen Suicide Rate" I Publication: Her CompusjUVM: 2.5M*l I ?So there's a pot of gold at the end of that rainbow flag?The legalization of same sex marriage may have reduced the teen suicide rate. in a study published Monday by the Johns Hopkins University School of Public Health, researchers found suicides decreased in high school students, particularly LGBT students, when a state legalized same sex marriage prior to the Supreme Court decision." "Using Analytics to Improve Suicide Prevention" I Publication: Heaithcore iT NewsjU?v'M: I "The Substance Abuse and Mental Health Services Administration (SAMHSAj-funded Zero Suicide project works under the belief that suicide deaths for individuals under care within health and behavioral health systems are preventable. The project uses a combination of best evidence, best practices and innovative practices to prevent all suicides. it is an aspirational goal, but a valuable one. These prevention efforts rely on clinicians, including physicians, nurses and social workers, to follow best practices and evidence to move toward that goal." Feb. 23, 2017 Surveys Cleveland Schools' Suicide Rate" I Publication: ldeostreomlUVM: I ?More than 20% of Cleveland Metropolitan School District students surveyed by the Centers for Disease Control reported having attempted suicide in 2015. Out of 19 urban school districts surveyed across the United States, Cleveland had the highest rate of attempted suicide.? ?Cleveland School District has Highest Suicide Rates in I Publication: News Talk 1490 - Cleveland, Ohio (UVM: I "According to the CDC, more high school students in Cleveland are attempting to take their own lives, than in any other American city. Two out of every ten high school student enrolled in Cleveland Metropolitan Schools, according to the CDC, tried to kill themselves in 2015. Twentyr percent of the CMSD high school population is suicidal; one of the highest numbers in the United States." VIOLENCE PREVENTION Feb. 18, 2017 "Advocates Hope to Create Anti-Violence G?mdswell" I Publication: St. Cloud TimeslUVM: II "Katie Cashman championing Green Dot, a bystander intervention-based program that's meant to encourage widespread community action and cultural change. The shift is being propelled by Anna Marie?s Alliance and the Central Minnesota Sexual Assault Center, two local nonprofits that deal with the aftermath violence can have, particularly on women and children. Green Dot is a program that trains community members to end and prevent violence, by encouraging people bystanders to do something." Total unique visits per month of publication?s website [within one month prior to date reported) From: Lenard, Courtney Sent: 2 Feb 2016 16:27:18 -0500 To: Houry, Debra E. Amy B. Cc: Connelly, Erin Subject: For Review: The Trace-gun violence Hi Deb, Kate Masters with The Trace requested an interview with you, originally stating she wanted to discuss: ?My article is going to be about violence research at the CDC versus the NIH, so most of questions would center on her approach to running the Center ,for injury Control and Prevention, accomplishments she's made, and priorities she'd still like to work on. Based on prior requests she has had with us (Wilmington and gun violence) and with NIH, asked for specific questions that we could address via email. Here they are. Responses have been reviewed/revised with Linda Dahlberg, OPP has also been in the loop. Responses are primarily pulled from our cleared (MA on the issue. I will also get HHS clearance once you review. Thank you! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence, therefore we decline to comment on theoretical consequences. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and nonuresearch activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence {about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence - was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IOM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non?fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the "The complexity and frequency of firearm violence, combined with its impact on the health and safety ofAmericans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer?reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 (investigator? initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: I one study (which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. IA 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; -A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; IA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? (approvedfreviewed by Division- of Population Health) The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009-2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 WWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27', 2012 i? . ode. go 103a2 . Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 a 1 .htm a. Livzn'rri-zzv lint-11rd-j l .. I I '15: rill-1'; .1: Sewing Lives and Protecting People from Violence and Iniu ry or tin-c. til its ailit'tl 1. tIi-u lilL?Ll [locum-.110 IN copy?; lil'oatli}. mica rm- Iiit- persons; cw ot illt' user and as not In Em: ls ar'n?ie V. B. Scarles et a1.: Suicides in Urban and Rural Counties in the US 23 ral nonadjacent decedents than urban decedents Physical health problems were more commonly cited among rural nonadjacent decedents than ru- ral adjacent or urban decedents. Discussion In this study of individual suicide decedents from 2006 to 2008, decedents in urban areas differed signi?cantly from those in rural areas with respect to multiple demograph- ic, mental health, and suicide event characteristics. There were four notable ?ndings in this study. First, there were signi?cant differences in mental health characteristics be? tween urban and rural decedents. Second. there was a cor~ relation between urban?rural status and histoiy of ?nancial, employment, substance abuse, and physical health issues. Third, consistent with prior work, rural decedents were more likely to use a ?rearm as the method of suicide. Final- ly, there was an identi?able relationship between proximity to an urban center and the tnental health characteristics of rural decedents. It is important to note that the ?ndings from this descriptive study of completed suicides cannot be used to infer causal relationships between various factors and suicide risk. Nonetheless, these study results are useful for identifying potential risk factors, evaluating previous theories, and informing future suicide research and inter? ventions. Mental Health and Treatment History In this study, rural decedents were less likely than urban decedents to have had a current mental health diagnosis, a previous history of mental health treatment, or a previous suicide attempt. These results are consistent with previous research ?ndings nationally and internationally that rural individuals are less likely to be diagnosed with and receive treatment for mental health problems than urban individuals (Crawford Brown, 2002; Fiske et al., 2005: Taylor et al., 2005). There are multiple plausible explanations for this. Previous research has found that stigma regarding mental illness may be greater in rural communities, so that those suffering from mental illness may isolate themselves rather than seek help from their community [Crawford 8: Brown, 2002). The differences in mental health treatment rates between urban and rural decedents in this study may also be explained by the theory that social isolation is greater in rural communities (Trout, 1980). With increased social isolation, it is less likely that an at-risk individual will be identi?ed. Additionally, social isolation in and of itself may affect risk. Finally, given the increased rates of ?rearm use by rural decedents, it is also plausible that rural decedents actually have lower rates of longstanding mental health problems and instead exhibit higher suicide rates owing to a higher lethality of impulsive attempts. Further research is necessary to determine which of these theories, if any, exn plain the lower treatment rates seen among rural decedents. (El 2013 Hogrefe Publishing While, overall, rural nonadjacent decedents were less likely to be in treatment at the time of death than urban decedents, those with a reported depressed mood were equally likely to be in treattnent, regardless of urban-rural status. It is not possible to determine conclusively what explains this difference based on information available in the VDRS, but these ?ndings suggest that future research should examine variations in access to and utilization of mental health treatment. In addition, an important ?nding is that among all groups of decedents, including the re? ported depressed mood group, treatment rates were less than 41%. This finding supports previous evidence that in both urban and rural areas there are substantial obstacles to treating individuals with mental health issues that pro- duce low rates of utilization in national and international communities (Hyman, 2000; Gonzalez et al., 2010; The 20001nvestigators., 2004). This high- lights the importance of identifying these obstacles in fu- ture research to enhance suicide prevention in all commu- nity types. Suicide Circumstances Factors that were more prevalent among urban decedents than rural decedents included history of substance abuse, job, and ?nancial problems. These results appear to contra- dict previous theories that cite increased alcohol and sub stance abuse and more pervasive job and ?nancial insecu- rity as factors that increase rural suicide risk {Taylor et al., 2005). However, from this analysis of only decedents we cannot estimate the magnitude of such social problems in the general population in each area, and the lacks some important economic variables. It is also worth noting that this analysis included suicide deaths that mostly oc? curred prior to the economic crisis that began in late 2008, Further research is necessary to determine whether urban dwellers in included counties have a higher incidence of these problems or instead have comparable rates of these problems but are somehow less able to cope with them. Rural nonadjacent decedents were also more likely to have a physical health problem cited as a contributing factor. Use of Firearms The increased use of ?rearms by rural decedents was one of the tnost obvious differences between urban and rural cases. This ?nding is consistent with results of communi- ty?based analyses (Andres 8t. Hempstead, 20l l) and sup? ports lethal means restriction as an essential component of suicide prevention efforts (Daigle, 2005; Hawton, 2007; Lewiecki, 2013; Miller Hemenway. 1999. 2008). Proximity to Urban Center Multiple mental health and suicide characteristics of rural decedents varied with proximity to an urban center. Nota- Crt'sr's 20 4: Vol. 35(1): I 8?26 Epidemiologic Fteviews Vol. 38, 2015 The Author 2016. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. DUI: 10.1093iepirevimxvt112 All rights reserved. For permissions. please e-mail: joumal5.permissions@oupcom. Advance Access publication: Feomary 10. 2016 What Do We Know About the Association Between Firearm Legislation and Firearm-Related Injuries? Julian Santaella~Tenorio*, Magdalena Gerda, Andres Villaveces, and Sandro Galea Correspondence to Dr. Julian Santaella-Tenorio. Departmental Epidemiology. Mailman School of Public Health. Columbia University. 122 West 163th Street. Room 515. New York. NY 10(132 le-mail: js4222?cumccolumbiaedu). Accepted for publication September 4. 2i] i 5. Firearms account for a substantial proportion of external causes of death, injury, and disability across the world. Legislation to regulate firearms has often been passed with the intent of reducing problems related to their use. However, lack of clarity around which interventions are effective remains a major challenge for policy development. Aiming to meet this challenge. we systematically reviewed studies exploring the associations between firearm? related laws and firearm homicides. suicides, and unintentional injuriesldeaths. We restricted our search to studies published from 1950 to 2014. Evidence from 130 studies in 10 countries suggests that in certain nations the simu ~ taneous implementation of laws targeting multiple firearms restrictions is associated with reductions in firearm deaths. Laws restricting the purchase of leg; background checks) and access to leg; safer storage} firearms are also associated with lower rates of intimate partner homicides and firearm unintentional deaths in children. re- spectively. Limitations of studies include challenges inherent to theirecological design. their execution. and the lack of robustness of findings to model specifications. High quality research on the association between the implemen- tation or repeal of firearm legislation (rather than the evaluation of existing laws) and firearm injuries would lead to a better understanding of what interventions are likely to work given local contexts. This information is key to move this field forward and for the development of effective policies that may counteract the burden that firearm injuries pose on populations. death; firearms; homicide; legislation; suicide; weapons; wounds and injuries Abbreviations: NCHS. National Center for Health Statistics: NFA. National Firearms Agreement; Uniform Grime Fieports. Iltll li 14D Epidemiol Flev g] down no inalouonog 1n mm; pops-humor] Er. Epidemiologic Reviews Advance Access published January 13, 2016 Epidemiologic Reviews The Author 2015. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions. please e-rnarl: journalspermissrons@oup.com. Effectiveness of Interventions to Promote Safe Firearm Storage Ali Rowhani-Rahbar*. Joseph A. Simonetti, and Frederick P. Rivara "t Correspondence to Dr. All Flowhani?Flahbar, Box 35?236, Department of Epidemiology, School of Public Health, University at Washington, Seattle, WA 93195 ie-maii: rowhani @uwedu]. Accepted for publication Juiy 27, 2015. Despite supportive evidence for an association between safe firearm storage and lower risk of ?rearm injury, the effectiveness of interventions that promote such practices remains unclear. Guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, we conducted a systematic review of ran~ domized and quasi-experimental controlled studies of sale firearm storage interventions using a prespecified search of 9 electronic databases with no restrictions on language, year, or location from inception through May 2015. Study selection and data extraction were independently performed by 2 investigators. The Cochrane Col- laboration?s domain-specific tool for assessing risk of bias was used to evaluate the quality of included studies. Seven clinic- and community-based studies published in 2000?201 2 using counseling with or without safety device provision met the inclusion criteria. All 3 studies that provided a safety device significantly improved firearm storage practices, while 3 of 4 studies that provided no safety device failed to show an effect. Heterogeneity of studies pre- cluded conducting a meta-analysis. We discuss methodological considerations, gaps in the literature, and recom- mendations for conducting future studies. Although additional studies are needed. the totality of evidence suggests that counseling augmented by device provision can effectively encourage individuals to store their firearms safely. firearms: program evaluation; safety Abbreviations: DVRD, domestic violence restraining order; intimate partner homicide; IPV, intimate partner violence. i'IJii-li 9mg. '5 tinting-3:1 tin Mindy] 3(1) .Iorpctu 'g [tourists 11?. ,rsomeitmnl'prou'o'windsur?ng tum; Preventive Medicine [20:5] 5?t4 Contents lists available at SoieneeDireot Preventive Medicine . journal homepage: wwvv.elsevier.comllocatelypmed Firearm injuries in the United States @mm Katherine A. Fowler Linda L. Dahlberg 3. Tadesse Haileyesus b. Joseph L. Annest '3 .1 Division of Violenre Prevention. Notional Center for injury Prevention. Centeisj'oi'Disense Control and Prevention. Atlanta. GA. United Stores 5 Division qt?tnulysis, Ros-enroll. and integration. Notional fenrerj'or injury ?evemion. Centeis for Disease Coiitml and Prevention. Atlanta. GA. United States PARTICLE INFO ABSTRACT Available 24hr?: 2015 Objective. This paper examines the epidemiology of fatal and nonfatal ?rearm violence in the United States. Trends over two decades in homicide. assault. self-directed and unintentional ?rearm injuries are described along with current demographic characteristics ofvidimization and health impact. Vim?: Method. Fatal ?rearm injury data were obtained from the National Vital Statistics System (MUSE). Nonlatal Eld?ifr?iology ?rearm injury data Were obtained from the National Electronic Injury Surveillance System (NEISSJ. Trends were tested using ,loinpoim regression analyses. CDC Cost of Injury modules were used to estimate costs associated with ?rearm deaths and injuries. Results. More than 32.000 persons die and over 61000 persons are injured by ?rearms each yea r. Case fatality rates are highest for self-harm related ?rearm injuries. followed by assault-related injuries. Males, I'aciali'ethnic minority populations. and young Americans [with the exception of ?rearm suicide) are disproportionately affected. The severity ofsuch injuries is distributed relatively evenly across outcomes from outpatient treatment to hospitalization to death. Firearm injuries resultin over $48 billion in medical and work loss costs annually. particularly fatal ?rearm injuries. From 1993 to 1999. rates of ?rearm violence declined signi?candy. Declines Were seen in both fatal and nonfatal ?reaiTn violence and across all types of intent While unintentional ?rearm deaths continued to decline from 2000 to 2012. ?rearm suicides increased and nonfatal ?rearm assaults increased to their highest level since 1995. tent-lesion. Firearm injuries are an important public health problem in the United States. contributing substantially each year to premature death. illness. and disability. Understanding the nature and impact of the problem is only a ?rst step toward preventing ?rearm violence. a science?driven approach to understand risk and protective factors and identify effective solutions is key to achieving measurable reductions in ?rearm violence. PuttiishedbscElseitieuor. D-anr-I-O Cage 1 LEE: Integrating Emergency Care ion Heath 8 Peer Reviewed Title: Lethal Means Counseling for Parents of Youth Seeking Emergency Care for Suicidality Journal issue: Western Journal _f Ems eg e__cy angina; tgerathg E_n1e_rge_r1cy _Ca_re with P_opui_ation_ Health 171, Author: Bunyan,_Ca_ro_l_W,, Colorado School of Public Health, Departments of Epidemiology and of Community and Behavioral Health, Program for Injury Prevention, Education and Research, Aurora, Colorado Becker, Amy, University of Colorado School of Medicine, Department of Aurora, Colorado Brandspigel, Sara, Colorado School of Public Health, Program for Injury Prevention, Education and Research, Aurora, Colorado BarbeLgItherine, Harvard University, Harvard T. H. Chan School of Public Health, Boston. Massachusetts Irudeau It'd?meg, Colorado Department of Public Health, Denver, Colorado Movins, Douglas, University of Colorado School of Medicine, Department of Aurora, Colorado Publication Date: 2016 Permalink: DOI: Acknowledgements: Acknowledgements: We acknowledge the assistance of Vicka Chaplin and Sivabalaji Kaliamurthy in data collection; Peter Lin for technical design of the online course and data collection process; Talia Brown for assistance in data analysis; Georgette Siparsky for assistance in records management; Elaine Frank for work on the training package; Jarrod Hindman and Lindsey Myers for supplying in-kind and financial support from the Colorado Department of Public Health and Environment through resources received from the Centers for Disease Control and Prevention to develop the online course and Dru Hunter for assistance in implementation. Funds from the LA. O'Shaughnessy Foundation, and Operational Effectiveness and Patient Safety Small Grants Program of Children's Hospital Colorado were used to purchase lock boxes and to support implementation and evaluation activities. We also appreciate the useful comments of Ashley Brooks-Russell and Marian Betz on a draft of this manuscript. The findings and conclusions in this eSchoiarsnIp prowdes open access. scholarly publishIng services to the University of California and delivers a dynamic a: 0? California research platform to scholars worldwide. report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Author Bio: Professor, Department of EpidemiologyProfessor, Department of Community and Behavioral PediatricsDirector, Program for injury Prevention, Education and Resaerch Assistant Professor, Department of Program Manager, Program for Injury Prevention, Education and Research Harvard Injury Control Research Center Harvard T. H. Chan School of Public Health Pubilc Health Scientist Professor. Department of Keywords: suicide, prevention, emergency care, lethal means Local Identi?er: uciem_westjem_28590 Abstract: Introduction: A youth?s emergency department (ED) visit for suicidal behaviors or ideation provides an opportunity to counsel families about securing medications and ?rearms lethal means counseling}. Methods: In this quality improvement project drawing on the Counseling on Access to Lethal Means (CALM) model, we trained 1E5 emergency clinicians to provide lethal means counseling with parents of patients under age 18 receiving care for suicidality and discharged home from a large children's hospital. Through chart reviews and follow-up interviews of parents who received the counseling, we examined what parents recalled, their reactions to the counseling session, and actions taken after discharge. Results: Between March and July 2014, staff counseled 209 of the 236 parents of eligible patients. We conducted follow-up interviews with 114 parents, or 55% of those receiving the intervention; 48% of those eligible. Parents had favorable impressions of the counseling and good recall of the main messages. Among the parents contacted at follow up, reported all medications in the home were looked as compared to fewer than 10% at the time of the visit. All who had indicated there were guns in the home at the time of the visit reported at follow up that all were currently locked, compared to reporting this at the time of the visit. Conclusion: Though a small project in just one hospital. our ?ndings demonstrate the feasibility of adding a counseling protocol to the discharge process within a pediatric emergency service. Our positive findings suggest that further study, including a randomized control trial in more facilities, is warranted. Supporting material: Figure Figure no.0 eSCholarship eSchoiarship provides open access. scholarly publishing .0 serwces to the or California and delivers a dynamic . . UT Galiiorrua research platfoin'i to scholars worldwide Copyright Information: Copyright 2015 by the article author(s). This work is made available underthe terms of the Creative Commons Attribution4.0 none 4.0 4.0 license. none 4.0 4.0! I I 3.. escholarship eScholarShip protiideal open access, scholarly publishing .0 0 . . SEWICES lo the of California and delivers a dynamic . Of California research platform to scholars worldwide. I. ORIGINAL RESEARCH Lethal Means Counseling for Parents of Youth Seeking Emergency Care for Suicidality Carol W. Runyan, MPH, *Colorado School of Public Health, Departments of Epidemiology and of Community Amy Becker, and Behavioral Health, Program for Injury Prevention, Education and Research, Aurora, Sara Brandspigel, lilIPHl Colorado Catherine Barber, iUniversity of Colorado School of Medicine, Department of Aurora, Colorado Aimee Trudeau, iColorado School of Public Health, Program for Injury Prevention, Education and Douglas Nevins, MDT Research, Aurora, Colorado ?Harvard University. Harvard T. H. Chan School of Public Health. Boston, Massachusetts ?Colorado Department of Public Health, Denver, Colorado Section Editor: Michael P. Wilson, MD, Submission history: Submitted September 4, 2015; Accepted November 30. 2015 Electronically published January 12, 2016 Full text available through open access at DOI: 10.5311lwestjem.20?l5.1123590 Introduction: A youth?s emergency department (ED) visit for suicidal behaviors or ideation provides an opportunity to counsel families about securing medications and ?rearms lethal means counseling). Methods: In this quality improvement project drawing on the Counseling on Access to Lethal Means (CALM) model, we trained 16 emergency clinicians to provide lethal means counseling with parents of patients under age 18 receiving care for suicidality and discharged home from a large children?s hospital. Through chart reviews and follow-up interviews of parents who received the counseling, we examined what parents recalled, their reactions to the counsding session, and actions taken after discharge. Results: Between March and July 2014, staff counseled 209 of the 236 parents of eligible patients. We conducted follow-up interviews with 114 parents, or 55% of those receiving the intervention; 48% of those eligible. Parents had favorable impressions of the counseling and good recall of the main messages. Among the parents contacted at follow up, 743% reported all medications In the home were locked as compared to fewer than 10% at the time of the visit. All who had indicated there were gone in the home at the time of the visit reported at follow up that all were currently locked, compared to 67% reporting this at the time of the visit. Conclusion: Though a small project in just one hospital, our ?ndings demonstrate the feasibility of adding a counseling protocol to the discharge process within a pediatric emergency service. Our positive ?ndings suggest that further study, including a randomized control trial in more facilities, is warranted. [WestJ Emerg Med. tl-lt :Ii Westem Journal Medicine 8 Volume XVII. NO. I January 2016 SOLUTIONS connecting Federal Partners Meeting Discussion Summary Introduction A meeting of representatives from the Departments of Education, Health and Human Services, and Justice, met in Washington, DC, on February 19-20, 2014, to discuss current efforts and future opportunities associated with firearm violence prevention research. The meeting objectives were to: discuss approaches for strengthening data to understand patterns and characteristics of ?rearm violence and to address research questions; 2] ensure that research carried out by the different agencies is complementary and builds upon individual and collective and 3] determine opportunities to collaborate on current or future efforts. The meeting was broken into four sessions. During the ?rst day, discussion focused on exploring the current environment of firearm violence prevention research [Session 1] and the data associated with it [Session particularly identifying gaps and what resources could be brought to bear on them. The second day built upon these conversations and explored how to create a complementary approach that builds upon individual and collective [Session It ended with a focused discussion on what actions could be taken to enhance coordination, communication, and collaboration [Session 4] between the Departments. Throughout the discussions, participants were encouraged to share information and ideas about each of the respective topics. However, there was no push to reach consensus or set priorities. Instead, through a series offacilitated discussions, participants were asked to react or respond to various topics or questions posed. In addition, the discussion topics built upon information gleaned from previous conversations the facilitators had with many ofthe participants prior to the meeting. This report summarizes the main themes that emerged from these discussions and should not be construed as re?ecting of?cial policies or positions of the meeting participants or the departments/agencies represented. 1-325 vi {Il'uHLl avenue. nw mlie 11-. 20005 .3334)?: 2'32 Lam Federal Partners Meeting Discussion Summary DAY 1 Session 1 - Research Discussion This first discussion was designed to better understand what ?rearm violence prevention research is currently being undertaken, identify what research gaps exist, and where particular research interests lie among the respective departments/ agencies. Participants were given a document entitled Research Discussion Handout [Appendix which contained a list of research topics that emerged from interviews conducted prior to the meeting or were included in the recent Institute of Medicine/National Research Council report, Priorities for Research to Reduce the Threat of Firearm-Related Violence. These topics were grouped under four topic headings: 1] access to firearms; 2] technological approaches; 3] triggers and in?uences of violence involving ?rearms; and 4] intervention strategies, policies, programs, that might prevent firearm violence. Working in small groups, participants were asked to review the list and contributed individually and as a team by keeping the following instructions at the forefront: 1. Discuss and identify any research gaps that may be associated with a respective category. 2. Share with your colleagues where your current work may be touching upon some ofthese research topics or themes. 3. Identify any research areas or information sharing opportunities where complementary efforts exist or would be beneficial in the future. Various responses emerged from these discussions and this feedback is grouped under the initial headings [mentioned above] for which it corresponded. Access to Firearms Much ofthe discussion in this area focused on the fundamental questions surrounding access to firearms and its in?uence in precipitating a violent act or event. In this vein, discussion focused on the need to better understand access as it relates to certain vulnerable populations youth, young adults, persons with suicidal intentions] and settings schools, businesses, public housing]. Likewise, understanding the various risk and protective factors that result from access to a firearm was identified as an important research area. In particular, exploring the nuances associated with using a firearm for defensive purposes in various situations and settings was recognized as a needed study area. Participants also raised the need for research exploring access as it relates to unintentional firearm injuries and nonfatal violence-related firearm injuries. At this point, several participants indicated that while these were important areas for exploration, data was largely lacking in these areas, particularly at the state and local level, which would make studies more difficult to pursue. 2 SOLUTIONS vcnr'mli nw 51ml.- 8 Eihllg? 011' 19:; 0.73? Federal Partners Meeting Discussion Summary In addition, participants discussed the need to better understand the physical characteristics of access as it related to both storage and acquisition. Questions about owners hip and storage were important ones for exploration. Participants noted that questions on ownership and storage practices were included in the Behavioral Risk Factor Surveillance System, but those questions have not been included since 2004. A suggestion was made to look back at those research questions and possibly include them into existing surveys. In another category, the need for better preventative practices and messaging around safe storage was suggested. Participants also noted that additional research to understand the distinction between access. ownership, and use, was an important area for consideration. For example, persons with access to ?rearms do not necessarily own them. Finally, another area ofdiscussion was the need to better understand the firearm supply line and secondary markets, including online and private sales, and their correlation to access issues. Technological Approaches A large portion of the discussion on this topic focused on discussing new technological approaches that were being developed and their possible implications for firearm violence. For instance, technology solutions for smart guns were mentioned as one avenue currently being evaluated. A review of patent filings found that the technology is quite mature, incorporating such techniques as locking mechanisms using biometric readers, creation of safe zones that disable guns and alerts sent to the owner via a mobile application when a firearm is moved. There are, however, questions around acceptance and adoption of these technologies, particularly the possible impact these technologies might have on various professional sectors police, private security] in performing their duties. Likewise, the emergence ofnew technologies such as 3-D printing bring into play a whole new set of research questions and the discussion then turned into considering how ammunition ?t into the equation. As several participants indicated, ammunition's role in firearm violence is not well understood nor is its possible use as an intervention strategy. In wrapping up this discussion, it was suggested that one approach might be to routinely conduct forecasting research on the availability of technologies and their impact. Finally, as a corollary to the technology discussion, participants also noted the need to generate greater awareness and recognition regarding gun safety. Participants discussed different research areas that could be explored to better understand consumers' attitudes towards existing or new gun safety technologies and how compliant they would he with them. Participants noted that lots oflessons could be learned from other areas where promoting safe behavior has prevented injuries or deaths. 3 SOLUTIONS HW 70 v. if]? {.37 93 1. gilf; (?73 com Federal Partners Meeting Discussion Summary Triggers and In?uences As expected, the conversations here reiterated a lot of the same research topics/ themes found under this heading in the handout provided to participants. Much discussion focused on the need to better understand the genetic, neurological or behavioral basis of substance abuse, especially alcohol and drugs, in violent events involving ?rearms. in addition, it was suggested that the need to distinguish between abuse and use as it relates to both alcohol and drugs was an important consideration. Alcohol use does not necessarily infer abuse and yet both may be important areas to explore to better understand the relationship between alcohol and ?rearm violence. Likewise, the impact of different drugs on decision- making and its correlation to ?rearm violence was another area that warranted examination. Finally, rather than examining alcohol and drugs separately, the importance ofassessing how the use of both alcohol and drugs may influence decision-making was also noted. Considerable discussion also ensued about the role of situational and contextual factors in influencing violence involving firearms. In particular, participants noted the need to better understand the relationship between alcohol availability and ?rearm violence. Grants have been awarded in the past to examine this area and while a relationship between alcohol availability and violence in general has been shown, further research is warranted on the relationship between availability and firearm violence speci?cally. It was noted that the IOM has been commissioned to conduct a systematic review ofthe literature on the relationship between alcohol and ?rearm violence. Participants also suggested that a community focus to the research was critical. This approach would allow more in~depth research and the ability to detect patterns and determine precipitating factors, as well as design interventions unique to localities. It also would assist in tracking firearm violence more closely across geographic settings. Participants also suggested that a community focus might help better identify those populations most at risk and those individuals or groups to tailor prevention messages or interventions. The individual factors that may trigger or influence violence involving firearms were contemplated as well. Mental health's role and its importance as a research topic was highlighted, particularly given recent events that have focused attention on mental health?s relationship to ?rearm violence. In addition, participants suggested that more research is needed to understand the perpetrator and victim relationship and its connection to firearm violence. In a similar fashion, examining the impact and repercussions ofa violent incident upon both victims and perpetrators was another important study area identi?ed. A life course approach to individual factors also was deemed critical to understand the developmental trajectory?child, teen, adult, elderly. a SOLUTIONS HW v. is-nnqra'i 201?Hlfj?llg gilf; (?73 com Federal Partners Meeting Discussion Summary Finally, research to better recognize the influence of social media, visual media, and marketing on firearm violence is warranted, particularly how exposure to violent media may trigger or in?uence violence involving a ?rearm. Intervention Stro tegies, Policies, and Programs A consistent theme that emerged from the discussions was the need for more research to identify which intervention strategies, policies, or programs effectively prevent ?rearm violence. At a minimum, participants recommended taking stock ofwhat currently exists in terms of evidence-based interventions and assessing whether they are ready to be scaled up or implemented. This approach could help identify areas where research is sufficient and where gaps still exist. In addition, the utility of evidence~based interventions in other areas also was raised. For instance, evidence-based programs addressing risk and protective factors associated with other public health issues [such as alcohol and substance abuse] might be adapted for firearm violence prevention. Another possibility could be assessing the applicability of skill-based programs for youth in preventing firearm violence; the assumption being that these programs generally reduce alcohol, drug, and tobacco use, as well as juvenile delinquency, so they might be extended to addressing firearm violence as well. However, caution was recommended since the same characteristics or assumptions would not necessarily apply. There is still a need to assess whether these strategies effectively reduce firearm violence. These suggestions led to other resources or interventions being mentioned. CrimeSolutions.gov is a repository for research on the effectiveness of programs and practices in criminal justice, juvenile justice, and crime victim services. Blueprints for Healthy Youth Development is another repository of effective violence prevention programs. In terms of speci?c interventions, violence interrupter strategies CeaseF ire, Cure Violence] could be explored further since a lot ofwhat they're doing in the midst of the con?ict is to broaden someone's perspective; this speaks to disrupting some ofthe in?uences or triggers that may lead to violence involving a firearm. Discussions also centered on the need for more systematic reviews of local, state, and national policies, to determine their effectiveness in preventing ?rearm violence. While there was a general agreement about this need and its merits, the research gaps previously identi?ed may yield the same conclusions as earlier systematic reviews because many of the gaps have not been addressed by research. As an example, it was noted that the last time this was undertaken by the Community Preventive Services Task Force about 10 years ago, they found that the evidence available was insufficient to determine the effectiveness ofany ofthe firearm laws reviewed singly or in combination waiting periods, background checks, etc.) to prevent violence or reduce violent outcomes. If such a review were to be undertaken, participants noted the importance of also taking into account the 5 SOLUTIONS HW l] v. EthlL-?j if]? {.37 93 1. gilf; (?73 com Federal Partners Meeting Discussion Summary difference between the policy enacted and how it?s implemented. As participants noted, enforcement authorities interpret policies differently and this has a direct impact on how the policy gets implemented within the community. At a minimum though, it was suggested that a repository that keeps a list ofall ?rearm laws or policies should be made available to researchers as one means to encourage future policy evaluation research. The need to assess the effectiveness of setting specific strategies also was cited by several participants. Settings mentioned included schools, workplaces, and homes. As was noted, numerous strategies, policies, and programs have been implemented in these settings, particularly schools and workplaces, but it?s not clear whether they are effective, and if the evidence exists, it?s not widely known. In particular, much emphasis has been placed on preparedness and response strategies in these settings but it?s not clear what works or if they can be applied to other settings. Likewise, communication and message campaigns reaching parents are popular strategies but few studies have been conducted to determine whether these education efforts are translating into increased awareness and better preparedness in their children. In a similar fashion, several programs aimed at healthcare providers enlist them to encourage gun safety in the home as well as assess risk. Yet, it's not clear whether these protocols are producing intended outcomes. Session 2 - Data Collection Discussion This session was designed in a similar fashion to the research discussion. Participants were given a document entitled Do to Collection Discussion Handout [Appendix which consisted primarily of data gaps identified through the phone interviews. Once again, each table reviewed the list and contributed individually and as a team by keeping the following instructions at the forefront: 1. Share with your colleagues where your current work may be touching upon some ofthese identified data gaps. 2. Discuss and identify any other data gaps that may be associated with a respective category. In essence, do we have the necessary data to examine the research questions or themes outlined in the earlier session? A number of data topics emerged, though none went outside ofthe broad categories identified in the interviews conducted with participants prior to this meeting. The school setting, both and college campuses, was a popular point of discussion. Most participants believed that there is much awareness around school violence from both a political and general public standpoint, but there are tremendous gaps in both research and data gathering to either understand these aspects or prevent this type of ?rearm violence. At the same time, the data that does exist in this area is very limited. A National Center for Education Statistics survey focused on the various reasons why students carry weapons to school and the prevalence of expulsions along with other data points. Information on types of weapons and ammunition is available but it is all event-specific. 5 SOLUTIONS HW 70 v. sis-Human 201?Hlfj?fig gilf; (?73 com Federal Partners Meeting Dis?cussion Summary CDC, in collaboration with the Departments of Education and Justice, has been tracking school-associated violent deaths since 1992. School-associated violent deaths include those that occur on school property, on the way to/from school, and at school-sponsored events. This is an important data collection system that could be better utilized to understand the characteristics of these events and possible strategies to prevent school shootings. Certainly, participants as a whole identified the need for community data along with state and national data, but recognized that there are barriers to this type of data collection. For instance, one agency experimented with gathering local data in hard-to-reach populations such as just booked arrestees, offenders involved in other criminal behavior [drug traf?cking, domestic violence, etc]. While this information is viewed as having great value, data collection of this type proved to be cost-prohibitive. Generally speaking, the team felt as though any research or data that has ?cross-over? elements to firearm violence such as substance abuse, mental illness, etc., as well as being conducted and gathered on the community level, is both extremely valuable and costly, but very necessary. As part of this discussion, analysis capability and capacity on the local level presented as an issue. The question ofwho would analyze the data and who would absorb the cost of this analysis was a concern; involving local academics and academic institutions and research practitioners was seen as necessary. The "Communities That Care" platform was cited as worth looking into as a model for collaboration and data utilization on the community level. One ofthe primary research focus areas that came out of both the report and the interviews is risk and protective factors. While various data gaps were identi?ed within this area, the general perspective was that data gathering has largely centered on risk factors and, although gaps still exist with respect to understanding risk factors, more is needed to understand protective factors. Participants noted a number ofother important data gaps including a lack ofgood information on gun ownership, attitudes about guns, reasons and motivations for gun ownership, and what types ofgun and what types of owners end up owning a crime gun. Other gaps noted include a lack ofinformation on gun purchases, including information on timing and characterization, particularly for adults at risk of completing suicide. Participants also noted the importance of context and understanding the circumstances surrounding events. The lack of data at the local and state level on nonfatal firearm violence was also mentioned as a significant gap as well as information on cost of ?rearm injury. The ability to and necessity of linking specific types of data was paramount throughout the day. In particular, participants felt that many current research gaps could be addressed if data were more standardized, more easily linked, and more complete. There is a lot of variability across data sets in the way deaths. assaults, behaviors, and circumstances are classified. Some participants noted that the National lv?iolent Death Reporting System links and pulls in various data sources including death records, law enforcement 7? SOLUTIONS HW 70 v. 201?l137j931. gilf; (?73 com Federal Partners Meeting Dis?cussion Summary reports, and coroner/medical examiner reports and allows for some potential linkage with other data sources. The National Vital Statistics System provides another linkage opportunity by asking coroners or medical examiners to add new data fields that might provide more information associated with the cause ofdeath. Other linkage areas included connecting local crime data with emergency department data from local hospitals, and connecting with private data systems insurance information; partner organization such as Gallup]. The importance of data linkage to facilitate longitudinal studies to better understand the long-term impacts of?rearm violence was also noted. At this time, according to the majority ofthe group, there is a lack oflong~term studies in the area of firearm violence. There is also a need to make data more widely accessible for analysis and reporting. The Web-based Injury Statistics Query and Reporting System was recognized as an interactive database that might be a good foundation for infrastructure to make various types of data easily available for analysis and reporting. There was a suggestion to look outside of firearm violence prevention research to ?nd some "bestpractices" in research and data collection and subsequent unexpected utilization. For example, there was mention of possibly applying surveillance and sampling methods utilized in research, in particular looking at snowball sampling versus respondent-driven sampling. The design of specific transportation and traffic data collection systems is a very deliberate and collaborative effort between the Department of Transportation the National Traffic Safety Administration and other agencies and is customized for local, state, and national levels. Finally, there was a brief discussion around policy implications and impact and the need for more data in this area. Most ofthis was a follow-up to the need for more policy evaluation research. Although, it should be mentioned that understanding the impact of policies on all levels state, national, local] and across all categories access in different populations] was an underlying theme throughout the discussion. DAY 2 Session 3 Building on Individual and Collective A main goal of the meeting was to ensure the research carried out by the different agencies is complementary and builds upon individual and collective To tackle this goal, participants concentrated on particular aSpects within the research and data collections arenas. For research, questions were posed to the participants to help define what constitutes a strategic investment and a complementary approach. These questions led to robust discussion about current priority setting processes [and related criteria] used by the various federal agencies to guide resource allocations. Participants also spent time 8 SOLUTIONS mv mull.- BTU -.-. gm: 073? Federal Partners Meeting Discussion Summary describing the characteristics ofa complementary approach and possible methods for ensuring that the approach builds upon individual or collective Returning to the data collection topic, participants tackled three themes that emerged during the previous day?s discussion; namely how to strengthen current data collection activities. Breakout groups were formed around each theme and each group was asked to explore the subject further with an to identify concrete action steps or processes that could be employed to address some of the more pressing needs. A summary ofthe suggestions generated for these two topics appears below. Compiemen tmy Approach to Research In addressing the research questions and related gaps, participants generally agreed that some type of organizational framework was needed to ensure that research investments were made in a manner that was both strategic and complementary. Participants then were asked to identify an approach that would facilitate such an outcome. The group coalesced around the following steps to help move the various departments and agencies in this direction: 1. Portfolio analysis Participants recommended that a more systematic review of existing and current research be conducted and under general categories such as those found in the report. This could be useful for identifying other research areas those related to criminal justice, mental health, etc]. This information then could be assessed to help identify where sufficient prevention research existed and where research gaps remained. This review also could help ensure new research was complementary or building on the existing knowledge base. 2. Prioritization - Participants also acknowledged that in order for strategic investments to be made some prioritization needed to occur. The framework outlined in the report could be used as a starting point but additional criteria would need to be developed to help guide priority setting. For instance, participants mentioned elements. such as feasibility and impact, as potential criteria that should be considered. 3. Competitive advantage Participants noted that the ?rst two items could then be used to engage agencies in further conversation around which department/ agencies are best suited to address the priority research questions or areas. This process would seek to align research topics with agency niches and avoid duplication of efforts or mission creep. In addition, this clari?cation could help agencies guide researchers or potential research activities to the appropriate area. 9 SOLUTIQNS nw 51ml.- 8 Ti] EUUIJE [31" 013.313; 19:; 0.73? Federal Partners Meeting Discussion Summary Strengthening the Data Throughout the course of the interviews and the group discussions, three top line actions were deemed necessary as a pathway to strengthening the data: 1. Enhance existing data making it better and linking it 2. Localize data - creating an infrastructure to facilitate and encourage local usage 3. Standardize data developing common de?nitions and data elements Enhance Existing Data The ?rst step in this process would be to create an inventory of relevant data sets and data collection systems. As a general point, everyone is aware of numerous existing databases but there is no one group that is aware ofall of them. The group felt that the inventory should not only re?ect the breadth of available data from different federal and non-federal sources, but also the depth in terms of the characteristics of the data source and specific types of information included within each data source. In addition to including existing data sources with ?rearm information, the group mentioned the importance of including other data sets in the inventory that could potentially be augmented to include information on firearms to assess the potential of adding questions] to further advance the ?eld. The ultimate goal is to design a "product" or deliverable that would act as a larger, query- driven database that could be accessible to a wide range of potential users. CDC has initiated work on an inventory, but noted that a collaborative, cross-agency endeavor is needed to make the inventory complete and robust. In addition to compiling the inventory, the group felt that it was important to assess the completeness ofinformation on ?rearms within existing systems and consider the feasibility of linking with other sources to improve completeness. Supporting rotations or details to different agencies was seen as a way to fully understand the and limitations of different sources and opportunities for data linkage. Analyzing the same questions across data sets to perform somewhat ofa meta-analysis and determine validity ofthe ?rearm information could also be useful for improving ?rearm data. Localize Data Apart from identifying local sources of data, there was much discussion of how to make good use ofdata for prevention purposes. Participants noted the importance of supporting infrastructure at the state and local level to facilitate the use of data for prevention, including identifying inter-agency partnerships that are currently working on the community level and those that might be necessary for success. Local of?cials want 10 SOLUTIONS nw yum.- 8 Ti] [31" 013.3131. 19:; 0.73? Federal Partners Meeting Dis?cussion Summary information that can be helpful to them; however, there are potential hurdles around data sharing, particularly in cases where there is personally identifiable information. Given the diverse nature of communities, it is dif?cult to create a single process, program, or template. Therefore, the group suggested the development ofa toolkit that could be used by all communities to offer some modi?cation or customization within a universal structure. The group suggested creating success stories in certain communities as a means to observe and gain insight as well as to promote acceptance and adoption. The idea of creating a federal collaborative parallel with a local/ state collaborative was also considered. As a point of potential modeling, the Perinatal Periods of Risk CityMatCH tool and the data collection methodology ofthe National Collaborative on Childhood Obesity were cited. It was also noted by this group that much ofthe data gathering and sharing on the local level is for the purpose of developing effective outreach and communications programs. Standardize Data This was a very process-oriented discussion dictated by the tactical nature of standardizing de?nitions and nomenclature in the collection of data. The group recognized a need for common data elements, validated questions, and consistent terminology and measures across survey instruments and data collection efforts. The identified objectives of this overall effort are to facilitate communication through consistency of terms, increase reliability and validity, create opportunities for level comparisons [local/state/federal], enhancing sustainability and creating enduring value and utilization across sectors. The process to make this happen started with the idea of a formal structure and a multi- stakeholder team. Team/initiative members would come from the areas oflaw, health, education, policy, and advocacy with the inclusion of practitioners, researchers and representatives from the victim?s perSpective. The team?s first directives would be to agree on goals and development of a statement of purpose. The idea of a stakeholder survey around existing de?nitions and how they are used in the space of firearm violence was thought to be a reasonable precursor to the ?rst meeting and for identifying interested participants. The group saw this as a very formal project with the end result being a co- branded product with agency logos. The group suggested that the participants of the federal partner meeting form a task force to develop the initial survey and determine who would receive it. It was suggested that CDC Spearhead this initially and then each participating agency would share in the work and hosting ofsubsequent meetings. The need for shared funding was also acknowledged and the idea of an interagency agreement to support logistics was brought to the table. 11 SOLUTIDNS HW 70 v. is-nnqra'i if]? Elf 93 1. gilf; (?73 Federal Partners Meeting Dis?cussion Summary Session 4 - Making It Happen In the final session, the primary focus was to identify immediate needs for information sharing. While this was somewhat repetitive given the previous conversations, there were some general observations. The participants were primarily focused on developing an approach for information sharing and learning from other collaborative information sharing programs. A General Accounting Office report, Practices That Can Heip Enhance and Sustain Caiiaboration across Federai Agencies, points to a number of cross-agency collaborations with common key elements ofsuccess including: General outreach Establish schedule for in-person meetings Establish shared goals early in existence and re-visit over time Importance ofleadership Leverage existing resources Pilot ideas The group indicated that it might be helpful to review this report to drive how to approach both information sharing and general collaboration. The NIH [a research query tool], and phConnect [an online collaboration tool for public health professionals] were both cited as models for integrating data and sharing information. More formal mechanisms such as the initiation of federal committees or interagency workgroups also were noted the Federal Working Group on Suicide Prevention, Violence Against Women working group, USAID working group on orphans and children]. CLOSING This report provides a high level summary ofthe discussions that transpired on February 19-20, 2014, among key federal partners. The report highlights some of the main points raised in regards to current efforts and future opportunities associated with firearm violence prevention research. It also conveys some of the main suggestions made by the meeting participants to address critical components oftheir collective work. However, the report should not be construed as reflecting the full range of ideas, suggestions, or Opportunities generated over the course of the two days. In particular, the forum provided participants with an opportunity to share information about their current ?rearm violence prevention research, programs, or efforts, and these exchanges helped identify potential areas for improved engagement around this work among various federal agencies. These conversations aren?t captured in this report and yet are acknowledged here to demonstrate 12 SOLUTIONS nw 51ml.- 8 [1'11" 0137,13; 19:; 0.73? Federal Partners Meeting Discussion Summary the commitment shown by participants in moving the topic forward. inally} participants recognized the need to continue conversations and information sharing, be it through informal or formal channels [see discussion above], and its importance in ultimately achieving successful outcomes for ?rearm violence prevention. 13 - SOLUTIONS 1025 vurmom avenue. nw smte 830 cit; 20005 202.531'243j 202 63739733 Federal Partners Meeting Discussion Summary Appendix A Research Discussion Handout Priority Topics/Themes Access to ?rearms Better understanding of background checks/point of purchase denials Firearm supply line and its in?uence on firearm violence Better understanding ofsecondary markets, including online sales, private sales Youth and young adult access, possession, carrying Understanding of access in other vulnerable populations (children, perpetrators of partner violence, persons with suicidal intentions or who have made a previous attempts] Understanding ofaccessibility of ?rearms in vulnerable settings such as schools, businesses, and public housing Risk and protective factors associated with access In?uence ofaccess on risk ofinjuries and deaths Influence ofaccess on protection defensive gun use] from violence and crime Decision-making processes/trade-offs around use of ?rearms Technological Approaches Technological approaches that are likely to have the greatest impact on ?rearm violence Consumer attitudes toward safety technologies Understanding of how compliant consumers would be with different safety technologies Understanding of how potential technologies might impact various professional sectors police, private security] in performing their duties Triggers and in?uences of violence involving ?rearms 14 Role ofgenetic, neurological or behavioral basis of substance abuse, especially alcohol and drugs in violent events involving ?rearms Mental health factors, including role of stress and prior trauma Exposure to violent media Situational and contextual factors availability of alcohol/drugs, alcohol outlet density, other economic and environmental factors that influence the likelihood of ?rearm violence] Role of environmental design with respect to schools and other settings and its influence on risk for firearm violence HW 870 v. is-nnqra'i gil? (?73 Federal Partners Meeting Discussion Summary - Individual factors impulsivity, other motivation factors, prior histories of abuse or victimization] 0 Linkages between different types of violence child maltreatment, intimate partner violence, suicidal behavior) and risk for perpetrating firearm violence Which intervention strategies, policies, programs prevent firearm violence? - local, state, and national policies background checks; stand your ground laws; child access prevention laws] setting-Speci?c strategies schools, campuses, workplaces, homes, communities] 0 gun safety education programs for children and adults - counseling and other healthcare provider education programs enforcement strategies around prohibited purchasers whether existing evidence-based programs for interpersonal or self-directed violence are effective in preventing firearm violence 15 SOLUTIONS W23 vermom .JVL-riu-g nw 31:1 do 210005 201? 631' 243:1 20:: (his 373':- Federal Partners Meeting Discussion Summary Appendix Data Collection Discussion Handout Data Gaps Identified a State-specific population data on ?rearm use, acquisition, ownership, carrying, and storage practices to assess the effectiveness of ?rearm injury prevention programs and policies. 0 State level data on nonfatal ?rearm injuries and better national and state level population-based data on the health outcomes of nonfatal ?rearm injuries short and long-term impairment and disability], quality of life measures, and the cost of injury and payer information. I Better and more complete state and national level pepulation-based data on fatal and nonfatal firearm injury circumstances intent of injury, type of firearm used, victims perpetrator relationship, place of occurrence, work-relatedness, alcohol and drug involvement, gang-related, drug-related, underlying circumstances ofthe injury incident such as homelessness, financial problems, marital/family/spousal/partner problems, firearm used for self-defense] I Better population-based data on risk/ behavioral factors of ?rearm injuries [homicide/assault, suicide/intentional self-harm, unintentional] in the home presence of children in the home, family disputes, alcohol and drug problems, mental health issues, ?nancial problems]. I Better population-based data on risk/ behavioral factors of firearm injuries [homicide/assault, suicide/intentional self-harm, unintentional] outside the home crime-related, drug-related, gang-related, drive-by shooting, sexual violence, intimate partner violence, mental health issues, work-relatedness, joblessness, financial problems, alcohol use during hunting/recreational activities, homelessness]. Better population~based data on all US school-based fatal and nonfatal firearm injuries characteristics ofthe perpetrator, type offirearm used. source ofthe weapon and ammunition, emergency response [type of response and timing ofresponse]. 16 SOLUTIONS my yum.- 8 Ti] 11K: :13 1173? From: Bonzo, Sandra E. (CDCIONDIEHJOM Sent: 1? Mar 2016 12:05:40 -0400 To: Houry, Debra E. Amy B. Cc: Ikeda, Robin Subject: FW: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Attachments: 2016-03-16 Carper Letter to CDC re gun violence research.pdf May be a coincidence but compare questions in the attached letter to the questions from Kate Masters in early February. From: Jones, Kamara Sent: Tuesday, March 15, 2016 4:00 PM To: Robinson, MichaelJ Burden, Bernadette OS - interviews Beeton, Jonathan Broido, Tara Gianelli, Diane Migliaccio, Kate Cc: Lenard, Courtney Harben, Kathy (CDCIODIOADC) Bryant, LaKia R. Sent: Monday, March 14, 2016 5:44:37 PM To: 05 Interviews; Robinson, Michael (H Cc: Lenard, Courtney Harben, Kathy Bryant, La Kia R. (CDCIODIOADQ Subject: FW: CDC Interview {email} request from The Trace: gun violence DEADLINE: 03?14?16 ASPA Media Interview Request Template Reporter: Kate Masters Organization: The Trace Phone Subject: gun violence Deadline: 03-14-16 Spokesperson: emailed response only. Kate Masters with The Trace has a follow up, please see her several previous requests in the thread below in addition the proposed CDC response. Her deadline is today. From Kate: Thanks again for all the information about the it was definitely helpful and that piece should be up on our site soon. i'm emailing today because my editors and are in the drafting phase of my piece on gun violence research at the CDC, and wanted to let you lcnow that the basis of the story is that the CDC is avoiding the issue of gun violence and bowing to political pressure by essentially foregoing research on firearms, even though there are things the agency could be doing. This is coming from former employees of the CDC, as well as outside gun violence researchers. i wanted to tell you this so there would be no surprise when the article came out, and also because wanted to give the CDC a chance to respond to what others are saying. That response could be a statement from you, or would still love to speak with Dr. Houry directly about the lack of gun research at the injury Center, but do recommend addressing these statements somehow so that the CDC '5 voice is included in the piece. Proposed Response: CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. More than 117,000 Americans are non?fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-54 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the "The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." The President has requested that CDC conduct research into the causes and prevention of gun violence and the IBM Report noted a number of research areas that might have bipartisan support. CDC is ready to conduct that research if funds are appropriated by Congress. Thanks in advance, Bernadette Burden Senior Public Affairs Specialist News Media Branch Division of Public Affairs (404)639-3236 From: Robinson, Michael Sent: Friday, February 12, 2016 11:22 AM To: Lenard, Courtney Blackmore, Rebecca Medvedev, Bree Cabezas, Miriam ; Beeton, Jonathan Broido, Tara (HHSXOASH) Colson, Angela Gianelli, Diane (DASH) Migliaccio, Kate (H Cabezas, Miriam Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette Fine, Amanda Subject: RE: CDC Interview {email} request from The Trace: gun violence 0k From: Lenard, Courtney [mailtozzvq5@cdc.qovl Sent: Friday, February 12, 2016 11:16 AM To: Robinson, Michael Blackmore, Rebecca Medvedev, Bree Cabezas, Miriam Beeton, Jonathan Broiclo, Tara Colson, Angela Gianelli, Diane Migliaccio, Kate Cabezas, Miriam (HHSIASFR) Cc: Connelly, Erin Dorigo, Leslie (CDCIONDIEHINCIPC): Lane, Gabraelle Harben, Kathy Burden, Bernadette Fine, Amanda Subject: RE: CDC Interview (email) request from The Trace: gun violence Good morning, Deadline is COB today. Thank you! Courtney From: Robinson, Michael Sent: Thursday, February 11, 2016 4:50 PM To: Lenard, Courtney Blackmore, Rebecca Medvedev, Bree Cabezas, Miriam Beeton, Jonathan (OSIOASH) Broido, Tara Colson, Angela Gianelli, Diane (DASH) Migliaccio, Kate (HHSIOASH) Cabezas, Miriam Cc: Connelly, Erin Dorigo, Leslie Lane, [Sabraelle Harben, Kathy Burden, Bernadette (CDCIODIOADC) Fine, Amanda Subject: RE: CDC interview {email} request from The Trace: gun violence Hi ?Addirlg ASFR What?s the deadline for this info? Best, From: Lenard, Courtney (CDCIONDIEHINCIPC) Sent: Thursday, February 11, 2016 4:48 PM To: Robinson, Michael OS - Interviews: Cabezas, Miriam Beeton, Jonathan Broido, Tara Colson, Angela Gianelli, Diane Migliaccio, Kate Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette Fine, Amanda (NIHIOD) Subject: RE: CDC Interview (email) request from The Trace: gun violence Good afternoon, Another follow up from Kate with The Trace: I also know that the President requested the full $23.5 million required to place in all 50 states and the District of Columbia in his FY2017 budget request. I asked the White House why that decision was made and why the was prioritized this year, and they told me to check with the CDC. So do you guys have any information on why that request was made and why it was important to the administration? Proposed Response: The President?s budget request for has been for 523.5m for several years [since the FY14 request). Expansion of to all 50 states and DC has been a priority for the administration since FY14. Although CDC has seen incremental increases [including most recently in FY 16) and will be able to expand the program this year, the FY17 request will allow CDC to expand the program further to truly have a national program [all 50 states and DC). is the only state-based surveillance system that pools information from multiple data sources into a usable, anonymous data base. It covers all types of violent deaths including homicides, suicides, and child maltreatment fatalities in all settings and for all age groups. Thanks much! Courtney From: Robinson, Michael Sent: Thursday, February 04, 2016 4:21 PM To: Lenard, Courtney OS Interviews Cabezas, Miriam Beeton, Jonathan Broido, Tara Colson, Angela Gianeili, Diane Migliaccio, Kate (Kate.Migliaccio@hhs.gov> Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette (CDCKODIOADC) Fine, Amanda Subject: RE: CDC interview {email} request from The Trace: gun violence 0k From: Lenard, Courtney Sent: Thursday, February 04, 2016 4:19 PM To: Robinson, Michael OS - Interviews: Cabezas, Miriam Beeton, Jonathan Broido, Tara Colson, Angela (HHSIOASH): Gianeili, Diane Migliaccio, Kate (HHSIDASH) Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette Fine, Amanda Subject: RE: CDC Interview (email) request from The Trace: gun violence Good afternoon, We have a follow up from Kate: does the CDC still have a ?gentleman's agreement" with the gun lobby to report out, to the lobby, any gun research completed by their grantees, whether that research was actually completed with CDC funds or not? Proposed response, this question came up in the AP interview from a few months ago and this is what we said: We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out to the NRA in recent years. Thanks much! Courtney From: Robinson, Michael Sent: Wednesday, February 03, 2016 1:27 PM To: 05 - Interviews Lenard, Courtney Cc: Connelly, Erin Dorigo, Leslie Lane, Ga braelle Harben, Kathy Bu rden, Bernadette (CDCIODXOADC) Fine, Amanda Subject: FW: CDC Interview {email} request from The Trace: gun violence 0k is new) From: Lenard, Courtney Sent: Wednesday, February 03, 2016 1:05 PM To: 05 - Interviews Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraeile Harben, Kathy Burden, Bernadette Fine, Amanda (NIHIDD) Subject: CDC Interview (email) request from The Trace: gun violence ASPA Media Interview Request Outlet: The Trace Reporter: Kate Masters Phone: {Sill 643-4275 Subject: gun violence research Deadline: today Spokesperson: email response attributed to Deb Houry, MD, MPH, director, Injury Center Expected place of publication (print, online, broadcast]: print Expected date of publicationfairing: n/a Expected prominence leg. front page, Sunday, evening/morning show, etc): nfa Background: She requested to interview Deb Hoary. "My article is going to be about viaience research at the CDC versus the NH, so most of my questions woaid center on her approach to running the Center for injury Controi and Prevention, accompiishments she?s made, and priorities she?d like to work on. Actual questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall. budget to go to gun research? 3. In 2013, the NIH announced a new funding program that called Specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? 8. Did the CDC stoi monitoring U.S. gun ownership in 2004, and why? 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non~research activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence {about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The IOM RC research agenda Priorities for Research to Reduce the Threat of Firearm?Related Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IOM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the "The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.? 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention lACEsj, and universities awarded R01 {investigator- initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: - one study [which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. - A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; - A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: WEE Firearm injuries in the United States Prev Med. 2015 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 Gang Homicides Five U.S. Cities, 2003-2008 MMWR. January 27", 2012 mm? 103 a2.htm Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 ss 630 la 1 .htm From: Houry, Debra E. Sent: Wednesday, March 16, 2016 2:18 PM To: ikeda, Robin (CDCIONDIEHXOD) Bonzo, Sandra E. (CDCIDNDIEHIOD) Cc: Peeples, Amy B. Subject: FW: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Fyi? received today Opp will begin working on it Deb Houry, MD, MPH Director National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 4WD Buford Highway, Mail Stop Atlanta, GA 30341 Twitter: @DebHouerDC Phone: 483-4696 Fax: [770] 488-4222 From: Morris, Dena Sent: Wednesday, March 16, 2016 1:59 PM To: Frieden, Thomas {Tom} Schuchat, Anne MD Villar, Carmen S. Berger, Sherri Daniel, Katherine Lvon Hourv, Debra E. (CDCIONDIEHKNCIPCJ Subject: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research For your awareness. HUN . Ir.- SD Elf? a't? . ??lm?s t'tRlI?l?ifuh Fl. UELAWJEHE RUE-Z Pmemu gum CLAIRE H1 Pa. xEr-rl'l rEh?. 16er Mt ANA I l?l AI Ali-V- Elt DWWL rte-mast 3.51m wv-mmr: HEIDI Noam - . run Arm?rt. use; com A. Boone. vow "It . . [a tt? [n?tt c. MILHIHAN ?ll- ?r uhh?. Nilsmxaoja ON HOMELAND srcumrv AND GOVERNMENTAL AFFAIRS WASHINGTON. DC 20510-8250 March 16.. 2016 Dr. Tom Frieden Director Centers for Disease Control and Prevention 1600 Clifton Road Atlanta. GA 30329 Dear Director Fricdcn: I write today to request information regarding the Centers for Disease Control and Prevention's (CDC) support for scienti?c research into the causes and prevention of gun violence. As the largest collection of public health professionals conducting scienti?c research for injury prevention in the world, the National Center for lnjury Prevention and Control (Injury Center) has a mission to prevent violence and injuries, and reduce their consequences- Using a public health approach of de?ning problems, identifying risk factors. and testing prevention strategies, the Injury Center has been at the forefront ot?identil?ying scienti?cally sound solutions to reducing injuries and saving lives. In the 19905. the Injury Center played an important role in conducting high- quality, peer-reviewed research into the underlying causes of gun violence. But this changed starting in 1996 when Congress began inserting language into annual spending bills prohibiting the CDC from spending its funds ?to advocate or promote gun control."1 While this languages?sponsored by then Representative Jay Dickey?only prohibits the use of funds to support legislative efforts to limit access to ?rearms, it has often been misconstrued to ban any and all scienti?c research on gun violence. As a result. public health researchers at the CDC and other federal agencies have been discouraged from conducting scienti?c research on gun violence. Although the CDC self-directs a portion of its nearly $6.2 billion annual budget to a wide variety of intra? and extramural research, the CDC has been reluctant to devote funding to gun violence research without a speci?c appropriation from Congress. Scientists at the CDC have expressed frustration with their inability to conduct more extensive studies on gun violence, vvhich could help to reduce the over 30,000 Americans killed by gun violence each year.? I PL. 104-208, I [ll Stat. 3009-244 (Sep. 30, ?396). 3 Jess Bidgood. When (Jim lr'fofence Felt Like a Disease, a C533 in Delaware Turned to the NEW TIMES (Dec. 24, 2015}. Encouragingly, recent developments at the CDC have shown that your agency has the ability do more to assist communities that struggle with gun violence. In my home town of Wihnington, Delaware, the CDC conducted an investigation into elevated levels of gun violence after receiving a request from Wilmington of?cials and Delaware?s Department of Health and Social Services. Released in December 2015, the results of this investigation identi?ed many of the root causes of gun violence in the community and offered on how prevention and early intervention could reduce violence for those most at risk.3 In February 2013, the CDC also released the results of an investigation of youth suicide clusters in Delaware?s Kent and Sussex counties, ?nding that 45 percent of suicides between January 2009 and May 2012 were committed using ?rearms. I am optimistic that Delaware can bene?t from the work and believe that many other communities across the United States could also bene?t from similar scienti?c research, as well. In a Washington Post op-ed with the Injury Center?s former director Mark Rosenberg, Representative Dickey came out in support of additional research, writing that: are in strong agreement now that scienti?c research should be conducted into preventing ?rearm injuries and that ways to prevent ?rearm deaths can be found without encroaching on the rights of legitimate gun owners. The same evidence-based approach that is saving millions of lives from motor-vehicle crashes, as well as from smoking, cancer and HIWAID S, can help reduce the toll of deaths and injuries from gun violence."4 As a supporter of the Second Amendment to the United States Constitution, I believe that law-abiding citizens have the right to buy and own ?rearms. I also believe that we can take common sense steps to reduce gun violence. With more than 1 1?,000 Am?icans injured or killed each year with ?rearms, conducting scienti?c research on gun violence is one such step.? Enclosed with this letter is a set of questions and requests for information for your response. I ask that you please respond by April 15, 2016. The Committee?s minority staff is authorized to conduct this investigation under the authority of Senate Rule XXV and Senate Resolution 73 (114th Congress). If you or members of your staff have any questions about this request, please feel free to contact Kevin Burris at (202) 224-2627. Thank you for your attention to this matter. 3? Steven Sumner, et. a1, Eievored Rates of Urban Firearm Violence and Opportunities for Prevention? Wiimingron, Delmar-e, Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (Nov. 3, 2015]. 4 Jay Dickey and Mark Rosenberg, How to Protect Gun Rights While Reducing the Toll af?rm Violence, Wasnmoron Posr (Dec. 25, 2015). 5 Centers for Disease Control and Prevention, Web-based Injury Statistics Query and Reporting System (WISQARS), Fora! and Nonforot? injury Reports (2013). With best personal regards, I am Sincerely yours, awe. Thomas R. Carper Ranking Member Enclosure cc: The Honorable Ron Johnson Chairman Questions for Dr. Tom rieden Director, Centers for Disease Control and Preventittn l. Please describe the policy toward scienti?c research into the causes and prevention of gun violence. 2. Has the CDC or the Department of Health and Human Services? Of?ce of the General Counsel conducted any analysis of the Dickey Amendment, including the types of gun violence research that are still permissible? If so, please provide this analysis. Lu In the aftermath of the shooting at Sandy Hook Elementary School in December 20121 President Obama issued a memorandum directing the Secretary of Health and Human Services (HHS), through the Director of the CDC and other agencies within HHS, to conduct 0r spensor research into the causes of gun violence and the ways to prevent it.?rJ Please describe the efforts CDC has taken in reaponse to this memorandum. 4. In April 2013. the National Center for Injury Prevention and Control asked the Institute of Medicine to recommend a research agenda on the public health aspects of fireann-related violence:7 Please describe the actions the CDC plans to take in response to the ?ndings of the Institute of Medicine report issued in June 2013. 5. From l996 to the present, please describe notable examples of research conducted or ?lnded by the DC, including research by or through the National Center for injury Prevention and Control, related to understanding gun violence. Please also provide all instances when the CDC included requests for gun violence research in its research proposal solicitation materials. 6. For each year from FY1996 to FY2015, what portion of the budget, including the budget of the National Center for Injury Prevention and Control, has been devoted to gun violence research? 7. Each year, Division of Violence Prevention solicits investigator-initiated research via an Grant Program Announcement. The language in these announcements signals to grant-seeking public health researchers the research priorities of the CDC and its Division of Violence Prevention. Please describe any Division ol?Violence Prevention's ROI Grant Program Announcements related to gun violence research put forward from 1996 to the present. 5? Presidential Memorandum - Engaging in Public Health Research on the Causes and Prevention of Gun Violence (Jan. 16, 2013). New Report Identifies Research Priorities for Most Pressing Gm: Violence Probl'ems in US. National Academies of Sciences. Engineering. and Medicine (June 5, 2013). 8. The National Violent Death Reporting System collects and combines data from multiple sources to provide states and communities with a more complete record ot?the circumstances surrounding violent deaths. Participation from all 50 states would significantly increase the amount of data available to the National Violent Death Reporting System and, thereby, improve its effectiveness. In how many states has the National Violent Death Reporting System been implemented? How many states have applied to be included in this system? What circumstances have prevented all state applicants from being added to the National Violent Death Reporting System? 9. Has the CDC previously entered into any agreements with the National Ri?e Association offering to provide advanced notice of any publication on the subject of gun violence? If so, please provide a description of any such agreements as well as communications and documents memorializing the agreements. 10. From 1996 to the present, has the CDC instructed any employee or researcher to not conduct scienti?c research on gun violence? Has the CDC instructed any employees or researchers to re-write reports submitted for publication to avoid using any variation of the word 1 l. What remedies are available to CDC researchers who believe their scienti?c research has been inappropriately suppressed or discouraged? Please describe any review or appeals processes and include a list of the of?ces or review boards who would address any such concerns. From: aec1@cdc.gov Sent: 6 Apr 2016 19:16:17 -0400 To: Blair, Janet Jeffrey Howard Cc: Frazier, Lerov Jr. Subject: Fw: Over 100 orgs sign letter to Congress re: research Attachments: Impedance: High Greetings: in case you hadn't rec'd this msg. Alex Sent from my BlackBerry 10 smartphone. From: Reimels, Elizabeth (CDCIONDIEHINCIPC) Sent: Wednesday, April 6, 2016 08:51 To: Crosby, Alexander (CDCIONDIEHINCIPC) Subject: Fw: Over 100 orgs sign letter to Congress re: research Sent from my BlackBerrv 10 smartphone. From: Dorigo, Leslie Sent: Wednesday, April 6, 2016 8:08 AM To: Hourv, Debra E. Peoples, Amy B. Connolly, Erin Patterson, Sara S. Solhtalab, Elizabeth Lenard, Courtney;r Reimels, Elizabeth Middlebrooks, Jennifer Burton, Tessa Mercy, James Dahlberg, Linda L. Simon, Thomas Subject: Over 100 orgs sign letter to Congress re: CDCigun research Not sure who all is around this week or checking BB while outI but wanted to share this Public health groups urge Congress to allow funding of gun control research Nearly 150 public health organizations including heavy hitters like the American Medical Association, Doctors for America, and have sent a letter to Congress this morning urging lawmakers to end restrictions on gun violence research. The CDC has been banned from funding research that might promote gun control since 1996. white-house/CDC letter 4-6 FlNAL.pdf Full letter attached/at link, and pasted below for those on BB. April 6, 2016 The Honorable Thad Cochran Chairman, Appropriations Committee U.S. Senate Washington, DC 20515 The Honorable Barbara Mikulski Vice Chairwoman, Appropriations Committee U.S. Senate Washington, DC 20515 The Honorable Harold Rogers Chairman, Appropriations Committee U.S. House of Representatives Washington, DC 20515 The Honorable Nita Lowey Ranking Member, Appropriations Committee U.S. House of Representatives Washington, DC 20515 Dear Senator/ Representative: The undersigned health care, public health, scientific organizations and research universities representing over 1 million members across the country urge you to end the dramatic chilling effect of the current rider language restricting gun violence research and to fund this critical work at the Centers for Disease Control and Prevention (CDC). In 1996, Congress passed the so-called Dickey amendment as a rider to the Labor- Health and Human Services-Education Appropriations bill. The language stated that the CDC could not fund research that would ?advocate or promote gun control,? and the language has remained in each subsequent annual funding bill. At the same time, Congress cut CDC funding for this research. Although the Dickey amendment does not explicitly prevent research on gun violence, the combination of these two actions has caused a dramatic chilling effect on federal research that has stalled and stymied progress on gathering critical data to inform prevention of gun violence for the past 20 years. Furthermore, it has discouraged the next generation of researchers from entering the ?eld. Gun violence is a serious public health epidemic resulting in the senseless deaths of an average of 91 Americans, and another 108 gun injuries, each and every day. A central part of preventing future tragedies is through conducting rigorous scienti?c research as this has been a proven successful approach in reducing deaths due to other injuries. Health care providers and public health professionals are overwhelmed in emergency departments, clinics, offices, and communities with the victims of mass shootings, homicides, suicides, accidental shootings, and ?rearm injuries. Medical professionals and our communities work to address the devastating and long-lasting physical and emotional effects of gun violence on victims, their families and their friends, but are hampered by the insuf?cient body of evidence-based research to use to point communities toward proven gun violence prevention programs and policies. Former Representative Jay Dickey author of the current language that has effectively restricted gun violence research, recently noted that, ?it is my position that somehow or someway we should slowly but methodically fund [gun] research until a solution is reached. Doing nothing is no longer an acceptable solution.? Here are some of the critical questions that enhanced research would help us answer: 1) Mat is the best way to protect toddlers from accidentally ?ring a ?rearm? Safe ?rearm storage works, but what kinds of campaigns best encourage safe storage? What safe storage methods are the most effective and most likely to be adopted? What should be the trigger pull on a ?rearm so a toddler can?t use it? 2) What are the most effective ways to prevent gun-related suicides? Two- thirds of ?rearm related deaths are suicides. Are ?rearm suicides more spontaneous than non-firearm suicides? Do other risk factors vary by method? How do we prevent it in different populations?active military, veterans, those with mental illness, law enforcement or correctional officers, the elderly, or teenagers? 3) What is the impact of the variety of state policies being enacted? How are different policies around safe storage, mental health, public education, and background checks impacting ?rearm injuries and deaths? The National Center for Injury Prevention and Control is an important part of answering these types of questions. Public health uniquely brings together a comprehensive approach connecting the complex factors that result in violence and injuries including clinical, social, criminal, mental health, and environmental factors. The impact of federal public health research in reducing deaths from car accidents, smoking and Sudden Infant Death has been well proven. Decades ago, we did not know infant car seats should be rear-facing. Robust research on car accidents and subsequent legislation has helped save hundreds of thousands of lives without preventing people from being able to drive. It?s time to apply the same approach to reducing gun violence in our communities. As professionals dedicated to the health of the nation and to the application of sound science to improving the lives of our fellow Americans, we urge you to take action this year. Americans deserve to know that we are working with the best tools and information in the ?ght to reduce gun violence deaths and injuries. As Congress works to craft the FY 2017 Labor-HHS-Education Appropriations bill, we urge you to provide the Centers for Disease Control and Prevention with funding for research into the causes and prevention of gun violence. Thank you for your consideration. We look forward to working with you to improve health and protect the safety of all Americans. Sincerely, Academic Consortium for Integrative Medicine 8: Health Academic Pediatric Association Alameda Health System Department of Emergency Medicine American Academy of Family Physicians American Academy of Pediatrics American Association for the Advancement of Science American Association of Colleges of Pharmacy American Association of Nurse Practitioners American College of Emergency Physicians American College of Emergency Physicians, California Chapter American College of Occupational and Environmental Medicine American College of Physicians American Congress of Obstetricians and Gynecologists American Educational Research Association American Geriatrics Society American Medical Association American Medical Student Association American Medical Women's Association American Pediatric Society American Association American Association American Public Health Association American Society for Clinical Pathology American Society of Hematology American Thoracic Society American Trauma Society Arkansas Public Health Association Asociacion de Salud Publica de Puerto Rico Association for Science Association of American Universities Association of Medical School Pediatric Department Chairs Association of Population Centers Association of Public and Land?grant Universities Big Cities Health Coalition Boulder County Public Health Brigham Specialties California Center for Public Health Advocacy California Public Health Association-North Center for Science and Democracy at the Union of Concerned Scientists Central Oregon Medical Society Champaign? Urbana Public Health District Chicago Center for Chicago chapter Physicians for Social Responsibility Colorado Public Health Association Committee of Interns and Residents/SEIU Healthcare Congregation Gates of Heaven Consortium of Social Science Associations Council of State and Territorial Epidemiologists Cure Violence Delaware Academy of Medicine Delaware Public Health Association Doctors Council SEIU Doctors for America Eastern Association for the Surgery of Trauma Federation of Associations in Behavioral and Brain Sciences Florida Chapter of the American Academy of Pediatrics, Inc. Futures Without Violence Georgia Public Health Association Hawaii Public Health Association Health Of?cers Association of California Houston Health Department Illinois Public Health Association International Society for Developmental Iowa Chapter Physicians for Social Responsibility Iowa Public Health Association PS Health Network Kansas Public Health Association Koop Institute KU Department of Preventive Medicine and Public Health Law and Society Association Lee County Health Department Local Public Health Association of Minnesota Louisiana Center for Health Equity Maine Public Health Association Maryland Academy of Family Physicians Minnesota Public Health Association Montana Public Health Association National AHEC Organization National Association of County and City Health Of?cials National Association of Medical Examiners National Association of Nurse Practitioners in Women?s Health National Association of Social Workers National Association of State Emergency Medical Services Of?cials National Association of State Head Injury Administrators National Black Nurses Association National Hispanic Medical Association National Medical Association National Network of Public Health Institutes National Physicians Alliance National Violence Prevention Network Nevada Public Health Association New Hampshire Public Health Association New Mexico Public Health Association North Carolina Public Health Association Ohio Public Health Association Ohio Public Health Association Oregon Academy of Family Physicians Oregon Physicians for Social Responsibility Oregon Public Health Association Pediatric Policy Council Physicians for Social Responsibility, Arizona Chapter Physicians for a National Health Program NY Metro Chapter Physicians for Reproductive Health Physicians for Social Responsibility Northeast Ohio Physicians for Social Responsibility Wisconsin Physicians for Social Responsibility, Arizona Chapter Physicians for Social Responsibility/ New York Physicians for the Prevention of Gun Violence Population Association of America Prevention Institute Society Public Health Association of Nebraska Public Health Association of New York City Public Health Institute ResearchlAmerica RiverStone Health Safe States Alliance San Francisco Bay Area Chapter, Physicians for Social Responsibility Society for Adolescent Health and Medicine Society for Advancement of Violence and Injury Research Society for Mathematical Society for Pediatric Research Society for Research Society for Public Health Education Society of Experimental Social Society of General Internal Medicine Southern California Public Health Association Southwest Ohio Society of Family Medicine Student National Medical Association Suicide Awareness Voices of Education Texas Doctors for Social Responsibility Texas Public Health Association Trauma Foundation Tri-County Health Department Trust for America?s Health United Physicians of Newtown Vermont Public Health Association Virginia Public Health Association Washington Chapter of the American Academy of Pediatrics Washington State Public Health Association Wellness Institute of Greater Buffalo Whiteside County Health Department cc: The Honorable Mitch McConnell The Honorable Paul Ryan The Honorable Harry Reid The Honorable Na newr Pelosi Members of Congress April 6, 2016 The Honorable Thad Cochran The Honorable Harold Rogers Chairman, Appropriations Committee Chairman, Appropriations Committee U.S. Senate U.S. House of Representatives Washington, DC 20515 Washington, DC 20515 The Honorable Barbara Mikulski The Honorable Nita Lowey Vice Chairwoman, Appropriations Ranking Member, Appropriations Committee Committee U.S. Senate U.S. House of Representatives Washington, DC 20515 Washington, DC 20515 Dear Senator/ Representative: The undersigned health care, public health, scienti?c organizations and research universities representing over 1 million members across the country urge you to end the dramatic chilling effect of the current rider language restricting gun violence research and to fund this critical work at the Centers for Disease Control and Prevention (CDC). In 1996, Congress passed the so-called Dickey amendment as a rider to the Labor-Health and Human Services?Education Appropriations bill. The language stated that the CDC could not fund research that would ?advocate or promote gun control,? and the language has remained in each subsequent annual funding bill. At the same time, Congress cut CDC funding for this research. Although the Dickey amendment does not explicitly prevent research on gun violence, the combination of these two actions has caused a dramatic chilling effect on federal research that has stalled and stymied progress on gathering critical data to inform prevention of gun violence for the past 20 years. Furthermore, it has discouraged the next generation of researchers from entering the field. Gun violence is a serious public health epidemic resulting in the senseless deaths of an average of 91 Americans, and another 108 gun injuries, each and every day. A central part of preventing future tragedies is through conducting rigorous scientific research as this has been a proven successful approach in reducing deaths due to other injuries. Health care providers and public health professionals are overwhelmed in emergency departments, clinics, offices, and communities with the victims of mass shootings, homicides, suicides, accidental shootings, and firearm injuries. Medical professionals and our communities work to address the devastating and long-lasting physical and emotional effects of gun violence on victims, their families and their friends, but are hampered by the insuf?cient body of evidence?based research to use to point communities toward proven gun violence prevention programs and policies. Former Representative Jay Dickey (R-AR), author of the current language that has effectively restricted gun violence research, recently noted that, ?it is my position that somehow or someway we should slowly but methodically fund [gun] research until a solution is reached. Doing nothing is no longer an acceptable solution.? Here are some of the critical questions that enhanced research would help us answer: 1) What is the best way to protect toddlers from accidentally ?ring a ?rearm? Safe ?rearm storage works, but what kinds of campaigns best encourage safe storage? What safe storage methods are the most effective and most likely to be adopted? What should be the trigger pull on a ?rearm so a toddler can?t use it? 2) What are the most effective ways to prevent gun-related suicides? Two-thirds of ?rearm related deaths are suicides. Are ?rearm suicides more spontaneous than non-firearm suicides? Do other risk factors vary by method? How do we prevent it in different populations? active military, veterans, those with mental illness, law enforcement or correctional officers, the elderly, or teenagers? 3) What is the impact of the variety of state policies being enacted? How are different policies around safe storage, mental health, public education, and background checks impacting ?rearm injuries and deaths? The National Center for Injury Prevention and Control is an important part of answering these types of questions. Public health uniquely brings together a comprehensive approach connecting the complex factors that result in violence and injuries including clinical, social, criminal, mental health, and environmental factors. The impact of federal public health research in reducing deaths from car accidents, smoking and Sudden Infant Death has been well proven. Decades ago, we did not know infant car seats should be rear-facing. Robust research on car accidents and subsequent legislation has helped save hundreds of thousands of lives without preventing people from being able to drive. It?s time to apply the same approach to reducing gun violence in our communities. As professionals dedicated to the health of the nation and to the application of sound science to improving the lives of our fellow Americans, we urge you to take action this year. Americans deserve to know that we are working with the best tools and information in the fight to reduce gun violence deaths and injuries. As Congress works to craft the FY 2017 Labor-HHS-Education Appropriations bill, we urge you to provide the Centers for Disease Control and Prevention with funding for research into the causes and prevention of gun violence. Thank you for your consideration. We look forward to working with you to improve health and protect the safety of all Americans. Sincerely, Academic Consortium for Integrative Medicine 8: Health Academic Pediatric Association Alameda Health System Department of Emergency Medicine American Academy of Family Physicians American Academy of Pediatrics American Association for the Advancement of Science American Association of Colleges of Pharmacy American Association of Nurse Practitioners American College of Emergency Physicians American College of Emergency Physicians, California Chapter American College of Occupational and Environmental Medicine American College of Physicians American Congress of Obstetricians and Gynecologists American Educational Research Association American Geriatrics Society American Medical Association American Medical Student Association American Medical Women's Association American Pediatric Society American Association American Association American Public Health Association American Society for Clinical Pathology American Society of Hematology American Thoracic Society American Trauma Society Arkansas Public Health Association Asociacion de Salud P?blica de Puerto Rico Association for Science Association of American Universities Association of Medical School Pediatric Department Chairs Association of Population Centers Association of Public and Land-grant Universities Big Cities Health Coalition Boulder County Public Health Brigham Specialties California Center for Public Health Advocacy California Public Health Association-North Center for Science and Democracy at the Union of Concerned Scientists Central Oregon Medical Society Champaign-Urbana Public Health District Chicago Center for Chicago chapter Physicians for Social Responsibility Colorado Public Health Association Committee of Interns and Residents/SEIU Healthcare Congregation Gates of Heaven Consortium of Social Science Associations Council of State and Territorial Epidemiologists Cure Violence Delaware Academy of Medicine Delaware Public Health Association Doctors Council SEIU Doctors for America Eastern Association for the Surgery of Trauma Federation of Associations in Behavioral and Brain Sciences Florida Chapter of the American Academy of Pediatrics, Inc. Futures Without Violence Georgia Public Health Association Hawaii Public Health Association Health Of?cers Association of California Houston Health Department Illinois Public Health Association International Society for Developmental Iowa Chapter Physicians for Social Responsibility Iowa Public Health Association PS Health Network Kansas Public Health Association Koop Institute KU Department of Preventive Medicine and Public Health Law and Society Association Lee County Health Department Local Public Health Association of Minnesota Louisiana Center for Health Equity Maine Public Health Association Maryland Academy of Family Physicians Minnesota Public Health Association Montana Public Health Association National AHEC Organization National Association of County and City Health Officials National Association of Medical Examiners National Association of Nurse Practitioners in Women?s Health National Association of Social Workers National Association of State Emergency Medical Services Of?cials National Association of State Head Injury Administrators National Black Nurses Association National Hispanic Medical Association National Medical Association National Network of Public Health Institutes National Physicians Alliance National Violence Prevention Network Nevada Public Health Association New Hampshire Public Health Association New Mexico Public Health Association North Carolina Public Health Association Ohio Public Health Association Ohio Public Health Association Oregon Academy of Family Physicians Oregon Physicians for Social Responsibility Oregon Public Health Association Pediatric Policy Council Physicians for Social Responsibility, Arizona Chapter Physicians for a National Health Program NY Metro Chapter Physicians for Reproductive Health Physicians for Social Responsibility Northeast Ohio Physicians for Social Responsibility Wisconsin Physicians for Social Responsibility, Arizona Chapter Physicians for Social Responsibility/ New York Physicians for the Prevention of Gun Violence Population Association of America Prevention Institute Society Public Health Association of Nebraska Public Health Association of New York City Public Health Institute Research lAmerica RiverStone Health Safe States Alliance San Francisco Bay Area Chapter, Physicians for Social Responsibility Society for Adolescent Health and Medicine Society for Advancement of Violence and Injury Research Society for Mathematical Society for Pediatric Research Society for Research Society for Public Health Education Society of Experimental Social Society of General Internal Medicine Southern California Public Health Association Southwest Ohio Society of Family Medicine Student National Medical Association Suicide Awareness Voices of Education Texas Doctors for Social ReSponsibility Texas Public Health Association Trauma Foundation Tri-County Health Department Trust for America's Health United Physicians of Newtown Vermont Public Health Association Virginia Public Health Association Washington Chapter of the American Academy of Pediatrics Washington State Public Health Association Wellness Institute of Greater Buffalo Whiteside County Health Department cc: The Honorable Mitch McConnell The Honorable Paul Ryan The Honorable Harry Reid The Honorable Nancy Pelosi Members of Congress From: Houry, Debra E. Sent: 16 Jun 2016 14:48:15 +0000 To: Patterson, Sara S. B. Peeples (asb0@cdc.gov} Subject: FW: Schatz key take aways if helpful for tomorrow for Dr Frieden Fyi- I mentioned this to amy already- Will fill you in too sara about larger issue Deb Houry, MD, MPH Director National Centerfor Injury Prevention and Control, Centers for Disease Control and Prevention 4?70 Buford Highway, Mail Stop Atlanta, GA 30341 Twitter: Phone: (770} 488-4696 Fax: (770) 488-4222 (H) 201 6 FEderal Employee Survey {mpc-wt?rica tmrtiojr-Jc'. Change From: Houry, Debra E. Sent: Wednesday, June 15, 2016 8:4? PM To: Foti, Morris, Dena Subject: Schatz key take aways if helpful for tomorrow for Dr Frieden Met with Aimee his health LA- she?s a pediatrician so gets public health! injury prevention Falls- big interest of the Senator- they had been briefed by American College of Prev Med re the CPT code we have been working with them on- this CPT code was recently rejected by AMA- we will be resubmitting this month. They may be interested in sending letter of support to AMA re this (of note, HI has one of the lowest rates of falls in US- has good community based Tai Chi program) Suicide- advocates recently met with them- I mentioned the FY17 request and what our vision for work in suicide would be {community level interventions in states and tribal communities; implementing evidence based approaches; expanding nationallyj- she said they are extremely interested in suicide and would like to support our efforts FV- she brought this up esp with AMA resolution this week re lifting Dickey amendment. I talked about the work we were doing (child injury papers, optional module, projects) but talked about the importance of report language and! or appropriation. She wants to have a follow up discussion on this to see how they can help move this forward From: Mercy, James i hit 5) Sent: 19 Apr 2016 08:02:52 -0400 To: Houry, Debra Subject: FW: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353690 Attachments: 2353690 Carper Response- Gun Violence Draft V5 [003).docx Deb, ibjiijii .lim From: Reimels, Elizabeth Sent: Monday, April 18, 2016 9:48 AM To: Solhtalab, Elizabeth Cc: Belser-Vega, Elizabeth Patterson, Sara S. Mercy, James (CDCIONDIEHINCIPC) Dahlberg, Linda L. (CDCXONDIEHINCIPC) Subject: FW: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353690 Hello! This is looking really good, but we have some concerns about some of the edits that were made. (Lilli: Can we still provide feedback on this version? Thanks! From: Dahlberg, Linda L. (CDCIONDIEHINCIPCI Sent: Monday, April 18, 2016 9:02 AM To: Mercy, James Reimels, Elizabeth Subject: FW: Support for Gun Violence Research Senator Thomas Carper Folder 2353690 From: Solhtalab, Elizabeth Sent: Monday, April 18, 2016 8:15 AM To: Dahlberg, Linda L. DVP Policy Requests (CDC) Cc: BelserrVega, Elizabeth Cc: Solhtalab, Elizabeth Cc: Villar, Carmen S. Hoffmann, Lauren Richards, Bridget Lubar, Debra Subject: RE: URGENT FOR APPROVAL: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353590 I?m ok it if Deb is From: Payne, Rebecca L. Sent: Friday, April 15, 2016 5:03 PM To: Frieden, Thomas {Tomi <1ng Cc: Villar, Carmen S. From: NCIPC Self-Directed Violence Prevention Listserv on behalf of Crosby, Alexander Sent: 17 Jun 2016 12:36:19 +0000 To: Subject: FW: Section] Re: fvi article on guns and Attachments: Greetings: In case you hadn?t seen this article. Alex From: On BehalfOf Dr. Donald Wayne Olson Sent: Thursday, June 16. 2016 9:28 PM To: Leslie Fisher ICEHS Section Subject: Section] Re: fyi article on guns and Greetings Les I've attached an article that expressly studied the question: WOULD BANNING FIREARMS REDUCE MURDER AND Their concluding remarks: If you are surprised by [our] so [are we]. [We] did not begin this research with any intent to ?exonerate" handguns, but there it is--a negative ?nding. to be sure, but a negative ?nding is nevertheless a positive contribution. It directs us where not to aim public health resourcesm Wm-? w? m-m-m-m?m?m?-m-m-m Manage your Group settings: To reply to sender (Dr. Donald Wayne Olson): To view sender's pro?le. click this link: Dr. Donald Wavne Olson To post to entire group, send email to: ICEHS Section@connect.anha.org To email the group moderator(s) (Fran. Lara, Kevin, Dawn. Teresa}: ICEHS To UNSUBSCRIBE or change delivery settings. click this link: edit delivery settings To UNSUBSCRIBE from this group. send email to: ICEHS To remove yourself from this group, send email to: ICEHS To visit this group on the web, click this link: view group Powered by Thank you all, Don Olson DC, FASBE, DACS On Jun 16, 2016, at 3:58 PM, Leslie Fisher wrote: On Thursday, June I6, 2016 4:37 PM, LES FISHER {h jtt? II lwrote: Let the "Fourth Estate" continue to observe that nih et a1 can, if congressional program and funding ban is lifted, be part of the solution. Best. Les My HistoriOgraphy: Leadership in Child Injury is at: Les Fisher, M.P.H., Archivistinstorian ICEHS Section, Executive Leadership Mentor and Coach Show original message On Thursday, June 16,2016 10:50 AM, "Halpert, Leon? wrote: The biggest questions about gun violence that researchers would still like to see answered Updated by Brad Phone-T on June 15, 20176, 3:20 pm. ET invalid-:1unit-um There's still a lot we don?t know. (Shutterstoe k) There are a few big things we know about gun Violence in America: The US has way more guns per capita than any other country. It has far more gun homicides per capita than other wealthy countries. States with more guns have more gun deaths. And people with guns in their homes are more likely to be killed or to kill themselves with guns. But just as importantly, there?s an enormous amount that researchers still don?t know. There's ?nstratingly little evidence on what policies work best to reduce gun violence. (Australia saw a drop in homicides and suicides after con?scating everyone's guns in the 19905, but that would likely never happen here.) Experts still don't have a great sense of what impact stricter background checks have, or how the "informal" gun trade operates, or even how people use guns in crimes. "We have super?cial knowledge of most gun violence topics,? says Michael Nance, director of the Pediatric Trauma Center at the Children's Hospital of Philadelphia. And this ignorance has major consequences. It's awfully hard to step gun Violence if we can't even agree on basic facts about how and why it happens. This ignorance is partly by design. Since the 1990s, Congress has prevented various federal agencies from gathering more detailed data on gun violence. The Centers for Disease Control and Prevention (CDC), which has elaborate data gathering and monitoring programs for other public health crises like Ebola or heart disease, has been dissuaded from researching gun violence. The Bureau of Alcohol, Tobacco, Firearms, and Explosives QM distribute much ofits trace data for research purposes. Obamacarelimits doctors? ability to gather data on patients' gun use. To get a sense of what we're missing, I surveyed a number of researchers in the ?eld and asked them about the most pressing questions about gun violence that they'd like to see answered. Here's what they said. We still don't know some very basic facts about gun violence in America (Joshua Lott/Gerri! Images} 1) How are guns actually used? Tom Smith of NORC at the University of Chicago pointed out that "studying how guns are actually used in general" was a top research priority -- including the question of how many people use guns for defensive purposes. Other researchers pointed to related questions like: What percentage of gun owners even commit gun crimes? Why do gun accidents occur? Who's involved? Are criminals deterred by guns? These questions are a very basic starting point. 2) Can we get better data on the victims of gun violence? Nance also pointed out that our data on the victims of gun violence leaves a lot to be desired. Researchers typically rely on death data ("one of the few known and reliable data points you can't hide the bodies," he says). But without more detailed data on who actually owns guns and who is exposed to guns, it can be hard to put these deaths in context. And it would be good to have more detailed data on gun injuries that don result in death. Daniel Webster, a professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, says, "We still don't know nearly enough about nonfatal gunshot wounds, including how often they occur." That makes it much harder to get a full picture of gun violence. 3) What state laws, if any, work best to reduce gun violence? Michael Siegel, a professor of public health at Boston University, pointed to these three (broad) topics as the most pressing unanswered questions: 1. What state laws, if any, are effective in reducing rates of ?rearm Violence? 2. Is there a differential impact of state ?rearm-related laws on homicide rates among white vs. African?American persons? 3. Are higher gun ownership levels related to higher ?rearm homicide rates because of a causal relationship or because people respond to high homicide rates by purchasing ?rearms? There has already been some research on state- level gun control policies. For example, after Connecticut passed a law requiring gun purchasers to ?rst obtain a license, one study found that gm; homicides fell by 40 percent. When Missouri repealed a similar law, g? homicides increased by 23 percent. But, in part because they are retrospective and it's impossible to run controlled experiments, studies like these remain hotly debated. And there are all sorts of related questions here that (other) researchers would love to know the answers to. Do limits on high? capacity magazines reduce deaths? Do restrictions on alcohol sales make any difference? What about policies that make concealed carry licenses easier to obtain? To really dig in, researchers would have to study state policies in far more detail. But, says Siegel, that will require need much better data than is currently on offer. He'd like to see more detailed state-level data on household gun ownership, on ?rearm policies, and on how well (or not) those policies are actually enforced. 4) How do people who commit gun crimes actually get access to their guns? Cathy Barber, who directs the Means Matter Campaign at the Harvard School of Public Health's Injury Control Research Center, listed these as big unanswered questions: Pretty much every gun starts out as a legal gun. Among the guns that are actually used in crimes, how did they get there? That is, how many are used by their initial legal purchaser and did that person pass a background check? If the gun was not used by the initial purchaser, how did it get to the person who used it in a crime? Straw purchase? Gun traf?cking (buying in a state with lax laws and transportng for street sales in state with stricter laws)? Theft? (and what type of theft? Theft from individual homes or from gun shops or what? And if from people's homes, do these tend to be unsecured guns kept for self?defense purchases the gun in the bedside table?), etc., etc. I think that both gun rights people and gun control people would be interested in the very speci?c answers to these questions and ?guring out ways that we all could prevent the sort of cross-overs from legal to illegal possession and use. A couple of other researchers agreed with this line of inquiry. Here's Nance: "We need to know how weapons move in society to know how to best limit movement in the wrong direction (to those un?t to own).? And here's Smith: "Understanding the 'informal' gun market, that is guns that are acquired from others than licenses ?rearms dealers and therefore without background checks." 5) Is there any way to predict gun suicides? Nearly 21,000 peOple in the United States use guns to kill themselves each year, accounting for about two?thirds of all gun deaths. "We need to know more about how to predict who will commit suicide using a ?rearm," says Webster, "and ways to prevent Back in 2013, a report from the Institutes of Medicine added some related questionsaround this topic that needed answering: Does gun ownership affect whether people kill themselves? And what?s the best way to restrict ?rearm access to those with severe mental illnesses? 6) Does media Violence have any impact on actual violence? This question came from Brad Bushman, a professor of communication and at Ohio State University: My research focuses on media violence. We know that youth who see movie Characters drink alcohol are more likely to drink alcohol themselves. Similarly, we know that youth who see movie characters smoke cigarettes are more likely to smoke themselves. What about the impact of youth seeing movie characters with guns? Does exposure to movie characters with guns in?uence youth attitudes and behaviors about guns do they think guns are cooler? are they more willing to own or use a gun? do they think guns make males more masculine?)? 7) What do we know about stopping mass shootings? I'll add one more question to the list, which was considered a pressing research topic in the 2013 Institutes of Medicine report: "What characteristics differentiate mass shootings that were prevented from those that were carried out?" One big reason current research into US gun violence is so dismal (Kevin Cox/Gerri: Images) It's fair to call gun violence a public health crisis: Some 32,383 Americans were killed by guns in 2013. And for other health crises, like Ebola or heart disease, the CDC usually springs into action, by ?nding studies and research that look into the best policies to deal with the problem. But that's not really the case here. Back in 1996, Congress worked with the National Ri?e Association to enact a law banning the CDC from funding any research that would ?advocate or promote gun control." Technically, this wasn't a ban on all gun research (and the CDC wasn't doing advocacy anyway). But the law seemed vague and menacing enough that the agency shied away from most gun Violence research, period. Funding for gun violence research by the CDC dropped 96 percent between 1996 and 2012. Today, federal agencies spend just $2 million annually on gun Violence prevention compared with, say, $21 million ?it; the study of headaches. And the broader ?eld has withered over that period: Gun studies as a percentage of peer? reviewed research dropped 60 percent since 1996. Today there are about a dozen researchers in the country whose primary focus is on preventing gun violence. Private foundations and universities, such as the Johns Hopkins Bloomberg School of Public Health, have been partly able to pick up the slack, but private funders can rarely sustain the big, complicated data gathering and monitoring programs that the federal government can conduct. And that's a problem because, as the researchers above noted, one of the biggest lacunae in gun research is data. "If you look at other major public health issues, like Zika or Ebola or heart disease, the CDC is really a very authoritative source," says Andrew Rosenberg of the Union of Concerned Scientists. ?Privately funded research can be helpful, but there?s no substitute for the CDC. They can do monitoring programs, long?term tracking, the stuff that?s hard to fund with a one-off grant from this or that foundation." Siegel agrees: ?The CDC has a critical role to play, so the ?rst matter that needs to be resolved is restoring the CDC's ability to conduct ?rearm-related research." So will this situation ever change? After the Sandy Hook massacre in 2013, President Obama siu, ned an executive order directing the CDC to start studying "the causes of gun violence." But very little has happened in the years since. The CDC didn?t actually budget. The problem, Rosenberg says, is that so long as that congressional amendment is in place. the CDC is unlikely to move forward. Lately, there have been some calls to restore research. Republican Rep. Jay Dickey, who spearheaded the original CDC amendment, expressed remorse about the whole thing last year: wish we had started the proper research and kept it going all this time. I have regrets. If we had somehow gotten the research going, we could have somehow found a solution to the gun violence without there being any restrictions on the Second Amendmen If you would like to unsubscribe from this ListServ LIST, please send an email to leave the email Subject blank, and include the following "one" line in the Body of the email: signoff NCIPC-SDVP WOULD BANNING FIREARMS REDUCE MURDER AND A REVIEW OF INTERNATIONAL AND SOME DOMESTIC EVIDENCE DON B. AND GARY INTRODUCTION 650 I. VIOLENCE: THE DECISIVENESS OF SOCIAL FACTORS 660 II. ASKING THE WRONG QUESTION 662 DO ORDINARY PEOPLE 665 IV. MORE GUNS, LESS 6730 V. GEOGRAPHIC, HISTORICAL AND DEMOGRAPHIC PATTERNS 673 A. Demographic Patterns 676 B. MaCro-historical Evidence: From the Middle Ages to the 20'? Century 678 Later and More Specific Macro-Historical Evidence 684 D. Geographic Patterns Within Nations 685 Don B. Kates (LL.B., Yale, 1966) is an American criminologist and constitutional lawyer associated with the Paci?c Research Institute, San Francisco. He may be con? tacted at dbkatest?earthlinlmnet; 360?66??2688; 22608 N.E. 2?9?1 Ave, Battle Ground, WA 98604. Gary Mauser University of California, Irvine, is a Canadian crimi? nologist and university professor at Simon Fraser University, Burnaby, BC lCanada. He may be contacted at mausere'vsfuca, and 604-291-3652. We gratefully acknowledge the generous contributions of Professor Thomas 13. Cole (University of North Carolina at Chapel Hill, Social Medicine and Epidemiology); Chief Superintendent Colin Greenwood {West Yorkshire Constabulary, ret.); CB. Kates; Abigail Kohn {University of Sydney, Law}; David B. Kopel (Independence Institute); Professor Timothy D. Lytton [Albany Law School); Professor William Alex Priclemore (University of Oklahoma, Sociology); Professor Randolph Roth (Ohio State University, History); Professor Thomas Velk (McGill University, Eco- nomics and Chairman of the North American Studies Program); Professor Robert Weisberg (Stanford Law School); and john Whitley (University Of Adelaide, Eco? nomics). Any merits of this paper re?ect their advice and contributions,- errors are entirely ours. 650 Harvard Journal of Law Er Public Policy 30 E. Geographic Comparisons: European Gun Ownership and Murder Rates 637 F. Geographic Comparisons: Gun-Ownership and Suicide Rates 690 CONCLUSION 693 INTRODUCTION International evidence and comparisons have long been offered as proof of the mantra that more guns mean more deaths and that fewer guns, therefore, mean fewer deaths.a Unfortunately, such discussions are all too often been afflicted by misconceptions and factual error and focus on comparisons that are unrepresentative. It may be useful to begin with a few examples. There is a com- pound assertion that guns are uniquely available in the United States compared with other modern developed nations, which is why (to) the United States has by far the highest murder rate. Though these assertions have been endlessly repeated, statement is, in fact, false and statement is substantially so. Since at least 1965, the false assertion that the United States has the industrialized world's highest murder rate has been an artifact of politically motivated Soviet minimization designed to hide the true homicide rates.2 Since well before that date, the Soviet Union 1. See, GUDWIN, MURDER USA: THE Wars WE KILL EACH OTHER 281 (HTS) (?Areas with the highest proportion of gun owners also boast the highest homicide ratios; those with the fewest gun owners have the N. PETE SHIELDS, Guns DIE, PEOPLE Do 64 (1981} (quoting and endorsing an English academies remark: ?We cannot help but believe that America ought to share the basic premise of our gun legislation?that the availability of firearms breeds vio? lence"); Janice Stimerville, Gun Control as immunization, AM. MED. NEWS, Jan. 3, 1994, at 9 (quoting public health activist Katherine Christoffel, M.D.: ?Guns are a virus that must be eradicated . . . .Get rid of the guns, get rid of the bullets, and you get rid of the Deane Calhoun, Front Controversy to Prevention: Building Ef? fective Firearm Policies, PROTECTION NETWORK Nannie, Winter 1989?90, at l? are not just an inanimate object [sic], but in fact are a social ill"); see also WENDY CUKIER 6: Werner W. SIDEL, THE GLOBAL GUN EPIDEMIC: FROM Swim-roar NIGHT SPECIALS To Aka-1:75 {2006); Susan Baker, Without Guns, Do People Kill People? ?5 AM. J. PUB. 587 (1985]; Paul Cotton, Violence increasingly Viewed as Politic Health Challenge, 26? J. AM. MED. 11?1 (1992),- Diane Schetky, Children and Handguns: A Public Health Concern, 139 AM. J. D15. CHILD. 229, 230 {1985); Lois A. Fingerhut 6: Joel C. Kleinman, international and interstate Comparisons of Homicides Among Young Males, 263 J. AM. MED. 3292, 3295 (1990). 2. Sec William Alex Pridemore, Using Newly Available Hon-iicirie Data to Two About lr?iolcnce in an international Context: A Research Note, 5 STUD. 26? (2001). No.2] Would Banning Firearms Reduce Murder and Suicide? 651 possessed extremely stringent gun controls3 that were effectuated by a police state apparatus providing stringent enforcement" So successful was that regime that few Russian civilians now have firearms and very few murders involve them.5 Yet, manifest suc- cess in keeping its people disarrned did not prevent the Soviet Union from having far and away the highest murder rate in the developed world? In the 19605 and early 19705, the gun-less Sow viet Union's murder rates paralleled or generally exceeded those of gun-ridden America. While American rates stabilized and then steeply declined, however, Russian murder increased so drasti- cally that by the Early 1990s the Russian rate was three times higher than that of the United States. Between 1998-2004 (the lat- est figure available for Russia), Russian murder rates were nearly four times higher than American rates. Similar murder rates also characterize the Ukraine, Estonia, Latvia, Lithuania, and various other now-independent European nations of the former U.S.S.R.7 Thus, in the United States and the former Soviet Union transition- ing into current-day Russia, ?homicide results suggest that where 3. SEE GEORGE NEWTON d: FRANKLIN ZIMRING, FIREARMS AND VIOLENCE 133 AMERICAN LIFE: A STAFF REPORT SUBMITTED To Tl IF. NATIONAL COMMISSION ON THE CAUSES AND PREVENTION OF VIOLENCE 119I S: 11.3 4. Russian law flatly prohibits civilian possession of handguns and limits long guns to licensed hunters. Iii. For more on the stringency of enforcement, see Ray- mond Kessler, Gun Control and Political Power, 5 LAW Q. 381, 389 (1983), and Randy E. Barnett Don B. Kates, UI-rder Fire: The New Consensus on the Second Amendment, 45 EMORY L. I. 1139, 1239 {1996} {noting an unusual further element of Soviet gun policy: the Soviet Army adopted unique firearm calibers so that, even if its soldiers could not be prevented from returning with foreign gun souvenirs from foreign wars, ammunition for them would be unavailable in the Soviet Union). 5. See Pridemore, supra note 2, at 2'71. 6. Russian homicide data given in this article (for years 1965?99) were kindly sup? plied us by Professor Pridemore from his research in Russian ministry sources (on file with authors). See also infra Table 1 {reporting Russian homicide data for 2002). The highest U.S. homicide rate ever reported was 10.5 per 100,000 in 1980. See Jeffery A. Miron, Violence, Guns, and Drugs: A Analysis, 44 IS: ECON. 615, 624?25 tbl.1 (2001]. As of 2001, the rate was below 6. Id. The latest rates available for the Ukraine, Belarus, and other former Soviet nations in Europe come from the mid-19905, when all were well above 10 and most were 50% to 150% higher. Id. Note that the US. rates given above are rates reported by the FBI. There are two different sources of US. murder rates. The FBI murder data is based on reports it obtains from police agencies throughout the nation. These data are significantly less complete than the alternative {used in this article unless otherwise explicitly stated) rates of the U.S. Public Health Service, which are derived from data collected from medical examiners' offices nationwide. Though the latter data are more comprehen? sive, and the Public Health Service murder rate is higher, they have the dis- advantage of being slower to appear than the FBI homicide data. 652 Harvard Teams! of Law Er Public Policy [Vol. 30 guns are scarce other weapons are substituted in killings."? While American gun ownership is quite high, Table 1 shows many other developed nations Norway, Finland, Germany, France, Denmark) with high rates of gun ownership. These countries, however, have murder rates as low or lower than many devel- oped nations in which gun ownership is much rarer. For example, Luxemboorg, where handguns are totally banned and ownership of any kind of gun is minimal, had a murder rate nine times higher than Germany in 2002.9 Table 1: European Gan Ownership and Murder Rates (rates given are per 100,000 people and in descending order) Nation Murder Rate Rate of Gun Ownership Russia 20.54 [2002] 4,000 Luxembourg 9.01 [2002] c. 0 Hungary 2.22 [2003] 2,000 Finland 1.98 [20041 39,000 Sweden 1.8? [2001] 24,000 Poland ?1.29 [2003] 1,500 France 1.65 [2003] 30,000 Denmark 1.21 [2003] 19,000 Greece 1.12 [2003] 11,000 Switzerland 0.99 [2003] 16,000 Germany 0.93 [2003] 30,000 Norway 0.81 [2001] 36,000 Austria 0.80 [2002] 12,000 Notes: This table covers all the Continental European nations for which the two data sets given are both available. In every case, we have given the homicide data for 2003 or the closest year thereto because that is the year of the publication From which the gun ownership data are taken. Gun ownership data comes from GRADUATE INSTITUTE OF INTERNATIONAL STUDIES, SMALL ARMS Sunver 64 031.22, 65 tbl.2.3 {2003). The homicide rate data comes from an annually published report, CANADIAN CENTRE FOR JUSTICE STATISTICS, IN CANADA, JURISTAT, for the years 2001?2004. Each year?s report gives homicide sta- tistics for a dozen or so Foreign nations in a section labeled ?Homicide Rates for Selected Countries." This section of the reports gives no explana- 8. GARY KLECR, TARGETING GUNS: FIREARMS AND THEIR CONTROL 20 (199?) (dis- cussing patterns revealed by studies in the United States}. 9. Our assertions as to the legality of handguns are based on 0N CRIME PREVENTION c5: CRIM. JUSTICE, UN. ECON. IS: Soc. COUNCIL, UNITED NATIONS INTERNATIONAL STUDY ON FIREARMS REGULATION 26, tbl. 2-1 (1997 draft). No. 2] Would Banning Firearms Reduce Murder and Suicide? 653 tion of why it selects the various nations whose homicide statistics it cov? ers. Also without explanation, the nations covered differ from year to year. Thus, for instance, murder statistics for Germany and Hungary are given in all four of the pamphlets {2001, 2002, 2003, 2004), for Russia in three years {2001, 2002, and 2004), for France in two years {2001 and 2003), and for Norway and Sweden in only one year {2001). The same pattern appears when comparisons of violence to gun ownership are made within nations. Indeed, ?data on fire- arms ownership by constabulary area in England,? like data from the United States, show ?a negative correlation,?10 that is, ?where ?rearms are most dense violent crime rates are lowest, and where guns are least dense violent Crime rates are high? Many different data sets from various kinds of sources are summarized as follows by the leading text: [T]here is no consistent significant positive association be? tween gun ownership levels and violence rates: across (1) time within the United States, (2) US. cities, counties within Illinois, (4) country-sized areas like England, US. states, (5) regions of the United States, (6) nations, or (7) population subgroups . . . .12 A second misconception about the relationship between fire- arms and violence attributes Europe?s generally low homicide 10. JOYCE Les MALCOLM, GUNS AND VIOLENCE: The ENGLISH EXPERIENCE 204 (2002). 11. Hans Toch Alan Lizotte, Research and Policy: The Case for Gun Control, in ?Er SOCIAL POLICY 223, 232 (Peter Suedfeld i5: Philip E. Tetlock eds., 1992); see also id. at 234 IS: n.10 fact that national patterns show little violent crime where guns are most dense implies that guns do not elicit aggression in any meaningful way. . . .Quite the contrary, these findings suggest that high saturations of guns in places, or something correlated with that condition, inhibit illegal aggres- Approaching the matter from a different direction, the earliest data (nineteenth century on) reveals that the American jurisdictions with the most stringent gun con- trols are in general the ones with the highest murder rates. Conversely, American states with homicide rates as low as Western Europe's have high gun ownership, and impose no controls designed to deny guns to law-abiding, responsible adults. Many possible reasons may be offered for these two facts, but none Suggests that gun control reduces murder. For examination of a wide variety of studies ?nding little evidence in support of the efficacy of gun controls in reducing violence, see JAMES B. JACOBS, CAN GUN- CONTROL 111?20 (2002); KLECK, supra note 8, at 351?72,- JOHN R. LOTT, In, MORE GUNS, Less CRIME: UNDERSTANDING CRIME AND GUN CONTROL LAWS 19-20 (1998); D. WRIGHT ET AL, UNDER THE GUN: WEAPONS, CRIME AND VIOLENCE IN AMERICA 307?08 {1933); Matthew R. DeZee, Gun Control Legislation: impact and ideology, 5 LAW ll: POI Q. 36?, 369?71 (1933). 12. KLECK, supra note 8, at 22?23. 654 Harvard Journal of Law Er Public Policy 30 rates to stringent gun control. That attribution cannot be accu- rate since murder in Europe was at an all-time low before the gun controls were introduced.13 For instance, virtually the only English gun control during the nineteenth and early twentieth centuries was the practice that police patrolled without guns. During this period gun control prevailed far less in England or Europe than in certain American states which nevertheless had?and continue to have?murder rates that were and are comparatively very high.H In this connection, two recent studies are pertinent. In 2004, the US. National Academy of Sciences released its evaluation from a review of 253 journal articles, 99 books, 43 government publications, and some original empirical research. It failed to idEntify any gun control that had reduced violent crime, sui- cide, or gun accidents.15 The same conclusion was reached in 2003 by the US. Centers for Disease Control?s review of then- extant studies.? Stringent gun controls were not adopted in England and Western Europe until after World War I. Consistent with the Outcomes of the recent American studies just mentioned, these strict controls did not stEm the general trend of ever-growing violent crime throughout the post-WWII industrialized world including the United States and Russia. Professor Malcolm?s study of English gun law and violent crime summarizes that 13. Barnett tie: Kates, supra note 4, at 138?42. 14. In the period between 1900 and 1935, Arkansas, Hawaii, Michigan, Missouri, New Jersey, New York, North Carolina, Oregon, and South Carolina adopted laws variously requiring a license to own or buy a handgun or banning handgun pur? chase altogether, and ?Saturday Night bans existed in ennessee, Ar? kansas, and various other Southern states. Don B. Katee, Jr., Toward a Histort,I of Handgun Prohibition in the United States, in RESTRICTING THE LIBERAL SKlz'l?l'lCS SPEAK Our 14?15 {Dan E. Kates, Jr. ed, 1979). 15. CHARLES F. WELLFORD ET AL, RESEARCH COUNCIL, FIREARMS AND VIOLENCE: A CRITICAL REVIEW 6?10 {2804). It is perhaps not amiss to note that the review panel, which was set up during the Clinton Administration, was composed almost entirely of scholars who, to the extent their views were publicly known be- fore their appointments, favored gun control. 16. Task Force on Communit}r Preventitive Servs., Ctrs. for Disease Control, First Reports Evaluating the Effectiveness of Strategies for Preventing Violence: Firearms Laws, 52 8: Monsieur WKLY. REP. RECOMMENDATIONS a REP.) 11, to (20GB), available at The CDC is vehemently.r anti-gun and interpreted its results to show not that the "more guns equal more deat mantra is erroneous, but only that the scores of stud- ies it reviewed were inconclusivelv done. No. 2] Would Banning Firearms Reduce Murder and Suicide? 655 nation's nineteenth and twentieth century experience as fol- lows: The peacefulness England used to enjoyr was not the result of strict gun laws. When it had no firearms restrictions [nines teenth and early twentieth century] England had little vio- lent crime, while the present extraordinarily stringent gun controls have not stopped the increase in violence or even the increase in armed violence.? Armed crime, never a problem in England, has now be- come one. Handguns are banned but the Kingdom has mil~ lions of illegal firearms. Criminals have no trouble finding them and exhibit a new willingness to use them. In the deo ade after 195?, the use of guns in serious crime increased a hundredfold.13 In the late 1990s, England moved from stringent controls to a complete ban of all handguns and many types of long guns. Hundreds of thousands of guns were confiscated from those owners law-abiding enough to turn them in to authorities. Without suggesting this caused violence, the ban?s ineffective- ness was such that by the year 2000 violent crime had so in- Creased that England and Wales had Europe?s highest violent crime rate, far surpassing even the United States.? Today, Eng- lish news media headline violence in terms redolent of the dolel?ul, melodramatic language that for so long characterized American news reports?? One sapect of England's recent ex- MALCOLM, supra note 10, at 219. 18. id. at 209. 19. See Esther Bouten et al., Criminal Victimization in Seventeen industrialized Conn- h?it?s, in CRIME VICTMIZATION IN COMPAMUVE PERSPECTIVE: RESULTS FROM THE INTERNATIONAL CRIME VICTIMS SURVEY, was?zoos at 13, 15?16 (Paul Nieuwbeerta ed, 2002]. The surveys involved were conducted under the auspices of the govern- ments of each nation and the general supervision of the University of Leiden and the Dutch Ministry of Justice. 20. See, Gun Crime Crowns;r ?Like Cancer, BBC NEWS, May 2003, David Bamber, Crime 'l?reliles as Weapons and Drugs Flood British Cities, TELEGRAPH {London}, Feb. 2002, Jason Bennetto, Firearms Amnesty to Tackle Surge in Can Crime, INDEPENDENT (Lon- don), Dee. 27, 2002, at [an Burrell, Police More to Tackle Huge Rise in Can Crime, INDEPENDENT (London), Jan. 15, 2001, at 3; Daniel Foggo Carl ?We Are Reelingr with the Murders, We Are in a Crisis with Major Crime,? SUNDAY TELEGRAPH (London), Mar. 13, 2005, at 4; Johann Hari, The British Become Trigger Happy, NEW STATESMAN (London), Nov. 5, 2001, at 35; Philip Johnston, Gun Crime Rises Despite Danblane Pistol Ban, DAILY TELEGRAPH (London), Jul. 2001, at 05; David Leppard ti: Rachel Dobson, Murder Rate Soars to Highest ?n a Century, SUNDAY TIMES (Lon- ass Harvard Journal of Low Er Public Policy [Vol. 30 perience deserves note, given how often and favorably advo- cates have compared English gun policy to its American coun- terpart over the past 35 years.? A generally unstated issue in this notoriously emotional debate was the effect of the Warren Court and later restrictions on police powers on American gun policy. Critics of these decisions pointed to soaring American erirne rates and argued simplistically that such decisions caused, or at least hampered, police in suppressing crime. But to some supporters of these judicial decisions, the example of England argued that the solution to crime was to restrict guns, not civil liberties. To gun control advocates, England, the Cradle of our liberties, was a nation made so peaceful by strict gun control that its police did not even need to carry guns. The United States, it was argued, could attain such a desirable situation by radically reducing gun ownership, preferably by banning and confiscating handguns. The results discussed earlier contradict those expectations. On the one hand, despite constant and substantially increasing gun ownership, the United States saw progressive and dramatic re- ductions in criminal violence in the 1990s. On the other hand, the same time period in the United Kinngm saw a constant and dramatic increase in violent crime to which England's response was ever-more drastic gun control including, eventually, banning and confiscating all handguns and many types of long guns.22 Nevertheless, criminal violence rampantly increased so that by 2000 England surpassed the United States to become one of the developed world?s most violence-ridden nations. don), Oct. 13, 2002, at 1; Adam Mitchell, Gun Killings Double (PS Police Claim Progress, DAILY TELEGRAPH (London), Aug. 2001, at 13301111 Steele, Police Fear :1 New Crime Wnoe as School?Age Muggers Graduate to Guns, DAILY TELEGRAPH (London), Jan. 3, 2002, at 04,- ]on Ungoed?Thomas, Killings Rise us 3m illegal Guns Flood Britain, DAY TLMES (London), jan. 16, 2000; Peter thlridl, Britain?s Tough Gun. Control Lows Ternied Total Failure: Lend ofl-lope and Gunmnning, PUNCH MAG, May 3, 2000. 21. Sec, 2.3., CARL BAKAL, THE TO BEAR ARMS 10?11, 31, 229 (1966); RAMSEY CLARK, IN AMERICA 104?05, 109 {19370}; AMITAI ETZIONI 8: RICHARD KEMP, TECI-INDIDGICAL SHORTCUTS TO SOCIAL 136 {1973); Natl Coalition to Ban Handguns, A Shooting Gallery Called America (undated, unpaginated pamphlet},- supra note I, at 63?154; Irwin Bloch, Gun Control Would Reduce Crime, re? printed in Would Gun Control Reduce Crime 19'?r (David Bender cd., 1989); Robert S. Drinan, Banning Handguns lr?llonlnr Reduce Crime, reprinted in GUNS ll: CRIME 45?46 (Tarara Roleff ed., 1999}. 22. supra note 10, at 164-216. We should clarify that the twin trends toward more violent crime and more gun control began long before the 19905. See ill. No. 2] Would Banning Firearms Reduce Murder and Suicide? 657'r To conserve the resources of the inundated criminal justice system, English police no longer investigate burglary and ?mi- nor assaults.?23 As of 2006, if the police catch a mugger, robber, or burglar, or other ?minor? criminal in the act, the policy is to release them with a warning rather than to arrest and prosecute them.24 It used to be that English police vehemently opposed the idea of armed policing. Today, ever more police are being armed. Justifying the assignment of armed squads to block roads and carry out random car searches, a police commander asserts: ?It is a massive deterrent to gunmen if they think that there are going to be armed police.?25 How far is that from the rationale on which 40 American states have enacted laws giv- ing qualified, trained citizens the right to carry concealed guns? Indeed, news media editorials have appeared in England argu- ing that civilians should be allowed guns for defense??9 There is currently a vigorous controversy over proposals (which the Blair government first endorsed but now opposes) to amend the law of self-defense to protect victims from prosecution for using deadly force against burglars.2T The divergence between the United States and the British Commonwealth became especially pronounced during the 23. Daniel Foggo, Don?t Bother About Burglary, PoliCe Told, SUNDAY TELEGRAPH (LONDON), Ian. 12, 2003, at (?Police have been ordered not to bother investigating crimes such as burglary, vandalism and assaults unless evidence pointing to the culprits is easily available, The Sunday Telegraph can reveal. Under new guidelines, officers have been informed that only "serious" crimes, such as murder, rape or so- called hate crimes, should be investigated as a matter of course. In all other cases, unless there is immediate and compelling evidence, such as fingerprints or DNA material, the crime will be listed for no tu rther action"). 24. Steve Doughty, Let OE With Caution Police Told, DAILY MAIL (London), Apr. 3, 2006, at 4. 25. Matthew Beard, Armed Police to Man Checkpoints in London as Drng~Relatetl Crime Soars, INDEPENDENT {London}, Sept. 7, 2002, at 2. 26 See Simon Heifer, if the State Fails Us, We Must Defend Ourselves, TELEGRAPH ONLFNE {London}, Feb. 24, 2002, see also Ian Bell, Dnhlane Made Us All Think About Gun Control . . . So What Went Wrong?, SUNDAY HERALD (Scotland), Feb. 24, 2007, Comment, The Night My Daughter Was Stabbed?Ami My Liberal Instincts Died, DAILY NEIL (London), Mar. 5, 2007, See Melissa Kite, Tories Launch Bill to Give Householders the Power to Tackle In? truders, SUNDAY TELEGRAPH (London), Dec. 26, zone, at 4; see also Renee Lerner, The Worldwide Popular Retell Against Proportionalit?t,r in Self-De?ner: Law, 2 IL. ECON. 8.: {2007). 658 Harvard Journal of Law Er Public Policy 30 19805 and 1990s. During these two decades, while Britain and the Commonwealth were making lawful firearm ownership increasingly difficult, more than 25 states in the United States passed laws allowing responsible citizens to carry concealed handguns. There are now 40 states where qualified citizens can obtain such a handgun permit.? As a result, the number of US. citizens allowed to carry concealed handguns in shopping malls, on the street, and in their cars has grown to 3.5 million men and women.29 Economists John Lott and David Mustard have suggested that these new laws contributed to the drop in homicide and violent crime rates. Based on 25 years of corre- lated statistics from all of the more than 3,000 American coun- ties, Lott and Mustard conclude that adoption of these statutes has deterred criminals from confrontation crime and caused murder and violent crime to fall faster in states that adopted this policy than in states that did not.? 28. In March 2006, Kansas and Nebraska became the 39th and 40th states, respec- tively, to pass ?shall issue" concealed carry legislation. In Kansas, the state legisla- ture voted to overturn the governor?s veto of the bipartisan legislation. Kansas House Overrides Concealed?Gans?Bill Veto, MORNING NEWS, Mar. 24, 2006. In Ne? braska, the governor signed the bill as passed by the state legislature. Kevin O?Hanlon, Concealed?Weapons Bill Adopted, LINCOLN JOURNAL STAR, Mar. 31, 2006. 29. Don Kates, The LimiteaI Importance of Gun Control from a Criminological Perspec? tive, in SUING THE GUN INDUSTRY: A BATTLE AT THE Caossaoaos or GUN CONTROL AND MASS TORTS 62, 64 (Timothy D. Lvtton ed ., 2005). 30. See John R. Lott Jr. 8.: David B. Mustard, Crime, Deterrence, and Riglit-lo-Carry Concealed Handguns, 26 J. LEGAL STUD. 1, 1 (1997),- see also JOHN R. LOTT, Ja., Moss GUNS, LFSS CRIME l9 {2d ed. 2000). This conclusion is vehemently rejected by anti- gun advocates and academics who oppose armed self?defense. See, Albert W. Alschuler, Two Guns, Four Grins, Six Guns, More Guns: Does Armin the Public Radars Crime?, 31 VAL. U. L. REV. 365, 366 Ian Ayn-es ll: John J. Donohue ll], Shooting Down the rMore Guns, Less Crinie' Hypothesis, 55 STAN. L. REV. 1193, 1197 {2003); Dan A. Black 6: Daniel S. Nagin, Do Right?to?Carry Louis Deter Violent riine?, 2? J. LEGAL STUD. 209, 209 (1998}; Franklin Zimring Gordon Hawkins, Concealed Handguns: Tlie Counterfeit Deterrent, RESPONSIVE COMMUNITY, Spring 199?, at 46; Daniel W. Webster, The Claims Tlial Right?lo?Carry Laws Reduce 1Violent Crime Are Unsabslanli? area (Johns Hopkins Center for Gun Policy and Research, 199?]. Several critics have now replicated Lott's work using additional or different data, additional control variables, or new or different statistical techniques the}.r deem superior to those Lott used. Interestingly, the replications all confirm Lott's general conclusions; some even find that Lott underestimated the crime-reductive effects of allowing good citizens to carry concealed guns. See Jeffrey A. Miron, Violence, Cans, and Drugs: A Cross-Country Analysis, 44 ll: ECON. 615 {2001},- David B. Mustard, The impact ofGan Laws on Police Deaths, 44 J.L. cl: ECON. 635 {200i John R. Lott, Jr. 8: John E. Wl'iitlev, Safe?Storage Gun Laws: Accidental Deaths, Suicides, and Crime, 44 St ECON. 659 {2001); Thomas B. Marvell, The impact of Banningr Juvenile Gan Posses? sion, 44 J.L. 8.: ECON. 691 (2001); JeffrEj.,r 5. Parker, Guns, Crime, and Academics: Sonic Re?ections on the Gun Control Debate, 44.- J.L. ECON. 715 {2001); Bruce L. Benson 8: No.2] Would Banning Firearms Reduce Murder and Suicide? 659 As indicated in the preceding footnote, the notion that more guns reduce crime is highly controversial. What the contro- versy has obscured from view is the corrosive effect of the Lott and Mustard work on the tenet that more guns equal more murder. As previously stated, adoption of state laws permit- ting millions of qualified citizens to carr}r guns has not resulted in more murder 0r violent crime in these states. Rather, adop- tion of these statutes has been followed by very significant re- ductions in murder and violence in these states. To determine whether this expansion of gun availability caused reductions in violent crime requires taking account of various other factors that might also have contributed to the decline. For instance, two of Lott's major critics, Donohue and Levitt, attribute much of the drop in violent crime that started in 19905 to the legalization of abortion in the 1970s, which they argue resulted in the non-birth of vast numbers of children who would have been disproportionately involved in violent crime had they existed in the 19905.31 The Lott-Mustard studies did not address the Donohue? Levitt thesis. Lott and Mustard did account, however, for two peculiarly American phenomena which many people believed may have been responsible for the 1990s crime reduction: the dramatic increase of the United States prison population and the number of executions. The prison population in the United States tripled during this time period, jumping from approxi- mately 100 prisoners per 100,000 in the late 19705 to more than 300 per 100,000 people in the general population in the early 19905.32 In addition, executions in the United States soared Brent D. Mast, Prioately Produced General Deterrence, 44 IL. 8: ECDN. T25 (2001); David E. Olson St Michael D. Maitz, Riglit-io?Carry Concealed Weapon Laws and Homi? ride in Large US. Counties: The E??ect on Weapon Types, Victim Characteristics, and View l?lm?O?-?lld?i? Relationships, 44 IL. ll: ECDN, 74'? [2001); Florenz Plassmann 32: T. Nicolaus 'I?idernan, Does the Right to Carry Concealed Handguns Deter Countable Cranes? Only a Count Analyst's Can Say, 44J.L. IS: ECDN. 3771 (2001}; Carlisle E. Moody, Testingr for the Effects of Concealed Weapons Laws: Speci?cation Errors and Robustness, 44 J.L. ll: ECON. T09 (2001); see also Florenz Plassman a John Whitley, Confirming ?More Guns, Less Crime,? 55 STAN. L. REV. 1313, 1316 (2003). In 2003, Lott reiterated and extended his findings, which were subsequently endorsed by three Nobel laureates. See Ions: R. LOTT, In, THE BIAS Aomusr Guns (2003). 31. See John J. Donohue l'Il sit Steven D. Levitt, The Impact of Legalimi Abortion on Crime, 116 Q. J. ECDN. (2001). 32. See Bureau of Justice Statistics, Key Facts at a Glance: Incarceration Rate, 1980? 2004 (Oct. 23, 2005), citing ALLEN BECK 15: PAIGE HARRISON, BUREAU OF JUSTICE STATISTICS, CORRECTIONAL POPULATIONS 1N THE UNITED STATES 1997 [2000), available at 660 Harvard lea-real of Law 8? Public Policy [Vol. 30 from approximately 5 per year in the early 19805 to more than 27 per year in the early 1990s.33 Neither of these trends is re- flected in Commonwealth countries. Although the reason is thus obscured, the undeniable result is that Violent crime, and homicide in particular, has plum- meted in the United States over the past 15 years.? The fall in the American crime rate is even more impressive when com- pared with the rest of the world. In 18 of the 25 countries sur- veyed by the British Home Office, violent crime increased during the 19905.35 This contrast should induce thoughtful people to wonder what happened in those nations, and to question policies based on the notion that introducing increas- ingly more restrictive firearm ownership laws reduces violent Crime. Perhaps the United States is doing something right in promoting firearms for law-abiding responsible adults. Or per- haps the United States' success in lowering its Violent crime rate relates to increasing its prison population or its death sen- tences?t Further research is required to identify more precisely which elements of the United States? approach are the most important, or whether all three elements acting in concert were necessary to reduce violent Crimes. I. VIOLENCE: THE DECISIVENESS OF SOCIAL FACTORS One reason the extent of gun ownership in a society does not spur the murder rate is that murderers are not spread evenly throughout the population. Analysis of perpetrator studies shows that Violent criminals?especially murderers?"almost f, and ALLEN BECK PAIGE HARRISON, BUREAU or jusnce PRISONERS IN 2004 (2005), available at 33. THOMAS BONCZAR TRACY L. SNELL, BUREAU OF JUSTICE STATISTICS BULLETIN, PUNISHMENT 2003, [2004), available at 34. See generally FBI, VIOLENT CRIME, violent_crimeiindex.himl; FBI, CRIME IN THE UNITED BY VOLUME AND RATE. 100,000 INHABITANIE, 1936?2005, 35. Sea Gordon Barclay et al., International Comparisons of Criminal lastio: Statistics I999, HOME OFFICE STAT. BULL. (Research Development and Statistics, U.K. Home Office, London, 2001, available at hosb601.pdf. 30. Several recent studies by economists calculate that each execution deters the commission of 19 murders. See Cass R. Sunstein Adrian Vermuele, ls Capital Puri? islmiant Marally Required? Acts, Omissions, Life-Lilia Tradayj?s, 58 STAN. L. REV. 903 (2005). No. 2] Would Banning Firearms Reduce Murder and Suicide? 661 uniformly have a long history of involvement in criminal behav- ior."3? So it would not appreciably raise violence if all law- abiding, responsible people had firearms because they are not the ones who rape, rob, or murder?? By the same token, violent crime would not fall if guns were totally banned to civilians. As the respective examples of Luxembourg and Russia suggest,? individuals who commit violent crimes will either find guns despite severe controls or will find other weapons to use. 45' Startling as the foregoing may seem, it represents the cross- national nerm, not some bizarre departure from it. If the man- tra ?more guns equal more death and fewer guns equal less death" were true, broad based cross-national comparisons should show that nations with higher gun ownership per cap- ita consistently have more death. Nations with higher gun ownership rates, however, do not have higher murder or sui- cide rates than those with lower gun ownership. Indeed many high gun ownership nations have much lower murder rates. Consider, for example, the wide divergence in murder rates among Continental European nations with widely divergent gun ownership rates. The non-correlation between gun ownership and murder is reinforced by examination of statistics from larger num- bers of nations across the developed world. Comparison of ?homicide and suicide mortality data for thirty-six nations (including the United States) for the period 1990:1995? to gun ownership levels showed ?no significant (at the 5% level) association between gun ownership levels and the to- tal homicide rate.? Consistent with this is a later European study of data from 21 nations in which ?no significant corre- lations [of gun ownership levels] with total suicide or homi- cide rates were found.?42 See Delbert 5. Elliott, Life-Tin?eateuiug Violence is Primarily a Crime Problem: A Focus on Prevention, 69 COLD. L. REV. 1089 (1998) (emphasis added). 38. See infra Part 111. 39. See supra notes 3?9 and Table l. 40. See supra Table 1 and infra Tables 2?3. 41. KLECK, supra note 8, at 254. The study also found no correlation to suicide rates. id. 42. Martin Killias et al., Guns, Violent Crime, and Suicide in 21 Countries, 43 CAN. J. CRIMINDLOGY (it CRIM. 429, ?130 {2001}. it bears emphasis that the authors, who are deeply anti-gun, emphasize the ?very strong correlations between the presence of guns in the home and suicide committed with gun"?as if there were some import 662 Harvard Journal of Law Er Public Policy 30 ll. ASKING THE WRONG QUESTION However unintentionally, the irrelevance of focusing on weaponry is highlighted by the most common theme in the more guns equal more death argument. Epitomizing this theme is a World Health Organization (WHO) report assert- ing, ?The easy availability of firearms has been associated with higher firearm mortality rates.?13 The authors, in noting that the presence of a gun in a home corresponds to a higher risk of suicide, apparently assume that if denied firearms, potential suicides will decide to live rather than turning to the numerous alternative suicide mechanisms. The evidence, however, indicates that denying one particular means to people who are motivated to commit suicide by social, eco- nomic, cultural, or other circumstances simply pushes them to some other means.44 Thus, it is not just the murder rate in gun-less Russia that is four times higher than the American rate; the Russian suicide rate is also about four times higher than the American rate.?15 to the death being by gun rather than by hanging, poison, or some other means. id; see also infra Part 43. WORLD HEALTH ORGANIZATION, SMALL ARMS AND GLOBAL 11 (2001) (emphasis added). This irrelevancy is endlessly repeated. Sec, Wendy Cukier, Small Arms and Light Weapons: A Public Health Approach, 9 WORLD AFF. 261, 2613, 26? (2002) (?Research has shown that rates of small arms death and injury are linked to small arms accessibility . . . . in industrialized countries, studies have shown that accessibility is related to ?rearm death rates . . . . Other approaches have examined the rates of death from ?rearms across regions, cities, high income coun- tries, and respondents to victimization surveys." (emphasis added} (internal cita? tions omitted); see also Neil Arya, Confronting the Small Arms Pandemic 324 BRITISH MED. J. 990 (2002),- E.G. Krug et al., Firearm?Related Deaths in the United States and 35 Other High and Upper?Middle?lncome Countries, 2? EPIDEMIOLOGY 214 (1988). 44. Sec JACOBS, supra note 11, at 120 the Brady Law did have the effect of modestly reducing ?rearms suicides . . . this effect was completely offset by an in? crease of the same magnitude in non?rearm suicide" resulting in the same number of deaths]; see also KI..F.CK, supra note 8, at 265?92 (summarizing and reviewing stud- ies regarding guns and suicide). Indeed, though without notingr the significance, the WHO report states that out of sample of 52 countries, ??rearms acmunted for only one-fifth of all suicides, just ahead of poisoning. . . . [Self-] strangulation, hang- ing] was the most frequently used method of suicide." WORLD HEALTH ORGANIZATION, supra note 43, at 3. 45. In 1999, the latest year for which we have Russian data, the American suicide rate was 10.? per 100,000 people, while the Russian suicide rate was almost ~11 per 100,000 people. William Alex Pridemore Andrew L. Spivak, Patterns of Suicide Mortality in Russia, 33 SUICIDE .5: Benavloa 132, 133 {2003}; Donna L. l-loyert ct al., Deaths: Final Data for 1999, VITAL STAT. REE, Sept. 21, 2001, at 6. No.2] Would Banning Firearms Reduce Murder and Suicide? 663 There is no social benefit in decreasing the availability of guns if the result is only to increase the use of other means of suicide and murder, resulting in more or less the same amount of death. Elementary as this point is, proponents of the more guns equal more death mantra seem oblivious to it. One study asserts that Americans are more likely to be shot to death than people in the world?s other 35 wealthier na- tions.? While this is literally true, it is irrelevant?except, perhaps to people terrified not of death per se but just death by gunshot. A fact that should be of greater concern?but which the study fails to mentionwis that per capita murder overall is only half as frequent in the United States as in sev- eral other nations where gar: murder is rarer, but murder by strangling, stabbing, or beating is much more frequent.? Of course, it may be speculated that murder rates around the world would be higher if guns were more available. But there is simply no evidence to support this. Like any specu- lation, it is not subject to conclusive disproof; but the Euro- pean data in Table 1 and the studies across 36 and 21 nations already discussed show no correlation of high gun owner- ship nations and greater murder per capita or lower gun ownership nations and less murder per capita.? To reiterate, the determinants of murder and suicide are basic social, economic, and Cultural factors, not the preva- lence of some form of deadly mechanism. In this connection, recall that the American jurisdictions which have the highest violent crime rates are precisely those with the most strin- gent gun controls.49 This correlation does not necessarily as. See ng et al., supra note 42, at 218?19. id. at 216. Two of those nations, Brazil and Estonia, had more than twice the overall murder rates of the United States. David C. Stolinsky, America: The Most Violent Nation 5 MED. SENTJNEL 199, 200 (2000}. Readers may question the value of comparing the United States to those particular nations; however, this comparison was first suggested by Krug. Krug et al., supra note as, at 215 (using thirty-six coun- tries, having among the highest GNP per capita as listed in the World Bank's 1994 World Development Report). All we have done is provide full murder rate informa? tion for these comparisons. 4-8. KLECK, supra note 8, at 254-; Killias et al., supra note at 430. 49. See infra notes 128-313 and accompanying text. For at least thirty years, gun ad- vocates have echoed in more or less identical terms the observation that twenty percent of American homicide is concentrated in four cities with the nation's most restrictive gun laws. See Firearms Legislation: Hearing Before the Subcomm. on Crime of the H. Comm. an the Judiciary, 94th Cong. 2394 (IQFB) (statement of Neal Knox). In October 2000, the head of a gun advocacy group ridiculed a Handgun Control 664 Harvard Jloo-real of Law Er Public Policy [Vol. 30 prove gun advocates? assertion that gun controls actually encourage crime by depriving victims of the means of self- defense. The explanation of this correlation may be political rather than criminological: jurisdictions afflicted with violent crime tend to severely restrict gun ownership. This, how- ever, does not suppress the crime, for banning guns cannot alleviate the socio?cultural and economic factors that are the real determinants of violence and crime rates. 5? Table 2: Murder Rates of ampeaa Nations that Baa Handguns as Compared to Their Neighbors that Allow Handguns [rates are per 100,000 persons) Nation Handgun Policy Murder Rate Year A. Belarus banned 10.40 late 19905 [Neighboring countries with gun law and murder rate data available] Poland allowed 1.98 2003 Russia banned 20.54 2002 B. Luxembourg banned 9.01 2002 {Neighboring countries with gun law and murder rate data available] Belgium allowed 1.20 late 19903 France allowed 1.65 2003 Germ any al owed 0.93 2003 C. Russia banned 20.54 2002 {Neighboring countries with gun law and murder rate data available] Finland allowed 1.98 2004 Norway allowed 0.81 2001 Notes: This table covers all the European nations for which the infor- mation given is available. As in Table 1, the homicide rate data comes from an annually published report, CANADIAN CENTRE Josnce STATISTICS, l-Iorvacros IN CANADA, JURISTAT. Once again, we are not arguing that the data in Table 2 shows that gun control causes nations to have much higher "scorecard" for its misleading attempts to inversel],F correlate violent crime rates to the extent of the various states? gun controls. 1' ie points out that, in fact, the. states with the most restrictive gun laws consistently have higher murder rates than states with less restrictive laws, while those with the least controls had the lowest homi- cide rates. Larry Pratt, Scorecard (2000), see also infra note 13]. 50. It is noteworthy that the correlation between more gun control and more crime seems to hold true in other nations, though much less strikingly than in the United States. See Miron, supra note 30, at I528. No. 2] Would Banning Firearms Reduce Murder and Suicide? 665 murder rates than neighboring nations that permit handgun ownership. Rather, we assert a political causation for the ob- served correlation that nations with stringent gun controls tend to have much higher murder rates than nations that allow guns. The political causation is that nations which have vio- lence problems tend to adopt severe gun controls, but these do not reduce violence, which is determined by basic socio? cultural and economic factors. The point is exemplified by the conclusions of the premier study of English gun control. Done by a senior English police official as his thesis at the Cambridge University Institute of Criminology and later published as a book, it found (as of the early 19705), ?Half a century of strict controls. . .has ended, pErversely, with a far greater use of [handguns] in crime than ever before." 5" The study also states that: No matter how one approaches the figures, one is forced to the rather startling conclusion that the use of firearms in crime was very much less [in England before 1920] when there were no controls of any sort and when anyone, con- victed criminal or lunatic, could buy any type of firearm without restriction.52 Of course the point of this analysis is not that the law should allow lunatics and criminals to own guns. The point is that vio- lence will be rare when the basic socio-cultural and economic determinants so dictate; and conversely, crime will rise in re- sponse to changes in those determinants?without much re- gard to the mere availability of seme particular weaponry or the severity of laws against it. DO ORDINARY PEOPLE The ?more guns equal more death? mantra seems plausible only when viewed through the rubric that murders mostly in- volve ordinary people who kill because they have access to a firearm when they get angry. If this were true, murder might well increase where people have ready access to firearms, but the available data provides no such correlation. Nations and 51. COLIN GREENWOOD, FIREARMS CONTROL: A Smart or ARMED CRIME AND FIREARMS CONTROL IN ENGLAND AND Wares 243 (1972). Bald. 666 Harvard Jlouraal of Law Er Public Policy 30 areas with more guns per capita do not have higher murder rates than those with fewer guns per capita.53 Nevertheless, critics of gun ownership often argue that a ?gun in the closet to protect against burglars will most likely be used to shoot a spouse in a moment of rage . . . . The problem is you and ate?laro?aliidiag folks;?54 that banning handgun posses- sion only for those with criminal records will ?fail to protect us from the most likely source of handgun murder: ordinary citi- zens;"55 that ?most gun-related homicides . . . are the result of impulsive actions taken by individuals who have little or no criminal background or who are known to the victims;?56 that ?the majority of firearm homicide[s occur] . . .not as the result of criminal activity, but because of arguments between people who know each other?? that each year there are thousands of gun murders "by law-abiding citizens who might have stayed law-abiding if they had not possessed firearms.?53 These comments appear to rest on no evidence and actually con? tradict facts that have so uniformly been established by homicide studies dating back to the 1890s that they have become ?crimino- logical axioms.?59 Insofar as studies focus on perpetrators, they show that neither a majority, nor many, nor virtually any murder- ers are ordinary ?law-abiding citizens?? Rather, almost all mur- derers are extremely aberrant individuals with life histories of violence, substance abuse, and other dangerous behaviors. ?The vast majority of persons involved in life- threatening violence have a long criminal record with many prior contacts with the justice ?Thus homicide?[whether] of a 53. See supra Tables 1?2 and notes 10?15;see infra Table 3 and notes 125?123?. 54. David Kairys, A Carriage in the Name off-?readout, PHILADELPHM INQUIRER, Sept. 12, 1988, at A15 (emphasis added}, quoted in Frank J. Vandall, A Preliminary Consid? eratioa of issues Raised in the Firearms Sellers humanity Bill, 33 AKRON- L. REV. 113, 118 n.28 (2005). 55. Nidmlas Dixon, Why We Should Baa Handguns in the United States, 12 ST. LOUIS U. PUB. L. REV. 243, 265?66 {1993) {emphasis added), quoted in 1v?andall, supra note 54, at 119, n.32. 56. J. Serrzaa, THE POerlcs or GUN CONTROL 147 (3rd ed. 1995) (empha? sis added}. 5'7. Violence Policy Center, Who Dies? A Look at Firearms Death and Injury in America, (last visited Nov. 2006). 58. Natl Coalition to Ban Handguns, supra note 21 (emphasis added). 59. See David M. Kennedy it: Anthony Braga, Homicide in Minneapolis: Research for Problem Solving, 2 HDMICIDE STUD. 263, 26? (1998). of}, See Elliott, supra note 37, at 1093. ea. id. No.2] Would Banning Firearms Reduce Murder and Suicide? 66? stranger or [of] someone known to the offender??is usually part of a pattern of violence, engaged in by people who are known . . . as violence pronefm Though only 15% of Americans over the age of 15 have arrest records,63 approximately 90 percent of ?adult mur- derers have adult records, with an average adult criminal career [involving crimes committed as an adult rather than a child] of six or more years, including four major adult felony These national statistics dovetail with data from local nineteenth and twentieth century studies. For example: victims as well as offenders [in 1950s and 1960s Philadelphia murders] . . . tended to be people with prior police records, usually for violent crimes such as as- saultf?j? ?The great majority of both perpetrators and victims of [19705 Harlem] assaults and murders had previous [adult] arrests, probably over 80% or more?) Boston police and probation officers in the 19905 agreed that of those juvenile-perpetrated murders where all the facts were known, virtually all were committed by gang members, though the killing was not necessarily gang- directed. 6? One example would be a gang member who stabs his girlfriend to death in a fit of anger.? Regardless of their arrests for other crimes, 80% of 199? Atlanta murder arrestees had at least one earlier drug offense with 70% having 3 or more prior drug of- tenses.?g A New York Times study of the 1,662 murders committed in that city in the years 2003?2005 found that ?[m]ore than 90 percent of the killers had criminal records.?m Baltimore police ?gures show that ?92 percent of murder suspects had [prior] criminal records in Several of the more recent homicide studies just reviewed 62. GERALD D. ROBIN, VIOLENT CRIME AND GUN CONTROL 48 (1991) (quoting Gary Kleck, The Assatnptions of Gun Control, in FIREARMS AND VIOLENCE 23, 43 {Don B. Kates ed., 1934)). 63. Mark Cooney, The Decline of Elite Homicide, 3'5 CRIMINOIDGY 381, 386 {1997]. 64.Ga1 Cc: Villar, Carmen S. (CDCIODIDCQ Hoffmann, Lauren Richards, Bridget goy>; Lubar, Debra Subject: RE: URGENT FOR APPROVAL: Support for Gun Violence Research Senator Thomas Carper Folder 2353690 it From: Dahlberg, Linda L. Sent: 4 Apr 2015 15:37:20 +0000 To: Reimels, Elizabeth Cc: Belser-Vega, Elizabeth Subject: RE: Action - please review proposed responses to qs 1-3: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Attachments: Carper.docx Hi Beth (bll5l Linda From: Reimels, Elizabeth Sent: Monday, April 04, 2016 10:41 AM To: Dahlberg, Linda L. (CDCIONDIEHINCIPC) Cc: Belser-Vega, Elizabeth Subject: Action - please review proposed responses to qs 1-3: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Linda, I wanted to give vou an opportunity to review our proposed responses to the other questions in the Carper response, which were prepared while you were out. I have included the raw info we received from program and a proposed response which is clearly labeled as such. Please let me know if you have any questions. 1. ibliil ifbiiSi Halli) If l'bll'i'l Proposed response see additions to the original list in red: lbl(5l (W5) (MG) Proposed response] (13K Response from progranl ([3151 (MG) 2. (W5) Proposed response (W5) (bus) I iiwii?i From: Reimels, Elizabeth Sent: Friday, April 01, 2016 1:15 PM To: Belser~Vega, Elizabeth Subject: RE: Action: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research (lot 5) From: Reimels, Elizabeth Sent: Friday, April 01, 2016 12:57 PM To: Belser-Vega, Elizabeth Subject: Re: Action: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Here is what I sent forward to Melissa who was going to check back with Elizabeth 5 before I reached back out to Kristen Holland ibll 5i ibli5l We haven't received all the answers back yet for a full review, which is what I was going to have you and Linda review again. Sorry I didn?t know you wanted to review these before I sent back to Elizabeth S. I figured they were ok since Torn reviewed them. Sorry! From: Cyril, Melissa R. (CDCKONDIEHINCIPC) Sent: Wednesday, March 30, 2016 6:33 PM To: Belser?Vega, Elizabeth Subject: RE: Action: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Hmm.. let me check with E5 before you push back. Will let you know. Thank you! From: Belser?Vega, Elizabeth Sent: Wednesday, March 30, 2016 5:49 PM To: Cyril, Melissa R. co: f0 cdc. ova- Subject: Re: Action: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Hi there! So sorry this is late! I (bit 3) I- A ib'llf?l Thank you! the EBV From: Cyril, Melissa R. (CDCIONDIEHJNCIPC) Sent: Monday, March 28, 2015 2:11:32 PM Eastern Time (US 3: Canada) To: DVP Policy Requests (CDC) Subject: FW: For Action Due by 1: Letter Senate HSGAC Ranking Member Carper regarding gun violence research Hi I have a couple of questions highlighted for you as we are working on a congressional response to Senator Ca rper?s inquiries. lb ii 5) i (bii'?i pas hoping to get these back by C03 Wednesday but let me know if that deadline is not feasible! Thank you so much! (bill 5i Here are some others you could add: ibll5] Thanks so much for your help! Best, Melissa From: Solhtalab, Elizabeth Sent: Monday, March 28, 2016 10:47 AM To: DVP Policy Requests (CDC) IWillia ms?Johnson, Mildred M. Greenspan, Arlene ; Newton, Donovan Cc: Cattledge, Gwendolyn Cyril, Melissa R. Patterson, Sara 5. Cc: Newton, Donovan Cattledge, Gwendolyn (CDCIONDIEHXNCIPC) Cyril, Melissa R. Patterson, Sara 5. Connelly, Erin Lenard, Courtney (CDCIONDIEHXNCIPC) Asekun, Adeyelu Subject: For Action Due by 4/1: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Importance: High Hi everyone, Attached is a letter from Senator Carper (D-DE) from the Committee on Homeland Security and Governmental Affairs {ranking member). The letter is in reference to firearm violence activities and he poses 11 questions to us that we must respond to by M15. Keeping in mind that all questions will have to go through clearance at every level within CDC and HHS, I would like to have responses compiled by no later than April tblti?l (b it lint s1 you feel like I mistakenly assigned a response, please let me know. 7. Each year. CDC '5 Division of Violence Prevention solicits investigator-initiated research via an 1" Grant Program Announcement. The language in these announcements signals to grant-seeking public health researchers the researclt priorities of the CDC and its Division of Violence Prevention. Please describe any Division of Violence Prevention's ROI Grant Program Announcements related to gun violence research put forward from 1996 to tlte present. (bit?Si 8. The National Violent Death Reporting System collects and combines data from multiple sources to provide states and communities with a more complete record of the circumstances surrounding violent deaths. Participation from all 50 states would signi?cantly increase the amount of data available to the National Violent Death Reporting System and. thereby, improve its effectiveness. In how many states has the National 1Violent Death Reporting System been implemented? How man}r states have applied to be included in this system? What circumstances have prevented all state applicants from being added to the National Violent Death Reporting System? (131(5) I 9. .Has the CDC previously entered into any agreements with the National Rifle Association offering to provide advanced notice of any publication on the subject of gun violence?? If so, please provide a description of an};r such agreements as well as communications and documents memorializing the agreementsl (h it 5} It). From l996 to the present. has the CDC instructed any employee or researcher to not conduct scienti?c research on gun violence? Has the CDC instructed any employees or researchers to re-write reports submitted for publication to avoid using any variation of the word (13115 st all for review. I. 1. What remedies are available to CDC researchers who believe their scientific research has been inappropriately suppressed or discouraged? Please describe any review or appeals processes and include a list of the of?ces or review boards who would address any such concerns. (bit 5] (b it 5 '1 Thanks, Elizabeth Elizabeth liolhtalabJr MFA Legislative Issues Management Team Lead Office of Policy and Partnerships National Center for Injury Prevention and Control Centers for Disease Control and Prevention p: 770.438.6151 bb: 404.219.8685 ikd cdc. ov telework on Tuesdays and Thursdays and can be reached via email' or blackberry From: Reimels, Elizabeth Sent: Mondav. April 04. 2016 10:41 AM To: Dahlberg, Linda L. ?lld0@cdc.gov> Cc: Belser-Vega, Elizabeth Subject: Re: Action: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Here is what I sent forward to Melissa who was going to check back with Elizabeth 5 before I reached back out to Kristen Hollanc {tutti} We haven?t received all the answers back yet for a full review, which is what I was going to have you and Linda review again. Sorry didn?t know you wanted to review these before I sent back to Elizabeth S. figured they were ok since Tom reviewed them. Sorry! From: Cyril, Melissa R. Sent: Wednesday, March 30, 2016 6:33 PM To: Belser-Vega, Elizabeth Subject: RE: Action: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Hmrn.. let me check with ES before you push back. Will let you know. Thank you! From: Belser-Vega, Elizabeth Sent: Wednesday, March 30, 2016 5:49 PM To: Cyril, Melissa R. Subject: Re: Action: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Hi there! So sorry this is late! So I like the answers {below} they gave don?t think really answers the question. I am going to reach back out and see if I can get a similar answer to #2 for I think they interpreted the request to be about funding 5 for 2016, but I interpret to read do we have the 2016 data yet- can you clarify for me before I push back? From: Dahlberg, Linda L. Sent: 4 Feb 2016 20:15:39 +0000 To: Mercy, James Subject: RE: ACTION: Do you have the report mentioned below? Okay I?ll let Courtney know. Thanks for checking. From: Mercy, James Sent: Thursday, February 04, 2016 3:11 PM To: Dahlberg, Linda L. Subject: RE: ACTION: Do you have the report mentioned below? I looked and can?t find it. From: Dahlberg, Linda L. (CDCIONDIEHINCIPCJ Sent: Thursday, February 04, 2016 1:37 PM To: Mercy, James (CDCIONDIEHINCIPC) <'am2 cdc. ov> Subject: ACTION: Do you have the report mentioned below? From: Lenard, Courtney Sent: Thursday, February 04, 2016 12:20 PM To: Dahlberg, Linda L. < ld0 cdc. ova- Subject: RE: For Review: The Trace-gun violence Thanks, Linda! From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 12:13 PM To: Lenard, Courtney cdc. ov> Subject: RE: For Review: The Trace-gun violence Not sure about this one - I?ll do some digging to see if i can find the report referenced below. From: Lenard, Courtney Sent: Thursday, February 04, 2016 11:09 AM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: Re: For Review: The Trace-gun violence Hi Courtney, The responses are fine. Thank you, Linda Sent from my BlackBerry From: Lenard, Courtney Sent: Wednesday, February 03, 2016 12:49 AM Eastern Standard Time To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. (CDCIONDIEHINCIPC) Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCIONDIEHINCIPC) Reimels, Elizabeth (CDCIONDIEHINCIPC) Subject: RE: For Review: The Trace-gun violence Hi Linda, Will you please take a look at the responses and let me know if you are ok with how they read? Deb revised but unfortunately I don?t have her exact changes. Looks like mainly she shortened some answers. Thank you! Courtney 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence {about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of Firearm-Reiated Vioierice a. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Reiatea' Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IOM and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged lei-34 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the IOMINRC, ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC~funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 (investigator- initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: tone study (which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; -A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 3. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? tap?tBVEdffewewed by Einstein afii?opsiatieni?es?hi The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1931?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 2012 Most recent Surveillance ummarjv: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January IT, 2014 );1-33 la] .htm From: Dahlberg, Linda L. Sent: Tuesday, February 02, 2016 3:55 PM To: Lenard, Courtney Mercy, James Simon, Thomas Soihtalab, Elizabeth Subject: RE: For Review: The Tracewgun violence Hi Courtney See edits in red below. I didn?t provide an answer for the first question. i will leave that one to someone else. Let me know if you have any questions. Linda From: Lenard, Courtney Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James Dahlberg, Linda L. (CDCIONDIEHINCIPC) Simon, Thomas Solhtalab, Elizabeth icocroNDIEHrNCIpci Cyril, Melissa ii. Cc: Connolly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (cocroNDIEH/Ncwci (cm) Reimels, Elizabeth (CDCXONDIEHINCIPC) Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb). Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on C11 Q3. Thanks much! Courtney Questions: I. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence {about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC conunissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firecrm-Heioted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Dbama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IOM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm?related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the ?The complexity and frequency of ?rearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries 7. Has the CDC dedicated any funding to research involvm?gwgun's or gun violence since the Dicky Amendlmentwas passed? If so got: h?f?i?i . imam?: nit 7:14: Following the FY 1997 appropriation language funded entities conducted some investigator- initiated, peer-reviewed studies on fatal and non- -fata firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 (investigator- initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: I- one study (which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 11A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 1990s and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the __ en_g_thl of the cgrrent survey and declining response rates in RDD surveys in general. 1 - .r-a'il' a. . . .. .1 Firearm injuries in the United States Prev Med. 2015 1 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 mn1623 03 1 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 1f mm640 8a 1 .htrn Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27, 2012 Most recent Survei?ance Summary.- Surveillance for 1Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17", 2014 a] .htm I Sawing lees and Protecting People from Violence and Inju ry From: Houry, Debra E. (CDCIONDIEHINCIPC) Sent: 24 Aug 2015 21:03:26 +0000 To: Fox, Kate Sara S. Amy B. Cc: Ghulamali, Sa bah Subject: RE: Draft TPs for Next Week: Please Review by Noon on Tuesday Thx- this works- maybe just a bit of info on what is together for girls? le how big, what they do, etc- I know we have VACS through them, but not familiar with the org itself Deb Houry, MD, MPH Director National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 4270 Buford Highway, Mail Stop Atlanta, GA 30341 Twitter: Phone: (720) 4884696 Fax: [720] 488422 From: Fox, Kate Sent: Wednesday, August 24, 2016 3:02 PM To: Houry, Debra E. Patterson, Sara S. PEEples, Amy B. Cc: Ghulamali, Sabah Subject: RE: Draft TPs for Next Week: Please Review by Noon on Tuesday Re: LDS: Paul Bonta decided that it wasn't worth pursuing at this point, given that they submitted a new application. He will, however, reduest 3 L05 if this application is rejected at the editorial panel meeting. Also, I?ve attached the last set of briefing materials. These are for the meet?and?greet with the new ExeCUtive Director of Together for Girls. We've kapt these materials higher?level and are including background materials, since we expect it be an informal meeting. Let us know if you have questions or need anything else. Thanks! Kate From: Houry, Debra E. Sent: Wednesday, August 24, 2016 1:38 PM To: Patterson, Sara S. Peeples, Amy B. Cc: Ghulamali, Sabah Fox, Kate Subject: RE: Draft TPs for Next Week: Please Review by Noon on Tuesday On Schatz I pulled my notes from last trip Falls- big interest of the Senator? they had been briefed by American College of Prev Med re the CPT code we have been working with them on? this CPT code was recently rejected by AMA- we will be resubmitting this month. They may be interested in sending letter of support to AMA re this (of note, HI has one of the lowest rates of falls in has good community based Tai Chi program) Suicide- advocates recently met with them- mentioned the FY17 request and what our vision for work in suicide would be {community level interventions in states and tribal communities; implementing evidence based approaches; expanding nationallyj- she said they are extremely interested in suicide and would like to support our efforts FV- she brought this up esp with AMA resolution this week re lifting Dickey amendment. I talked about the work we were doing (child injury papers, optional module, ICRC projects) but talked about the importance of report language and! or appropriation. She wants to have a follow up discussion on this to see how they can help move this forward Did we want to ask about LOS to and was there a follow up discussion regarding Deb Houry, MD, MPH Director National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 47?70 Buford Highway, Mail Stop Atlanta, GA 30341 Twitter: Phone: 488-4696 Fax: (770} 488-4222 From: Patterson, Sara S. Sent: Tuesday, August 23, 2016 9:07 PM To: Houry, Debra E. Peeples, Amy B. Cc: Ghulamali, Sabah Fox, Kate Subject: Draft TPs for Next Week: Please Review by Noon on Tuesday Hi Deb and Amy, Attached are the draft talking points for our two congressional briefings and the meetings with BIAAJNASHIA and AAMC next week. The one set of TPs that are outstanding are the ones you?ll need for your meeting with Together for Girls on Wednesday, Deb. If you could review and send Sabah and Kate any feedback by noon on Tuesday, they can finalize and get you (Debi a final packet on Friday before you head out. Deb, would you be OK bringing me a packet, too, when you come to I could print from home on Sunday when I return but it may be easier to just get a packet made at work if you don?t mind bringing it with you to DC. Thanks! Sara From: Houry, Debra E. (CDCIONDIEHJNCIPCJ Sent: 24 Aug 2015 1715031? +0000 To: Fox, Kate Sara S. Amy B. Cc: Ghulamali, Sa bah Subject: RE: Draft TPs for Next Week: Please Review by Noon on Tuesday Soundsgood Deb Houry, MD, MPH Director National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 4TH) Buford Highway, Mail Stop Atlanta, GA 30341 Twitter: Phone: 483-4695 Fax: [770) 488-4222 From: Fox, Kate Sent: Wednesday, August 24, 2016 1:50 PM To: Houry, Debra E. Patterson, Sara S. Peeples, Amy B. Cc: Ghulamali, Sabah Subject: RE: Draft TPs for Next Week: Please Review by Noon on Tuesday I?ll follow-up with Hilary to see if we followed up on the LOS. On FV, we?d recommend focusing on and mostly doing on FV. Based on what you discussed last time, I?m not sure there?s too much more we?d have to say, other than updating her on the other papers we have in the works. Maybe we can discuss in our 2:1 tomorrow? From: Houry, Debra E. Sent: Wednesday, August 24, 2016 1:38 PM To: Patterson, Sara S. Peeples, Amy B. Cc: Ghulamali, Sabah (CDCIONDIEHINCIPQ Fox, Kate Subject: RE: Draft TPs for Next Week: Please Review by Noon on Tuesday On Schatz I pulled my notes from last trip Falls? big interest of the Senator~ they had been briefed by American College of Prev Med re the CPT code we have been working with them on? this CPT code was recently rejected by we will be resubmitting this month. They may be interested in sending letter of support to AMA re this (of note, HI has one of the lowest rates of falls in US- has good community based Tai Chi program) Suicide? advocates recently met with them- i mentioned the request and what our vision for work in suicide would be {community level interventions in states and tribal communities; implementing evidence based approaches; expanding nationally)- she said they are extremely interested in suicide and would like to support our efforts FV- she brought this up esp with AMA resolution this week re lifting Dickey amendment. i talked about the work we were doing {child injury papers, optional module, projects) but talked about the importance of report language and/ or appropriation. She wants to have a follow up discussion on this to see how they can help move this forward Did we want to ask about LOS to AMA: and was there a follow up discussion regarding Deb Houry, MD, MPH Director National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 4?70 Buford Highway, Mail Stop Atlanta, GA 30341 Twitter: Phone: {770) 488-4696 Fax: [770] 488-4222 From: Patterson, Sara S. Sent: Tuesday, August 23, 2016 9:07 PM To: Houry, Debra E. Peeples, Amy B. Cc: Ghulamali, Sabah Fox, Kate Subject: Draft TPs for Next Week: Please Review by Noon on Tuesday Hi Deb and Amy, Attached are the draft talking points for our two congressional briefings and the meetings with and AAMC next week. The one set of TPs that are outstanding are the ones you?ll need for your meeting with Together for Girls on Wednesday, Deb. If you could review and send Sabah and Kate any feedback by noon on Tuesday, they can finalize and get you (Debl a final packet on Friday before you head out. Deb, would you be OK bringing me a packet, too, when you come to I could print from home on Sunday when I return?but it may be easier to just get a packet made at work if you don't mind bringing it with you to DC. Thanks! Sara Dahlberg, Linda L. From: Sent: 1 Aug 2016 15:44:44 +0000 To: Sloan, Robin Subject: RE: Firearms Inquiry You?re welcome. From: Sloan, Robin (CTR) Sent: Monday, August 01, 2016 11:18 AM To: Dahlberg, Linda L. Subject: RE: Firearms inquiry Good stuff. Thanks, Linda! Robin Sloan, .MA, Hi'?ltl'l From: Dahlberg, Linda L. Sent: Monday, August 01, 2016 11:00 AM To: Sloan, Robin (CDCIONDIEHINCIPC) (CTR) Subject: Firearms Inquiry Hey Linda, I think the question below is a new one. Can you help me with a response? Subject: Information on Gun Violence and Firearm Use From: General Public Email Address: Your Question: I am doing a study on gin violence and information that is collected for my internship. I am asking what sort of information, such as reports, data, statistics, and outcomes, were collected by the CDC before the Dickey Act was approved. Robin G. Sloan, MA, CCPH Health Communication Specialist I Carter Consulting, Inc. 7?70?433?4019 (office) 404-625-3222 {mobile} Telework Tu 8: Fri. Please email. Saving er. .md Protecting Peopte frornwokme and Inwcy From: Sucosky, Marissa Scalia Sent: 14 Oct 2016 16:45:51 -0400 To: Dahlberg, Linda L. Cc: Doyle, Nadine Subject: RE: firearms research -- please review by COB 10/14 Thank you very much, Linda! Marissa Scalia Sucosky, MPH Policy and ParTnerships Team Detoilee Blackberry: 404-384-9135 msucoskyC?E?cdcgov From: Dahlberg, Linda L. Sent: Friday, October 14, 2016 4:11 PM To: Sucosky, Marissa Scalia Cc: Doyle, Nadine Subject: RE: firearms research -- please review by C03 10f14 Hi Marissa . Here?s the response with my suggested edits in blue. 1 added Steve Summer?s recent paper and the AJPM supplement on the findings related to law enforcement, suicide, etc. Let me know if you have any questions. Thanks, Linda From: Sucosky, Marissa Scalia Sent: Tuesday, October 11, 2016 2:05 PM To: Dahlberg, Linda L. < ld0 cdc. ave Cc: Doyle, Nadine Subject: FW: firearms research -- please review by CUB 10/14 Hi, Linda, In response To The inquiry we received, please review The response we have draffed and le1' me know wheTher you have anything To add or change. Also, do you have web links for The discussion papers referenced in The IOM reporT Priorities for Research to Reduce the Threat of Firearm-Related Violence: oyouTh possession and acquisiTion of firearms I- The relaTionship beTween alcohol and firearm violence I firearm access for persons of risk of harming Themselves or oThers Please respond by COB This Friday 10/14. Marissa Scalia Sucosky, MPH Policy and ParTnerships Team DeTailee Blackberry: 404-384-9135 msucosky?cdogov Dear Dr. Zehrung: ib){5] il) l( 5 'i Recent examples are included below. it Findings from the National Violent Death Reporting System - Special Supplement: American Journal of Preventive Medicine; 2016 Nov; Sentinel events preceding youth firearm violence: an investigation of administrative data in Delaware. American Journal of Preventive Medicine; 2016 Nov; 647-655. - Firearm injuries in the United States. Preventive Medicine. 2015 . Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 i? mmwri?oreviewi? Additionally, in response to the President's Now is the Time plan released in January of 2013, CDC asked the Institute of Medicine (IOM) in collaboration with the National Research Council (NRC) to convene a committee to engage diverse stakeholders and identify the most pressing research questions on gun violence, including those with the greatest potential public health impact. The released their report Priorities for Research to Reduce the Threat of Firearm-Related Violenceon June 5, 2013. [Note that if you wanted to download a PDF, you just need to create a free guest account on the IOM page.) The CDC Foundation, in collaboraTion with The CDC, also commissioned The To develop and disseminate Three supplemental discussion papers focusing on priorities identified in 2013 report: youTh possession and acquisition of firearms; The relaTionship between alcohol and firearm violence: and firearm access for persons aT risk of harming Themselves or others. Direct Links To The Papers: SuiciderHomicidepdf. The In iurv Center Funding Opportunity AnnauncemenTs Web page lists funding opportunities That have been recently available in our Center. You might also be interested in The CDC Injury Center Research Priorities (scroll To The bottom of The webpage for direct links Ta Violence PrevenTion research Topics). I hope This addresses your quesTions. Please leT me know if you need additional informaTion. From: David Zehrung lmailto {1mm Sent: Monday, September 19, 2016 5:06 PM To: Sucosky, Marissa Scalia Subject: Fwd: firearms research Hi Marissa, DVP Inquiries suggested I reach out to you. As President-Elect of the Association, I am working on an issue that has arisen. Some of our members, in advocating for more gun control, have suggested that CDC is prohibited from conducting ?rearms related research. I contacted the CDC info folks, who provided the helpful statement at the bottom of this email. I?d be interested in understanding in greater detail about funding/research directions over the next year or so, as well as initiatives CDC has in place currently that might relate to ?rearms and violence andlor suicide. As an association, we are not interested in taking a stand on policy issues such as gun control, but we are interested in violence prevention efforts. This must sound rather vague. I guess two main lines of questions I have relate to a) things we can share with our membership that CDC is doing on these topics; b) possibly grants that might be available for PA to conduct research in this area. Regards, David David L. Zehrung, Greencastle, PA (bite) it no Begin forwarded message: From: Inquiries Subject: RE: firearms research Date: September 19. 2016 at 12:48:06 PM EDT (b lie} I (b if 6 3' Thank you for your inqu'n y. [b as; One of our Subject Matter Experts from CDC's Policy Team will be in contact with you by next week. In the meantime, please direct your questions to Marissa Scalia Sucosky at msucosk cdc. ov. From: David Zehrung iljalt?l Sant: Friday, September 16, 2016 2:50 PM To: Inquiries (CDC) Subject: Re: ?rearms research Thank you for your prompt and informative reply! I am President-Elect of the Association, and we are expanding our work on interpersonal violence, and suicide prevention. Is there a person at CDC I might speak withi?conespond with further regarding ?rearms research, the budget regarding this, etc? Much appreciated, David David L. Zehrung, \G?aencastle, PA 1. I On Sep 16, 2016, at 2:02 PM, DVP Inquiries (CDC) wrote: Thank you For contacting the Centers for Disease Control and Prevention. CDC appropriation language states that none of the funds made available to CDC may he used, in whole or in part, to advocate or promote gun control {in place since extended to all of HHS in 2012), but the language does not prohibit the CDC from conducting public health research into gun violence. CDC historically conducted research on ?rearm?related violence, and in 2013, the President called upon the CDC and other scienti?c agencies to conduct research into the causes and prevention of gun violence. The CDC and the Obama Administration are committed to engaging in this work, and many partners and several members of Congress are interested in CDC doing research on this topic. That said, CDC has very limited discretionary funding to conduct this research and would need the funding requested in the Y2017 President?s Budget to conduct signi?cant research in this area. From: Eiring, Hilary Sent: 21 Jun 2018 09:02:38 -0400 To: Houry, Debra E. Cc: Watkins, Jacqueline Brandon Amy B. (cocxonoiEH/NCIPC) Subject: RE: For Review: 00 TPs for NAM meeting Attachments: Trends in SAVD 1992-2016 v3.pptx, FACT Signs_ Suicide_6.7.2018_article.pdf, Kegler FA Homicides and Suicides Metro Areas lManuscript).docx, Redfield NAM Meeting NCIPC 6 20 2018 v2.docx Thanks. Updates attached. I confirmed with Li: Finkelman from NAM that she did call in to the BSC since she reached out about the slides and minutes. I also have attached the supplemental materials so that it's all in one place to go back to Hugh. lam confirming anticipated publication date for the MMWR - will send that to Jackie once I have it. Thanka Hilary From: Houry, Debra E. Sent: Wednesday, June 20, 2018 9:13 PM To: Eiring, Hilary Cc: Watkins, Jacqueline Nesbit, Brandon Peeples, Amy B. Subject: RE: For Review: OD TPs for NAM meeting I had a bunch of suggested edits? I also think there needs to be a BLUF for both of our sections and an ask where appropriate From: Eiring, Hilary Sent: Wednesday, June 20, 2018 3:01 PM To: Houry, Debra E. cdc. ova- Cc: Watkins, Jacqueline Nesbit, Brandon Subject: For Review: OD TPs for NAM meeting Hi Deb, We put together background information and talking points for Dr. Redfield?s meeting with NAM. I am still waiting for the MSA paper from DVP but wanted to go ahead and get this to you before we send on to the 00 (which will include the SAVD and Suicide Vital Signs) as well. I included information from Althea on the Mental Health Forum since the request did not go to her directly. Please let me know if you have any questionsfedits/concerns. Thank; Hilary From: Eiring, Hilary Sent: Friday, June 15, 2018 2:03 PM To: Watkins, Jacqueline nt2 cdc. ov> Subject: Re: 00 TPs for NAM meeting Yes, we can handle and I'll let you know if I have any questions. Thanks! From: Watkins, Jacqueline Date: June 15, 2013 at 1:57:23 PM EDT To: Eiring, Hilary Subject: OD TPs for NAM meeting Hilary, Dr. Redfield is meeting with NAM on June 26th and we?ve been asked to provide information to CDC DD bvlune 20th at 12noon. The agenda for the NAM meeting includes the following: 1. Vital Directions for Health and Health Care initiative (see attached checklist) 2. Action Collaborative on countering the opioid epidemic (see attached concept paper) 3. Potential research on GV For DD is requesting anv pertinent background or messages around the action collaborative. Deb noted that she and Anne are CDC reps to the action collaborative and we have funded it {Deb thinks $10klvr for 2 years). Deb suggested we mention that Liz from NAM called into our BSC meeting on benchmarking and has been communicating with Deb about our project and how hopefully it can help inform the consensus paper they are working on scheduled to come out in about 20 months. Either Anne or Deb will attend a kick off on Julv Hm. Deb also mentioned, there is a mental health forum Anne is funding for $50k and Althea is the rep don't know who that is, but assume you do? let me know if we need to figure out though}. For they asked for our standard GV talking points. Deb asked we include the MSA and SAVD in clearance (Elizabeth was tracking down the SAVD article the other day and should have it; do vou know anything about the to highlight that we are still continuing to produce GV surveillance papers and we will now be expanding our to al. 50 states. Deb suggested that we share the suicide vital signs. Also asked to mention we don?t have a dedicated line and that if we get an appropriation for for GV we would use the NAM research agenda to guide our funding announcements (especially around surveillance, safe storage, kids and vets}. Can you your team take the lead on this? Jackie RUNNING HEAD: SCHOOL-ASSOCIATED HOMICIDE-SUICIDES The Epidemiology of School-Associated Homicide-Suicides in the United States, 1994-2014 Ruth W. Leemis, Kristin. M. Holland, PhD,a Elizabeth M. Gaylor, Kameron Sheats, Jeffrey E. Hall, and Linda L. Johnson: ?Division of Violence Prevention. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 4?70 Buford Highway NE, MS F-64, Atlanta, GA, USA 30341 bOffice of Minority Health and Health Equity, Centers for Disease Control and Prevention; 4?70 Buford Hwy Mail Stop Atlanta, GA, USA 30341 CKama, 477?0 Buford Highway NE, MS F-64, Atlanta, GA. USA 3034] Correspondence should be directed to: Ruth W. Leemis, Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway NE, MS F-64, Atlanta, GA, USA 3034]. Telephone: 770-488-0681. Fax: 404-471?8603. Email: RLeemis?E?cdcgov Declarations of interest: None This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-pro?t sectors. Disclaimer: The ?ndings and conclusions in this report are those of the authors and do not necessarily represent the of?cial position of the Centers for Disease Control and Prevention. SCHOOL-ASSOCIATED HOMICIDE-SUICIDES Acknowledgements The authors would like to thank Dr. Susan M. Sutton Clawson for her contributions to data collection and electronic data entry. Dr. Sutton Clawson was af?liated with the Division of Violence Prevention at the National Center for Injury Prevention and Control within the Centers for Disease Control and Prevention at the time of study collaboration and was compensated as an ORISE Fellow by the Department of Justice. She now works at the United States Department of Health and Human Services, Of?ce of the Secretary. SCHOOL-ASSOCIATED HOMICIDE-SUICIDES The Epidemiology of School-Associated Homicide-Suicides in the United States, 1994-2014 Abstract School-associated homicide-suicides are tragic events that devastate the communities where they occur and even the nation at large. However, little is known about such events and how to prevent them. This study used the School-Associated Violent Death Surveillance System, a population-based epidemiological study, to assess national frequencies of school-associated homicide-suicides from July 1, 1994 through June 30, 2014 as well as event and decedent characteristics. Data were obtained from law enforcement investigative reports, structured telephone interviews with law enforcement of?cials, and media scans. Over 20 years, 42 (0-6 annually) school-associated homicide-suicide events resulted in 141 deaths: 98 homicides and 43 suicides. Six cases were mass killings. All 141 deaths (100.0%) involved firearms. Homicide victims were often female (n=59, non-Hispanic White (n=58, students (n=50, 58%) or facultyz?staff (n=24, Suicide decedents were mostly male (n=41, non-Hispanic White (n=25, community residents (n=16, students (n=11, or staff partners (11:9, Most events (n=27, 64%) involved intimate partner violence. Although school- associated homicide-suicides are rare, they involve a complex mix of interpersonal dynamics that are not often tied to conditions within schools themselves. Epidemiologic examinations of these events can help to inform prevention efforts. SCHOOL-ASSOCIATED HOMICIDE-SUICIDES Highlights Highlights are mandatory for this journal. They consist of a short collection of bullet points that convey the core findings of the article and should be submitted in a separate editable file in the online submission system. Please use 1Highlights' in the file name and include 3 to 5 bullet points (maximum 85 characters, including spaces, per bullet point). You can view example Highlights on our information site. Keywords 1violence; schools; epidemiology; homicide-suicide; intimate partner violence SCHOOL-ASSOCIATED HOMICIDE-SUICIDES Introduction TWhile are relatively rare in the US, approximately 1,500 Americans, about 13% of whom are children, die in homicide-suicide events annually By de?nition, these events involve multiple deaths and can have detrimental effects on the communities in which they occur and even the nation at large, as some events are highly publicized Yet, little epidemiological research on homicide-suicide exists, and most studies focus on localized or international samples, or are limited by brief time periods for which data are available Studies assessing contextual factors of homicide?suicides have demonstrated that they are usually perpetrated by adult men, typically result in adult female or child homicide victims, and are often precipitated by interpersonal or intimate partner violence Additionally, incidents are commonly perpetrated in private settings, such as the home While the rates of homicide-suicide events vary by study locale and time period, these characteristics of perpetrators, victims, and their relationships have been consistently reported across studies. However, there may be reason to believe that the demographic and relational characteristics of homicide-suicide events in school settings, in particular, differ from those perpetrated in private settings. For instance, case studies of mass shootings at schools indicate that both the victims and perpetrators of these events are often school-aged, and the perpetrator is frequently a classmate of the homicide victims; ostracism and teasing by fellow students are frequently noted as motivations for these events However, there is also evidence of exceptions to these commonalities, specifically where the perpetrator of a school shooting is identi?ed as an adult who was unknown to homicide victims [13,14]. While these studies are helpful for understanding relationship distinctions common to school shootings, their focus on mass shootings provides little to no information on violent deaths that occur in school settings but that result in a small number of victims or events that involve only family members and victims related to the perpetrator. Additionally, they provide little demographic information regarding the victims and perpetrators. SCHOOL-ASSOCIATED HOMICIDE-SUICIDES The School-Associated Violent Death Surveillance System (SAVD-SS) collects data on homicide, suicide, and legal intervention deaths and allows for analysis of all reported homicide-suicide events occurring in and around U.S. primary and secondary schools. Previous studies using SAVD-SS data have examined context and trends related to school-associated homicides and suicides. For example, from 1994 to 1999, there were 220 school-associated violent death (SAVD) events, 78% (n=172) of which were homicides, 13% (n=30) were suicides, and 5% (n=11) were homicide-suicides. The average annual rate of SAVDs during this period was very low less than 1 per 100,000 students SAVD-SS data have demonstrated that SAVDs remain rare events over time, and homicide-suicide events in the school setting are even rarer. To date, however, no SAVD-SS studies have closely examined homicide-suicide events in school settings, other than by count nor have they assessed decedent relationships and school affiliations in detail. The objective of the current study is to provide an epidemiologic characterization of school-associated homicide-suicides that occurred at elementary and secondary schools in the US. over a 20-year period, along with the demographic and relational characteristics of all victims and perpetrators involved. Material and Methods The SAVD-SS was initiated in 1992 by the Centers for Disease Control and Prevention (CDC), in collaboration with the Departments of Education and Justice, as an epidemiological study to describe the distribution of SAVDs and identify common features of these deaths. The includes descriptive data on violent deaths where a) the fatal injury occurred on the campus of a functioning elementary or secondary school in the U.S., b) while the victim was on the way toffrom regular sessions at such a school, or c) while the victim was attending or traveling toffrom a school-sponsored event. Information on violent deaths on university campuses are not included within the surveillance system due to dif?culties in identifying school boundaries and fewer policies about where students and staff are supposed to be. SAVD-SS cases include the deaths of students and non-students SCHOOL-ASSOCIATED HOMICIDE-SUICIDES family members, community residents), and were identi?ed through a systematic search of media databases via Nexis and then con?rmed through interviews with law enforcement (LE) of?cers familiar with each event. Data were obtained from LE investigative reports and structured telephone interviews with LE of?cials on an ongoing basis as part of the surveillance system?s protocol. The U.S. Of?ce of Management and Budget and Institutional Review Board approved data collection activities, and data are protected with an Assurance of Con?dentiality. As a result, detailed information about the speci?c locations and characteristics of these events cannot be disclosed. For this study, we examined the frequency and characteristics of homicide?suicide events from July 1994?June 2014 when at least one of the homicide or suicide deaths was school?associated.I Data collection tools were designed to gather information on SAVDS and any af?liated perpetrators, so data are available for school-associated homicides and suicides and off-campus suicides when decedents were also school-associated homicide perpetrators. Homicide deaths that occurred off-campus but were af?liated with the homicide-suicide event are noted within the system, but detailed demographic information for those victims is not collected. Thus, if a homicide victim is killed off-campus prior to an SAVD, information about the off-campus homicide victim may be limited. Of the 914 SAVDs captured by from 1994?2014, 42 school-associated homicide- suicides were identi?ed. Supplemental Nexis scans were conducted to identify case characteristics when LE interviews or reports were not received or lacked contextual information These scans used similar methods as a seminal study to identify decedent relationships and school af?liation which were otherwise missing. Speci?cally, Nexis search terms included relevant victim and school names; articles published within two years of the incident were coded for pertinent information. Data extraction forms were created in Epilnfo 3.5.4, which six researchers used to enter data from LE reports LE interviews and supplementary Nexis scans Two researchers conducted quality assurance reviews and cleaned the data. Finally, the frequency and nature of school- Due to a lack oi?complete data tier cases from Fall 1992 through Spring 1994, those years were not included in this study. SCHOOL-ASSOCIATED HOMICIDE-SUICIDES associated homicide-suicides were examined in SPSS v.23 using descriptive statistics. Attributes of interest included frequency of events, decedent demographics, relational characteristics, and school af?liation. Supplemental media scan and data extraction procedures as well as analyses were conducted in 2016 and 2017. Results Overall, 42 school-associated homicide-suicides occurred in and around U.S. schools from 1994?2014. Of those events, 34 involved one homicide decedent and one suicide decedent. Eight cases involved multiple homicide decedents, six of which were mass killings killings with three or more homicide victims) One of those eight cases also had multiple suicide decedents. The 42 school-associated homicide-suicides resulted in 141 deaths: 120 that were school- associated and 21 that occurred off campus prior or subsequent to a SAVD. Table 1 presents the number of deaths by homicide and suicide and according to school-association case criteria; average death counts for events and mass killings are also reported. All 141 deaths (100%) involved ?rearms. Table 1. Number of Deaths in 42 Homicide-Suicide Events, United States, 1994-2014 On-campus Deaths Off-campus Deaths Total Deaths (N=l4l) (n=120) (n=21) No. No. No. Homicide 86 (72) 12 98 (7'0)b Suicide 34 (28) 9 (43) 43 (3 Average (Range) Average (Range) Average (Range) Deaths per Event 228) (n=42 events) Deaths per Event 1Excluding Mass Killings?l (n=36 events) Deaths per Mass 1011.2 (4 - 28)c Killinga (n=6 events) ?Mass killings include cases where there are three or more homicide victims. bPercentages within categories may not sum to 100% due to rounding. cAverages for on-campus and off-campus death categories may not sum to equal the total death value due to rounding. Ranges are calculated across each individual event and cannot be summed across categories. SCHOOL-ASSOCIATED HOMICIDE-SUICIDES Decedent demographic characteristics and school af?liation are presented in Table 2. Homicide victims had a median age of 16.0 years (range 7 and were often female (n=59, non- Hispanic White (n=58, students (n=50, or (n=24, Suicide decedents had a median age of 30.0 years (range 12-76), and were mostly male (n=41, non-Hispanic White (n=25, and either community residents (n=l6, students (n=1 1, or staff partners Ten cases involved 44 hospitalizations for non-fatal injuries, with a median of 1.5 per case (range 1-24). Most non-fatal injuries 84%) occurred during mass killings. Four additional events involved students who may have intended to kill multiple people, according to information gathered by LE officers suicide decedent disclosed intent to kill many people), but did not succeed. Table 2. Homicide-Suicide Decadent Demographics, United States, 1994-2014 On-campus Homicide Victims Total Suicide Decedents Affiliation (n=43) Median (Range) Median (Range) Age 16.0 (7 months - 73) 30.0 (12 76) Sex No. No. Male (31) 41 (95) Female 59 (69) 2 (5) Race White, non-Hispanic 58 (67) 25 (58) Black, non-Hispanic 7 (8) 7 (16) Hispanic 10 (12) 7 (16) American Indian or Alaska 5 (6) 1 (2) Native Asian 1 (1) I (2) Unknown 5 (6) 2 (5) School Af?liation Community Resident 5 (6) 16 (37) Faculty:f Staff 24 (28) 1 (2) Student 50 (58) 11 (26) Partner of Staff 0 (0) 9 (21) Family Member of Student 4 (5) 4 (9) No or Unknown School 3 (4) 2 (5) aOff-campus homicide deaths that are af?liated with the homicide-suicide event are noted within the School-Associated Violent Death Surveillance System but detailed demographic and contextual information for those homicide victims are not collected. bPercentages within categories may not sum to 100% due to rounding. SCHOOL-ASSOCIATED HOMICIDE-SUICIDES 10 Figure 1 depicts the frequencies of school-associated homicide-suicides and deaths by academic year. Zero to six school-associated homicide-suicides occurred per year, and this number ?uctuated over time. Death counts varied according to the number of events but spiked in years with mass killings. The four mass killings that caused the highest spikes involved perpetrators who targeted many individuals within schools; the other two were family disputes that occurred on school property but had no known school connection. Most school-associated homicide-suicides occurred before classes began (n=14, while school was in session (n=14, or immediately after school or school-sponsored activities Events occurred mostly in public schools (11:36, While some events involved deaths in multiple locations, incidents most frequently occurred in parking lots or school driveways (n=16, campus lawns or outdoor walkways and hallways Events occurred in 24 states, with nine states experiencing two or more school-associated homicide- suicides. Figure l. Frequencies of Homicide-Suicide Events and Deaths by Academic Year Relationships between victims and perpetrators and their school affiliations varied across events. Most cases involved interpersonal or familial disputes between two (n=29, 69%) or more individuals SCHOOL-ASSOCIATED 1] Figure 2 highlights the nature of relationships between the 43 homicide perpetratorsfsuicide decedents and the 98 homicide victims. Most school?associated homicide-suicides (n=27, 64%) involved intimate partner violence (IPV) andx?or IPV corollary victims victims whose deaths were connected to IPV but who were not the perpetrator?s intimate partner; affair partners) [FY-related events resolted in one?third of the 98 homicide deaths (n=33, Four events involved four deaths of non-student family members. With respect to school-af?liated homicide victims, seven cases involved students or teachers targeting other school faculty/staff, resulting in a total of eight deaths. Six events involved students targeting classmates resulting in 21 homicide deaths. Finally, only three cases involved strangers targeting strangers, but these events resulted in the most homicides (n=32, Figure 2. lite-lationship=1 Af?liation between Homicide PerpetratorsfSuieide Decedents and Homicide Victims Decedent Relationships 35 32 ?13 Number of Homicide-Suicide Events Strangers IW 8: Corollary Classmates Facultny-taff Other Family Victims I Number of Cases A Number of Homicide Deaths aCases with more than one homicide victim may involve more than one relationship category. Figure 3 further delineates victim-perpetrator relationships according to decedents? school af?liation. The y-axis of the bar chart indicates Suicide decedents? school af?liation and the x-axis SCHOOL-ASSOCIATED HOMICIDE-SUICIDES 12 represents the number of homicide victims by school affiliation. Twenty-five of the 43 suicide decedents had a direct school affiliation. Among school-affiliated decedents, 12 were students or facultyi?staff, 9 were staff partners, and 4 were parents of students. Sixteen suicide decedents were community residents, and two suicide had no or an unknown af?liation with the school. Students represented 50 homicide deaths across ten events, and were killed by community residents, other students, and one person with unknown school affiliation. Twenty-four facultyi?staff members (24% of homicide deaths) were killed in 19 events by their partners, community residents, students, and another staff member. Community residents with no school affiliation were killed in twelve events by other community residents and a student?s parent and accounted for 15% of homicide deaths. Figure 3. School Af?liation of Homicide Perpetrators/Suicide Decedents and Homicide Victims Suicide Decadent Affiliation Homicide Victim Affiliation Community Resident (n=16) 14 28 2?1 Student (n=11) 2 Partner of Staff (n29) 9 Parent of Student 4 No or Unknown Affiliation FacuitviStaff Student I ?Community Resident 9 Parent of Student 1:3:1No or Unknown Af?liation ICases with more than one homicide victim may involve more than one relationship category. SCHOOL-ASSOCIATED HOMICIDE-SUICIDES 13 Discussion School-associated student homicides represent less than 1% of all youth homicides in the US. by extension, homicide-suicide events that occur at school are also very rare. Our ?ndings indicate that over the 20 years included in this study, there were four or fewer school-associated homicide- suicides per year with the exception of 2013-20 14, when six events occurred. The majority of cases involved interpersonal or family-related disputes, reinforcing evidence that school properties may serve as an opportunistic venue for targeted interpersonal violence [20,21]. This finding, coupled with the occurrence of six mass killings, is a testament to the relatively infrequent occurrence of multiple- homicide victim events However, four mass killings resulted in large numbers of deaths and injuries, primarily of students, due to the homicidal actions of students and strangers. The number of homicide victims is likely related to the lethality of ?rearms. Further, some perpetrators may have tried, but failed, to carry out multiple-victim homicides according to information gathered during LE investigations. Therefore, despite the rarity of these events, the tragic occurrence of multiple deaths per event warrants continued surveillance, research, and prevention efforts. School?associated homicide victims in this study were often young, White, females. These results converge with findings that homicide victims in homicide?suicide events outside of school settings are often adult White females [1,2,23,24], but differed from single-victim homicides which disproportionately result in young, Black male victims [25,26]. Further, suicide decedents were older than homicide victims, and often White males, which is relatively consistent with statistics for both suicide decedents and homicide perpetrators who die by suicide However, this demographic differs from homicide perpetrators who do not die by suicide, which generally have higher rates among Black males While facultyx?staff, community residents, staff partners, and parents were killed in many of the events included in this study, the school environment in which these violent acts SCHOOL-ASSOCIATED HOMICIDE-SUICIDES 14 take place is undoubtedly related to the greater frequency of student deaths compared to homicide- suicides outside of school settings. From 1994 to 2014, most school-associated homicide-suicides involved andfor IPV corollary victims, resulting in about one-third of homicide deaths. This ?nding is consistent with other studies, which have found that most homicide-suicides involve male perpetrators killing their female partners, often coinciding with problems of divorcefbreak-up and infidelity [2,3,10,24,29]. In fact, one of the most striking study ?ndings is the involvement of so many non-students in school-associated homicide?suicides. While the majority of homicide perpetrators/suicide decedents had a direct school affiliation, less than one-third were students or facultyz?staff; other school af?liations among this subgroup included staff partners or student family members. Moreover, more than one-third of perpetrators were nearby community residents with only an indirect school affiliation by proximity. Students represented the majority of homicide deaths across almost one-fourth of the cases, but community residents, and student family members also played a large role in the occurrence and death tolls of these events. This is reinforced by the fact that almost three-fourths of events involved IPV- or family-related issues, and that two of the mass killings involved family disputes. Because previous school-associated violence studies have focused largely on student and deaths [15,19], this finding is important and warrants more contextual research. Although there is some understanding of the circumstances preceding homicide-suicide events outside of school settings, more research is needed on circumstances preceding school-associated events. Situational factors for non-students intimate partner problems) may be vastly different than those relevant to students, and data on the frequency of their occurrence and the characteristics of suicide decedents and homicide perpetrators may provide valuable information to guide prevention While mass killings targeting students and teachers within schools are widely publicized, this study illustrates that isolated interpersonal events between students, school staff, parents, and community residents SCHOOL-ASSOCIATED HOMICIDE-SUICIDES 15 resulted in more overall deaths (n=72, 51%) than did the four mass killings targeting students and teachers (n=59, Thus, interpersonal violence prevention efforts are critical. Studying contextual factors may also provide insight as to whether events are motivated by homicidal anger or a planned suicide, or are a distinct act of violence [30,31]. The diversity of the individuals involved in school?associated homicide-suicides and the relationships between decedents suggests that prevention efforts should not only target students, but also school staff, parents, and community members. Comprehensive community-based strategies that aim to prevent youth violence, IPV, and suicide may also help to prevent homicide-suicides. For example, strategies that enhance school and community connectedness and access to mental health care, along with promotion of family environments that support healthy development may help ensure that the risk for suicide and perpetration of severe interpersonal violence never develops in the first place. The technical packages for violence prevention can serve as guidance for states and communities interested in implementing evidence-based programs and policies that have demonstrated impact on reducing interpersonal and self?directed violence Evidence?based programs for communities and schools include the Premarital Relationship Enhancement Program (PREP) and Strengthening Families i 0-14 which promote healthy relationships and family environments as well as the Good Behavior Game which has been shown to improve youth coping and problem-solving skills [3 3,34,35]. The results of this study should be considered in the context of several limitations. First, SAVD cases are identi?ed primarily through media scans; thus, unpublicized events may be excluded from analyses. Second, results are based on second-hand accounts of the event through LE investigations. Relevant factors, such as information on prior IPV or suicidal ideation, may be unknown or unreported, resulting in missing information. However, this is a general limitation of postmortem interview methodology given the nature of these deaths Third, information for two cases was abstracted from Nexis media scans. Although media articles were used only to identify relationships and school SCHOOL-ASSOCIATED HOMICIDE-SUICIDES 16 af?liations, the articles could have contained incorrect information. Fourth, because the SAVD-SS captures information on deaths but not non?lethal violence (unless it also involved a death), information is not known about homicide-suicide attempts that did not result in fatalities. Finally, despite the long period of assessment, ?ndings are drawn from a relatively small number of cases and may change as new cases occur. Conclusions Despite study limitations, ?ndings reinforce the rarity of school-associated homicide-suicides in the US. and provide information on the characteristics of decedents. This study builds upon previous research and provides important information about individuals with no or indirect ties to the school [15,19]. Although students and faculty/staff were the most frequent homicide victims, community residents were also commonly targeted. And, despite the large number of student homicides, parents, and community residents were killed in a greater number of isolated interpersonal events, often involving IPV. In comparison, only three cases over 20 years involved strangers targeting strangers, although these events resulted in the largest number of homicide deaths. Overall, almost two? thirds of suicide decedents were af?liated with the school, whereas one-third were nearby community residents. By describing these relationships, this study highlights the complexity of school-associated homicide-suicides and the need for implementation of comprehensive prevention strategies in schools, homes, and communities at large. RUNNING HEAD: SCHOOL-ASSOCIATED HOMICIDE-SUICIDES References Bossarte, R. M., Simon, T. R., Barker, L. (2006). Characteristics of homicide followed by suicide incidents in multiple states, 2003-04. inf Prev, 12 Suppl 2, ii33?ii38. 36iig.2006.012807 Logan, J., Hill, H. A.. Black, M. L., Crosby, A. E., Karch, D. L., Barnes. .1. D., Lubell, K. M. (2008). Characteristics of perpetrators in homicide-followed-by-Suieide incidents: National Violent Death Reporting System?17r US states, 2003?2005. American Epidemiol. 168(9), 105 6- 1 064. 093iajeikwn2l 3 Marzuk, P. M., Tardiff, K., 8.: Hirsch, C. S. (1992). The epidemiology of murder-suicide. JAMA, 267(23), 3179-3183. Fox, .I. A., Levin, J. (2014). Extreme killing: Understanding serial and mass murder. 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D., Mallonee, 8., Kruger, E., Rayno, K., Vance, A, Jordan, F. (2005). Epidemiology of homicide-suicide events: Oklahoma, 1994?2001.Am Forensic Med Portia}. 26(3), 229-235. [1 1] Logan, .1. E., Walsh, 8., Patel, N, Hall, J. (2013). Homicide?followed-by?suicide incidents involving child 1eictims. Am Health Behov. 32(4), 531?542. ll [12] Leary, M. R., Kowalski, R. M., Smith, L, Phillips, S. (2003). Teasing, rejection, and violence: Case studies of the school shootings. Aggress Behav, 29(3), 202-214. 1006] [13] Logue, J. N. (2008). Violent death in American schools in the 21st century: re?ections following the 2006 Amish School shootings. Sci: Health, 78(1), 58-61. 11 [14] Muschert, G. W. Research in school shootings. Socioiogy Compass. 60-80. 11 111217513020200700003); [15] Anderson, M., Kaufman, J., Simon, T. R., Barrios, L., Paulozzi, L., Ryan, CL, Hammond, R., Modzeleski, W., Feucht, T., Potter, L. (2001). School-associated violent deaths in the United States, 1994-1999. JAMA. 286(21), 2695?2702. l9 IDES [16] Swahn, M. H., Mahendra, R. R., Paulozzi, L. J., Winston, R. L., Shelley, G. A., Taliano, J., Frazier, L., Saul, J. R. (2003). Violent attacks on Middle Easterners in the United States during the month following the September 11, 2001 terrorist attacks. Prev, 187-189. l36lip.9.2.187 [17] Investigative Assistance for Violent Crimes Act of 2012, Pub. L. No. 1 12-265, 126 Stat. 2435. (2013}. [13] Smith, S. G., Fowler, K. A., Niolon, P. H. (2014). Intimate partner homicide and corollary victims in 16 states: National Violent Death Reporting System, 2003-2009. Am Public Health. 104(3), 461-466. [19] Modzeleski, W., Feucht, T., Rand, M., Hall, J., Simon, T., Butler, L-., Taylor, A., Hunter, M., Anderson, M. 85 Hertz, M. (2008). School-associated student homicides?United States, 1992-2006. MMWR Morb Mortal Wkly Rep, 57(2), 33-36. [20] Flannery, D., Modzeleski, W., 8; .1. (2013). Violence and School Shootings. Current 15(331), l-i. 1007lsl 1920?012-0331-6 [21] Vossekuil, B., Fein, R., Reddy, M., Borum, R., 8.: Modzeleski, W. (2002). The?nal report and?na?ings aftlte Safe School Initiative: lmplicatiansfar the prevention af'seliaal attacks in the United States. Washington, D.C.: US. Secret Service and US. Department of Education. [22] Borum, R., Cornell, D. G., Modzeleski, W., Jimerson, S. (2010). What Can Be Done About School Shootings? A Review of the Evidence. Educational Research, 39(1), 27-37. [23] Bridges, F. S., Lester, D. (201 Homicide?suicide in the United States. 1968?1975. Forensic Science International, 206(1?3 185-189. l016li.forsciint.201008.003 20 [24] Holland, K. M.., Brown, S. V., Hall. J. E., 8: Logan, J. E. (2015). Circumstances Preceding Homicide-Suicides Involving Child Victims: A Qualitative Analysis. Journal of Interpersonal Violence, 1?23. 10.1 177i08862605 5605124 [25] Lyons, B. H., Fowler, K. A., Jack, S. P., Betz, C. J., Blair, J. M. (2016). 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Jonrnoi ofCriminoi Justice, 27(4), 361-370. 10] (#80047- 2352199100008-2 21 SCHOOLASSOCIATED IDES [32] Centers for Disease Control and Prevention. (2017). Technical Packages for Violence Prevention: Using Evidence-based Strategies in Your Violence Prevention Efforts. Retrieved from [33] Braithwaite, S. R., Fincham, F. D. (2014). Computer-based prevention of intimate partner violence in marriage. Behaviom' Research and Therapy, 54(2014). 12-21. 1016/Lbr3t2013. 12.006 [34] Kellam, S. (3., Brown, C. H.., Poduska, J. M., Ialongo, N. S., Wang, W., Toyinbo, P., Petras H., Ford C., Windham, A., Wilcox, H. C. (2008). Effects ofa universal classroom behavior management program in ?rst and second grades on young adult behavioral, and social outcomes. DrugAicohol Depend, 95(Supplement 1), 35-828. [35] Spoth, R. L, Guyl], M., Day, S. X. (2002'). Universal family-focused interventions in alcohol-use disorder prevention: costeffectiveness and cost-bene?t analyses of two interventions. Stud Alcohol Dmgs, 63(2), 219-228. 52880532002632 [9 [36] Cavanagh, J. T., Carson, A. ., Sharpe, M., Lawrie, S. M. (2003). autopsy studies of suicide: a systematic review. Med, 33(3), 395-405. Figure 1a. Rates of School Associated Homicide per 100,000 Students ?single victim 0.03 0.0? 0.05 0.9001'- . 1001: 200 AAPC- 0.5/6 430 1006* 51?, 0.03 . 01?? 30%? 0,000)? (?at in?liav?i? Cafeogz 15.1016n?L ?-3911; {f9 jail! 0.02 - . - Lu;- th Rate per 100,000 Students *5 ?0 cf? 0.01 1992 199319319931094-1995995 20110142013315.2016 APC=Annua Percentage Change; AAPC=Average Annual Percentage ChangeDotted lines indi??l?t?J?JSMd rates and solid lines indicate modeled rates. for trend <0.05Victim rates were calculat Figure 1b. Rates of School Associated Homicide per 100,000 Students ?multiple victims 0.04 Victimazation rate Incidence rate A 0.035 /l l\ j: /l/l/W ?VA-aw? I . m: 54% 202014-201915 201.6 Rate per 100,000 Students 0 APC=Annual Percentage Change; AAPC=Average Annual Percentage ChangeDotted lines indigemse??d rates and solid lines indicate modeled rates. for trend <0.05Victim rates were calculat #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Weekly/Vol. 67 i No. 22 June 8, 2018 Vital Signs: Trends in State Suicide Rates United States, 1999?201 6 and Circumstances Contributing to Suicide 27 States, 2015 Deborah M. Stone. 5:th 'l?homas R. Simon l?hDi; Katherine A. Fowler, l?th; Scott R. Kegler, Pth; Keniing Yuan, Kristin M. Holland, Asha Z. hey-Stephenson, I?th; Alex E. Crosby, Abstract Introduction: Suicide rates in the United States have risen nearly 30% since 1999., and mental health conditions are one of several factors contributing to suicide. Examining stateelevel trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. Methods: Trends in age-adjusted suicide rates among persons aged :10 years, by state and sex, across six consecutive 3-year periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data From the National Violent Death Reporting System, covering 27 states in 20! 5, were used to examine contributing circumstances among decedents with and without known mental health conditions. Results: During 1999?20 16, suicide rates moreased signi?cantly in 44 states, with 25 states experiencing mcreases Rates increased significantly among males and females in 34 and 43 states, rmpectively. Fifty-four percent ofdecedents in 27 states in 201 5 did not have a known mental health condition. Among decedents with available information, several circumstances were signi?cantly more likely among those without known mental health conditions than INSIDE among those with mental health conditions, including 625 Invasive Methicillin-Resistant Staphylococcus oureus relationship problemsi'loss (45.1% versus life Infections Among Persons Who Inject Drugs Six Sites, 2005?201 6 629 Tobacco Product Use Among Middle and High School Students United States, 2011?2017 634 Update: Influenza Activity in the United States During stressors (50.5% versus and recent! impending crises (32.9% versus but these circumstances were common across groups. Conclusions: Suicide rates increased significantly the 201??18 Season and Composition ofthe 2018?19 across most states during 1999?2016. Various Influenza Vaccine circumstances contributed to suicides among persons 643 Update: ACIP Recommendations for the Use of With and without known mental health conditions. Quadrivalent Live Attenuated Influenza Vaccine Implications for Public Health Practice: States United Sis??95: 2018?19 Influenza 59350" can use a comprehensivg evidence?based public 646 Notes from the Hemorrhagic health approach to prevent suicide risk before it Fever Outbreak?Central Uganda, August?September occurs, identify and support persons at risk, prevent 201? reattempts, and help friends and family members in 6?48 QuickStats the aftermath of a suicide. Continuing Education examination available at infolitmliiweekly. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Introduction in 2016. nearly 45,000 suicides population [age-adjusted? occurred in the United States among persons aged :10 years From 1999 to 2015. suicide rates increased among both sexes, ail racial/ ethnic groups, and all urbanization levels (2.3). Suicide rates have also increased among persons in all age groups <75 years, with adults aged 45?64 having the largest absolute rate increase (from 13.2 per 100,000 persons [1999] to 19.2 per 100,000 [2016]) and the greatesr number ofsuicides (232,108) during the same period (1.3). Suicide is the tenth leading cause ofdeath and is one ofjust three leading causes that are increasing in addition, rates ofemergency department visits for nonfatal self-harm, a main risk factor for suicide, increased 42% from 2001 to 2016 (1). Together, suicides and self-harm injuries cost the nation approximately $730 billion per year in direct medical and work loss costs if}. The National Strategy for Suicide Prevention calls for a public health approach to suicide prevention with efforts span? ning multiple levels (individual, famiiyfrelationship, community, and societal]. Such a comprehensive approach underscores that suicide is rarely caused by any single factor. but rather, is deter? mined by multiple factors. Despite this call to action, suicide prevention largely focuses on identifying and tefEtring suicidal persons to mental health treatment and preventing reattempts (6). in addition to mental health conditions and prior suicide attempts, other contributing circumstances include social and economic problems, access to lethal means (eg, substances, firearms) among persons at risk, and poor coping and problem- solving skills Expanded awareness of these additional circum- stances contributing to suicide risk and action to address them can be] reach the national goal, established by the National Action Alliance of Suicide Prevention and the American Foundation for Suicide Prevention, of reducing the annual suicide rate 20% by 2025 To assist states in achieving this goal, CDC analyzed state?specific trends in suicide rates and assessed the multiple contributing factors to suicide; this report presents options for strategies to include in comprehensive suicide prevention efi'orts that are based on the best available evidence. Methods Suicide rates were analyzed for persons aged :10 years because determining suicidal intent in younger children can be difficult (8). Ageaspecific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (International Class?imrion ofDireiases, Fitme- Revision, underlying?cause?ofdeath codes ?37.0. Age? specific population estimates were obtained from U.S. Census Bureau/National Center for Health Statistics bridged?race population data releases. National and staterlevel suicide rate estimates were calculated for six consecutive 3?year aggregate periods spanning i999? 2016 (1999?2001; 2002?2004; 2005?2007; 2003?2010; 2011?2013; and 2014-2016). Rate estimates were age- adjusted to the U.S. 2000 standard population and expressed The of publications is published by the Center for Surveillance. Epidemiology, and Laboratory Services. Centers For Disease Control and Prevention US. Department DE Health and Human Services, Atlanta, GA 30329-4027. Suggc?ed citation: [nudist tomes; first three. then ct .1L. if more than steel [Report title]. MMWR Morb Mortal Wkly Rep 2018;67:linc1usive page numbers]. Centers for Disease Control and Prevention Robert R. Redfield, MD, Dir-retal- Annc Schucllat. MD. Principe! Depend Dirmor Leslie Dauphin. Acting Arterial? Diremar?r .S'rz?mcr Joanne Conn. MD. 542M, Dir-emu [wire 43am.- Quality Chesiey L. Richards, MD. MPH. Deputy Public Health Erin-tri?e 5mm: Michael F. ladetnaico. MD. MPH. Din-am: Center?rr Epidemiology mm'LdiEremmq Service: MMWR Editorial and Produetion Staff [Weaklyl Charlotte K. Kent. MPH. Acting Edimn'n Chief: Executive Editor- Jacqueline Gladier. MD. Editor Mary Dotr, MD. MPH, (Julius Editor Temsa F. Rutledge. Managing fairer Douglas W. Weathuwax. Lead Tat?nimi? Wtr??f?ar Glenn Damon. Soumya Dunworth, Teresa M. Hood. MS. manual Writer-a?oat: Martha F. Boyd. Lew} Visual Specialise Maureen A. Lei-ally. Julie C. Mnrtinroe. SmphenR. Spriggs. Tong Yang. Vitae! In?rmetfm Sammie: 'Quang M. Dean. MBA. H. King. Terraye M. Starr, Mona Yang, In?ramim spa-area MMWR Editorial Boon! Timothy F. Jones. MD. Matthew L. Buuitoo. MD. MPH Virginia A. Cains. MD Katherine Daniel. PM) Jonathan E. Fielding, IulD. MPH, NIBA David Fleming. MD eta MMWR Jun88,2018 r' Vol.6? No.22 William E. Helper-in. MD. DIPH. MPH King K. Holmes. MD. Robin Ikrda. MD. MPH Rim-.1 F. Khabbaz. MD Meadows. MSN. RN Jewel Mullen. MD. MPH. MFA Patricia Quinlislt. MD. MPH Patrick L. Remington. MD. MPH Carlos R'oig. M5. MA Wait-.1.? L. Roper. MD. MPH William Seha?iter. MD US Department of Health and Human ServicesiCemers for Disease Control and Prevention Morbidity and Mortality Weekly Report per 100,000 persons per?year. Age-adjusted suicide rate trends were modeled using the same 3-year data aggregates, employ- ing weighted least-squares regression with inverse-variance weighting. Modeled rate trends are reported in terms oF average annual percentage changes. Characteristics oF persons aged 1:10 years who died by suicide, with and without known mental health conditions, and the circumstances surrounding the suicides were compared in the 27 states? with complete data participating in CDC's National Violent Death Reporting System in 2015. defines mental health conditions as disorders and listed in the Diagnostic and Statistical Manual Disorders, Farr; Edition (9), with the exception oF problematic alcohol use and other subsranee use that are captured separately in VDRS aggregates data From three primary data sources: death certi?cates, coroneri'medical examiner reports (including toxi? cologyl, and law en Forcement reports. A range oF circumstances (relationship problems, life stressors, and recent or impending crises)I have been identi?ed as potential risk Factors For suicide in Circumstances captured are those identi?ed as con? tributing to suicide in coronerfmeclical examiner or law en Force? ment reports, which re?ect inForntation provided by Family and Friends at the time oF death. Decedents could have experienced multiple circumstances. Decedents with and without known mental health conditions were compared using chi-square tests. Logistic regression analyses were used to estimate adjusted odds ratios (aORsl with 95% confidence intervals (Cls), controlling For sex, age group, and tacoll ethnicity. Results The most recent overall suicide rates (representing 2014? 2016} varied FourFold, From 6.9 (District oF Columbia]I to 29.2 (Montana) per [00,000 persons per year (Supplementary Table; Across the study period, rates increased in all states except Nevada (where the rate was consistently high throughout the study period}, with absolute increases ranging From 0.8 per 100,000 (Delaware) to (Wyoming). Percentage increases in rates ranged From 5.9% (Delaware) to 57.6% (North Dakota), with increases >50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2012?2013 and 2015?2016 Scott R. Kegler, Linda L. Dahlberg. James A. Mercy. 1 National Center for Injuty Prevention and Control. Division of Analysis, Research, and Practice Integration 3 National Center for Injury Prevention and Control. Division of Violence Prevention Correspondence: Scott R. Keglcr 770 483-3830 Firearm homicides and suicides represent a continuing public health concern in the United States. During 2015?2016, a total of 27.394 ?rearm homicides and 44.955 ?rearm suicides occurred among US. residents (1). This includes 3,224 firearm homicides and 2,1 18 ?rearm suicides among 10?19 year olds. This report updates an earlier MM that provided statistics on ?rearm homicides and suicides in major metropolitan areas for 2006?2007 and 2009?2010, and places continued emphasis on 10?19 year olds in recognition of the importance of early prevention efforts. Firearm homicide and suicide rates were determined for the 50 most populous US. metropolitan statistical areas for 2012?2013 and 2015?2016 using mortality data from the National Vital Statistics System (NVSS) and population data from the US. Census Bureau. In contrast to the earlier report, which indicated that the all?ages ?rearm homicide rate had been declining both nationally and in large MSAs overall, current ?ndings show that rates have returned to levels comparable to those observed for 2006?2007. Consistent with the earlier report. current ?ndings show that the all-ages ?rearm suicide rate has continued to increase. both nationally and in large MSAs overall. Although the firearm suicide rate among 10?19 year olds remains notably lower than the all-ages rate. it has also shown continuing increases both nationally and in large MSAs collectively. These ?ndings can inform ongoing development and monitoring of strategies directed at reducing ?rearm-related violence. NVSS mortality data for 2012?201 3 and 2015?2016 were used to identify ?rearm homicides (Inter-nations! Classificatirm of'Dt'senses. Revision underlying cause codes and [101.4 [provisional]) and ?rearm suicides (codes among U.S. residents. Firearm homicide and suicide counts were tabulated for county groupings forming the 50 largest MSAs (by population rank mid- year 2016}.i Tabulated counts were integrated with U.S. Census Bureau population estimates for the counties forming these MSAs to calculate annual ?rearm homicide rates for persons of all ages and annual ?rearm suicide rates for persons of all ages 310 years (data for persons <10 years old were excluded because intent for often is not attributed to young children). Rates were similarly calculated for 10?19 year olds. All-ages rates were age-adjusted to the year 2000 US. standard. MSA-level data involving ?rearm homicide or suicide counts <20 are not reported separately due to concerns related to statistical reliability (stability) and data privacy. However, such data were included in the calculations for all large MSAs combined. All-ages firearm homicide rates during 20154016 varied widely among the 50 largest MSAs, ranging from 1.1 to 16.6 per 100,000 residents per year (Table). The rate for all large MSAs combined was 4.9. compared with a national rate of 4.4. This represents an increase from 2012?2013, when the rate for large MSAs combined was and the national rate was 35". Between 2012?2013 and 2015?2016 ?rearm homicide rates increased for 86% of large MSAs (43 of 50) considered individually. Among 10?19 year olds the ?rearm homicide rate for large MSAs combined was 4.7 during 2015?2016, compared with a national rate of 3.9. Similar to the all-ages rate, this represents an increase from 2012?2013, when the rate for large MSAs combined was 4.3 and the national rate was 3.4. Males accounted for approximately 85% of ?rearm homicide victims (all ages) during both reporting periods, for the 50 largest MSAs combined as well as nationally. All-ages ?rearm suicide rates during 2015?2016 also varied widely by large MSA, ranging from 1.5 to 13.5 (Table). The rate for large MSAs combined was 5.8, compared with a national rate of 7.7. This represents an increase from 2012?2013, when the rate for large MSAs combined was 5.6 and the national rate was 7.4. Firearm suicide rates among 10?19 year olds remained much lower than all-ages rates. The rate for this age group for large MSAs combined was 1.9 during 2015-2016, with a national rate of 2.5. This also represents an increase from 2012?2013, when the rate for large MSAs combined was 1.5 and the national rate was Similar to ?rearm homicides, males represented approximately 85% of ?rearm suicides (all ages) in both reporting periods, for the 50 largest MSAs combined and nationally. Discussion During 2015?2016, homicide was the 16th leading cause of death (all ages) in the United States and the third leading cause among 10?19 year olds, a ?rearm injury was the underlying cause in 74% of all homicides and in 87% of youth homicides (1). Previously observed decreases in ?rearm homicide rates have not continued, with more recent rates showing an increase both nationally and in large MSAs considered collectively. All-ages and youth ?rearm homicide rates in large MSAs overall have both remained higher than corresponding national rates. Concurrently, suicide was the 10th leading cause of death (all ages) nationally and the second leading cause for 10?19 year olds; a ?rearm injury was the underlying cause in 50% of all suicides and in 42% of youth suicides (1). Previously observed increases in all-ages ?rearm suicide rates continued in recent years, both nationally and in large MSAs collectively; youth ?rearm suicide rates also showed increases both nationally and in large MSAs overall. All-ages and youth ?rearm suicide rates in large MSAs overall have both remained lower than national rates. The ?ndings in this report are subject to several limitations. First, statistics on nonfatal injuries associated with ?rearm assault or self?harm are not presented because population-based nonfatal injury data are not available for MSAs. Second, although the statistics presented convey the seriousness of ?rearm violence among 10-19 year olds, other age groups not separately considered here had higher ?rearm homicide rates (persons 20-44 years old) or higher ?rearm suicide rates (all older age groups). It is too soon to know whether recent increases in ?rearm homicide rates in large MSAs, both all-ages and among youth, represent a short-term ?uctuation or the beginning of a longer?term trend. From 2015 to 2016, violent crime increased for the nation in cities with populations of 250,000 or more in suburban areas and in nonmetropolitan counties suggesting a short-term increase concentrated particularly in the core cities ofmetropolitan areas Efforts to continue to monitor this trend are important, but regardless of whether or not continued increases occur, ?rearm homicides are an important public health problem, particularly among young people. Preventing ?rearm homicides can be a challenge for cities across the country. Previous research, however, suggests that efforts to modify the physical and social environment in cities through abandoned building and vacant lot remediation, greening activities, street outreach and community norm change, low-income housing tax credits, and business improvement districts can signi?cantly reduce gun assaults, youth homicide, and other violent crime (3). In contrast to homicide, rates of suicide have been increasing in the US. since 1999 across states, all population groups, and in rural and urban settings (4-6). Rates of ?rearm suicide, in particular, began increasing coincident with the economic downturn of 2007?2008 and have continued to increase despite the subsequent economic recovery. After declining 7% from 1999 to 2006, rates of ?rearm suicide increased 21% from 2006 to 2016 {from 6.5 to 7.8 among those aged 10 and older} Urban areas recovered more quickly from the downturn than rural areas but the continued increase in rates of ?rearm suicide in large MSAs suggests that multiple factors are driving the increase and that a combination of prevention approaches might be necessary to reduce these risks. Efforts to strengthen household ?nancial security, stabilize housing, teach youth coping and problem-solving skills, identify and support people at risk, and proactive prevention policies in schools, workplaces and other organizational settings are associated with reduced rates of suicide, suicide attempts, andfor co-occurring risks such as substance abuse, depression, and social isolation Another factor likely affecting both ?rearm homicide and suicide is access to ?rearms by persons at risk of banning themselves or others. Research shows that the amount of time between deciding to act and attempting suicide can be as little as 10 minutes or less and that people tend not to substitute a different method when a highly lethal method is unavailable or dif?cult to access 9). Reducing access to lethal means during an acute suicidal crisis by safely storing ?rearms or temporarily removing them from the home can help reduce suicide risk, particularly among youth Preventing persons convicted of or under a restraining order for domestic violence from possessing a firearm has been associated with reductions in intimate partner?related homicide, including ?rearm homicide Efforts to strengthen the background check system to better screen for persons convicted of violent crimes or at risk of banning themselves or others may also prevent lethal ?rearm violence, although these policies need further study Firearm?related violence represents a continuing public health problem in the U.S., contributing substantially each year to premature death and disability. Understanding the patterns, characteristics, and impact of firearm violence is an important factor in preventing injuries and deaths. Available at .htm. An MSA is de?ned by the US. Of?ce of Management and Budget (OMB) as consisting of?at least one urbanized area of 50,000 or more population, plus adjacent territory that has a high degree of social and economic integration with the core as measured by commuting ties.? This report is based on the revised geographic delineations for MSAs issued by OMB in August 2017. The same MSAs were the 50 most populous during both reporting periods; rankings by total population changed References l. 10. CDC. Web?based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: US Department of Health and Human Services, 2017. Available at 11 11131;? ww .c dc . go vr?i i rvr?tvi so a rss" i ndex. l. U.S. Department of Justice, Federal Bureau of Investigation. Crime in the United States, Annual Reports for Years 1995?2016, Table 10. Available at: David-Ferdon C, Vivolo-Kantor, AM Dahlberg LL, Marshall KJ, Rainford N, Hall. JF. A comprehensive technical package for the prevention of youth violence and associated risk behaviors. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2016. Stone DM, Simon TR, Fowler KA, Kegler SR, Yuan, K, Holland KM, Ivey-Stephenson AZ, Crosby AE. Vital Signs: Trends in State Suicide Rates United States, 1999-2016 and Circumstances Contributing to Suicide 27 States, 2015. MMWR 2018; Curtin SC, Warner M, Hedegaard H. Increase in Suicide in the United States, 1999?2014. NCHS Data Brief. Hyattsville, MD: National Center for Health Statistics; 2016. Kegler SR, Stone Holland KM. Trends in Suicide by Level of Urbanization United States, 1999?2015, MMWR 2017; Stone DM. Holland KM, Banholovv BN, Crosby AE, Davis SP, Wilkins N. Preventing suicide: A technical package of policies, programs, and practice. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 201?. Deisenhammer EA, Ing CM, Strauss R, Kemmler G, Hinterhuber H, Weiss EM. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? C?h'n 2009; 70(1 1:19-24. Hawton K. Restricting access to methods of suicide: rationale and evaluation of this approach to suicide prevention. Crisis 200?; Webster DW, Wintemute 6.1. Effects of policies designed to keep firearms from high?risk individuals. Annual Review ofPabt'ic Health 2015; 36:21-37. Summary (Box) What is already known about this topic? Although ?rearm homicide rates in large metro areas are generally higher than for the nation overall, such rates had been declining more quickly than the national rate. In contrast, firearm suicide rates in large metro areas are generally lower than for the nation overall, but rates for both had been increasing. What is added by this report? In more recent. years, ?rearm homicide rates in large metro areas and the nation overall began increasing, returning to levels comparable to those seen a decade ago. Firearm suicide rates have continued to increase in large metro areas and the nation overall. What are the implications for public health practice? Firearm homicides and ?rearm suicides represent a continuing public health concern in the US. Ongoing tracking of rates at all geographic levels can provide important input for initiatives directed at reducing firearm-related violence. Dr. Redfield?National Academy of Medicine (NAM) Action Collaborative on Countering the Opioid Epidemic BLUF: The National Academy of Medicine (NAM), in partnership with the Aspen Institute (All, seeks to launch a two?year Action Collaborative on countering the U.S. opioid epidemic. ASK: Given the efforts we have underway at CDC, it would be great if either Anne Shcuchat or Deb Houry could brief the Action Collaborative on our indication specific guideline in order to inform the development ofthe consensus report. Background The Action Collaborative will be an NAM~faci itated standing body that brings together stakeholders nationally to advance progress across priority areas through collaboration, coordination, communication, and shared learning activities. These would be areas where the NAM can play an important role, and in particular, where they can help facilitate enhanced collaboration and coordination among stakeholder groups, many of which are already engaged in opioid initiatives of their own. The Collaborative membership will meet 2-3 times per year, in both public and closed sessions, with workgroups convening by phone regularly to advance the defined objectives of the Collaborative. The feed back and data generated from early outreach efforts, including a stakeholder survey, indicated several areas the Collaborative should emphasize. These include: health professional education and training; prescribing behavior and guidelines; medical treatment, including financing and strengthening the links between medical and supportive services; community engagement and resources; culture change and stigma; and research, data, and metrics. While they will ultimately use the July meeting to affirm the Collaborative?s focus areas, there is much enthusiasm and support for the Collaborative to address health professional education and training {creating an ?education continuum? across UME, GME, and opioid prescribing guidelines and behavior, treatment, and community-focused implementation models and resources. The Collaborative?s membership consists of individuals and entities from across the public, private, and non- governmental sectors, all working together to accelerate shared solutions and learning. Included among the entities participating are the Office of the Assistant Secretary for Health, the Food and Drug Administration, National Institute on Drug Abuse, Substance Abuse and Mental Health Services Administration, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the Department of Veterans Affairs, the American Medical Association, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education, the Accreditation Council for Continuing Medical Education, the Council of Medical Specialty Societies, the Federation of State Medical Boards, the American Hospital Association, the Hospital Corporation of America, and Aetna. The Collaborative?s membership will be finalized soon after the July 27 planning meeting. The July 27 meeting will seek to affirm the mission, goals, and objectives of the Collaborative, finalize the focus areas as well as to explore the objectives of the and potential activities to achieve those objectives. Notes: I Dr. Houry and Dr. Shuchat serve as CDC's representatives to NAM's Action Collaborative on countering the opioid epidemic and will participate in the kickoff on July 27?th and have contributed $10k to this effort. 0 Liz Finkelman [lead for this work at NAM) called into the NCIPC BSC meeting on 6f19 for the discussion on the ?Methodologies for Estimating Rates of Opioid Prescribing? project. 0 IF NEEDED: CDC is undertaking a new project to estimate best practice opioid prescribing in the United States. The plan is to estimate current opioid prescribing rates in the US for various conditions and procedures. Using clinical guidelines and related research, CDC will estimate what the prescribing rates would be for these conditions and procedures if best practices were followed. Based on this information, CDC will calculate how much the current prescribing rates for acute and chronic pain would need to change across the US population to be consistent with best practices. 0 This was presented to the Injury Center?s Boa rd of Scientific Counselors last week. The BBC voted to approve the formation of the workgroup after considering comments from the public. Most of the comments were suggestions for additional experts to consider as consultants or members of the workgroup occupational medicine, pharmacy, and behavioral health]. We will consider the suggestions and fine tune the group as needed as well as how it complements the work of the Action Collaborative. - Does the ?Methodologies for Estimating Rates of Opioid Prescribing" duplicate any other efforts that are underway by CDC or other agencies? 0 To the best of knowledge, these efforts are unique to any others that are underway. 0 With regard to other efforts, CDC is aware that the National Academy of Medicine is working with FDA on a study evaluating the evidence base for existing opioid prescribing guidelines, including identification of areas where guidelines are felt to be missing but necessary. 0 To help inform this work, NAM has convened the Collaborative composed of representatives from major medical specialty societies; beyond this particular study, this Collaborative may also pursue broader research into prescribing behaviors and the role of regulation in this space, among other ideas. 0 However, to our knowledge, undertaking does not address (2005 primary research question addressing the differences between opioid prescribing best practices and current prescribing data at a population level, the overarching focus of our project. 0 We are not aware of any other efforts underway by other stakeholders that address our main research question. I Related to this, we are leading a multi-HHS agency effort to leverage existing guidelines to develop best practices for opioid prescribing for specific indications? and settings; collaborate with AHRQ to update the evidence review around prescribing and update the CDC opioid prescribing guideline to include acute pain and specific indications as appropriate; and disseminate and identify tools and resources for providers. Using the clinical guidelines and related research, we will identify best practices for opioid prescribing for specific indications and for speci?c settings ED visits for ankle sprains, treatment for kidney stones, and post?surgical treatments for c?sections). Materials will be developed to provide clinical guidance to providers on best prescribing practices for these specific indications. NAM Forum on Mental Health and Substance Use Disorders Despite the high rates of comorbidity of physical and behavioral health conditions [which include mental health and substance~re ated and addictive disorders), the integration of services for these conditions into the American healthcare system has proved challenging. The Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine is developing a new Forum on Mental Health and Substance Use Disorders to address challenges in the delivery of high?quality care to individuals with these disorders that frequently intersect. The Forum will focus on data, policies, practices, and systems that affect the diagnosis and provision of care for mental health and substance use disorders. Its activities will focus on adults (including older adults) and will facilitate sustained attention to these disorders. The priorities of the Forum will be defined by the Forum members, and may evolve overtime based on emerging needs and opportunities, but the overarching theme will be access to care and challenges to the integration of mental healthcare with primary and specialty care. Forum participants will include representatives from a diverse group of stakeholders government agencies, professional associations, consumer and advocacy groups, private foundations, private insurers, and large pharmaceutical industry organizations. The tentative list of federal sponsoring agencies include VA, CMS, HRSA, SAMHSA and CDC. The Forum will host convening activities (primarily public workshops} and publish perspectives papers to illuminate shared challenges and potential solutions. Notes: Dr. Althea Grant serves as representatives to the Forum. The kickoff will likely be in September 2018. CDC is contributing $50k to the effort. Note: Mental Health and Substance Use Forum vs Action Collaborative on countering the opioid epidemic The work of the Forum and the Collaborative will be complementary and reinforcing of one another through shared learnings, and not redundant. While the Forum will have a broader scope and tackle issues pertaining to the larger fields of mental health and substance use disorders, the Collaborative will focus solely on targeted priorities related to addressing the opioid epidemic. Members of the same, core Academies? staff team will work across these activities to ensure coordination and continuity across these activities. Potential Research on Gun Violence BLUF: CDC does not have specific appropriated funding to support firearm violence research and prevention. Should Congress provide CDC with funding and direction to expand this work, CDC would look to pursue research activities that align with the priorities identified in the IOMIN RC report, Priorities for Research to Reduce the Threat of Firearm-Rated Vioience. Appropriations - Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? This language was extended to all HHS agencies in FY 2012. The language does not prohibit CDC from conducting public health research on firearm violence. CDC receives its funding through the appropriation process, which provides funding by topical line item. We currently conduct and fund research on a variety of injury?related topics, including youth violence, child abuse and neglect, domestic violence and sexual violence. - CDC does not have specific appropriated funding to support firearm violence research and prevention. Should Congress provide CDC with funding and direction to expand this work, CDC would look to pursue research activities that align with the priorities identified in the IOMINRC report, Priorities for Research to Reduce the Threat of Firearm-Rated Vioience. This includes understanding the characteristics of firearm violence; the risk and protective factors for interpersonal and self?directed firearm violence; safe storage, specific populations such as children and Veterans; and the effectiveness of interventions to prevent firearm violence. 0 However, CDC has and continues epi-aid investigation and analyses of data to document the public health burden of firearm injuries in the U.S. - Firearms are also a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 0 The recently released Vital Signs on Suicide, which you?ll hear more about next, is just one example of research we've done that includes a firearm component. Surveiilance I We also collect information on firearm?related violence through national surveillance systems. Another system is our National Violent Death Reporting System or - is the only state?based Surveillance system that pools data on violent deaths from multiple sources into a usable, anonymous database. It captures information about the firearm used in the violent death type of firearm, make and model, caliberfgauge) as well as information about whether the firearm was stolen, how it was stored, and whether it belonged to the victim. currently funds 40 states plus the District of Columbia and Puerto Rico, and with the increase in appropriations for FY 2018, the goal is to reach all 50 states. We have, and continue to, facilitate conversations with unfunded states to better understand what they need in order to join including resources, capacity, staffing, and leadership buy-in. We are also enhancing the system overall, through increasing efficiency in releasing data, in allowing access to data, and in assuring completeness of data. Data collection on firearm related- variables has varied across states, so we are assisting states in improving collection of those data as well. From: Lenard, Courtney Sent: 21 Mar 2016 16:32:47 To: Houry, Debra E. Amy B. Cc: Connelly, Erin Subject: Re: For Review: The Trace-gun violence Thank you! From: Hoary, Debra E. Sent: Monday, March 21. 2016 04:30 PM To: Lenard. Courtney Peoples. Amy B. Ce: Connolly, Erin Subject: RE: For Review: The Trace-gun vioience I think this is fine and yes attribution ok Deb Houry, MD, MPH Director National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 4770 Buford Highway, Mail Stop Atlanta, GA 30341 Twitter: Phone: {770) ?1884696 Fax: (770) 488?4222 From: Lenard, Courtney Sent: Monday, March 21, 2016 4:03 PM To: Houry, Debra E. Peeples, Amy B. Cc: Connelly, Erin (CDCIDNDIEHINCIPCJ Subject: RE: For Review: The Tracemgun violence Hi Deb, Kate Masters has come back with a follow up for you, she is publishing her piece tomorrow on CDC and gun violence research. I don?t think there is anything different to say and suggest repeating pretty much what we have already said to her. Are you ok with this attributed to you? DVP has reviewed. Thank you! Courtney Question for Deb: Does she think that the CDC does enough research on gun violence and prevention? is it doing everything it possibiy can under the current circumstances? Proposed Ressponse: The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. While firearm injuries are a mechanism of injury and can be examined in the context of other violence topics, the $10 million in the President?s budget request to Congress would be necessary to pursue the research priorities identified in the research agenda. From: Houry, Debra E. Sent: Tuesday, February 02, 2016 7:01 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Peeples, Amy B. Cc: Connelly, Erin (CDCIONDIEHINCIPQ Subject: RE: For Review: The Trace-gun violence See my edits below From: Lenard, Courtney Sent: Tuesday, February 02, 2016 4:27 PM To: Houry, Debra E. Peeples, Amy B. Cc: Connelly, Erin Subject: For Review: The Trace-gun violence Hi Deb, Kate Masters with The Trace requested an interview with you, originally stating she wanted to discuss: ?My article is going to be about violence research at the CDC versus the NIH, so most of my questions would center on her approach to running the Center for injury Control and Prevention, accomplishments she's made, and priorities she'd still like to work on. Based on prior requests she has had with us (Wilmington and gun violence} and with NIH, asked for specific questions that we could address via email. Here they are. Responses have been reviewed/revised with Linda Dahlberg, OPP has also been in the loop. Responses are primarily pulled from our cleared (MA on the issue. I will also get HHS clearance once you review. Thank you! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non~research activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence overtime, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence was released by the on June 5,2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IOM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non?fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the "The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.? 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers (ICRCs), the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01linvestigator? initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: 0 one study (which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. IA 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; IA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did_the CDC_stop monitoring U.S. gun ownership in 2004, and why? {a?pfoue?l/rengwed by Divi?on af?rmation Health-j The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more i_nformation_about please visit: Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .cdc. 111111623 0a] .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 I .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 Most recent VDRS Surveillance mummy: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 la1.htm .- ll- an Jq. Saving Lives and Protecting People from Violence and Inju ry From: Lenard, Courtney Sent: 10 Mar 2016 13:59:41 -0500 To: Dahlberg, Linda L. James Thomas Elizabeth Melissa R. (CDCIONDJEHINCIPC) Cc: Connelly, Erin Ga braelle Jennifer Alan J. (CTRl;Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Thank you, Linda! see how OADC would like to handle. From: Dahlberg, Linda L. Sent: Thursday, March 10, 2016 10:49 AM To: Lenard, Courtney Mercy, James Simon, Thomas Soihtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (CDCIONDIEHXNCIPC) Subject: RE: For Review: The Trace-gun violence Hi Courtney Not sure what else to say. The story they are proposing was first written by the Washington Post several months ago and has been picked up by other outlets. Dr. Frieden noted in recent conversations with members of Congress that given the President?s request for the CDC to conduct research into the causes and prevention of gun violence, it would be in best interest to have Congress appropriate funds for this work. That would make it clear that Congress wants to fund CDC to do gun violence research and would remove any ambiguity. Dr. Frieden noted that the IOM report conducted a few years ago lists many research avenues that might gain bipartisan support for research. Linda From: Lenard, Courtney (CDCIDNDIEHXNCIPC) Sent: Thursday, March 10, 2015 10:32 AM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin cedechc.gov>; Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (CDCIONDIEHINCIPC) Subject: RE: For Review: The Trace-gun violence Good morning! Kate Masters with The Trace has reached out again with the note below. You can see in the thread all that we have provided in the past. Aside from reiterating again, please let me know if you have any other thoughts on how to respond. Thankyou! Courtney From Kate: Thanks again for all the information about the It was defmitely helpful and that piece should be up on our site soon. I'm emailing today because my editors and]. are in the drafting phase of my piece on gun violence research at the CDC, and I wanted to let you know that the basis of the story is that the CDC is avoiding the issue of gun violence and bowing to political pressure by essentially foregoing research on ?rearms, even though there are things the agency could be doing. This is coming from former employees of the CDC, as well as outside gun violence researchers. I wanted to tell you this so there would be no surprise when the article came out, and also because I wanted to give the CDC a chance to respond to what others are saying. That response could be a statement from you, or I would still love to speak with Dr. Houry directly about the lack of gun research at the Injury Center, but I do recommend addressing these statements somehow so that the voice is included in the piece. From: Dahlberg, Linda L. Sent: Tuesday, February 09, 2016 8:55 AM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth (cocronolEH/Ncwci Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Suggest a simple response. ?We have not reached out to them specifically?. From: Lenard, Courtney Sent: Monday, February 08, 2016 6:14 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi? After previding this, We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out to the NRA in recent years. Here?s a follow up from The Trace: And when you say that you have not reached out to the NRA in recent years, do you mean that you have not informed them of ?rearm-related articles in recent years, or you just haven't reached out to them speci?cally? Has the CDC always alerted stakeholders on gun violence articles? Proposed Response: We have not informed the NRA of firearm?related articles in recent years. As previously mentioned, we routinely alert stakeholder organizations when relevant articles are released. Thanks much! Courtney From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 4:01 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Works for me, although I believe the word ?specifically" was deleted last time. We can save the second part if she comes back again. From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:59 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Subject: RE: For Review: The Trace-gun violence Here?s what we provided to AP, will the ?rst part work? We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out Specifically to the NRA in recent years. Mike Stobbe asked when it startedg?why it stopped, don?t think it is necessary at this point. Providing advance notification to NRA about forthcoming articles was done at the request of the NRA as a part of an effort to improve communication between our two organizations. We do not have documentation about when this started, but believe it was in the early 20005. The Associate Director for SciEnce in the National Center for Injury Prevention and Control provided advance notification of forthcoming articles, but not an advance copy of articles. The practice ended due to staff turnover in both organizations. From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 3:35 PM To: Lenard, Courtney Mercy, James Simon, Thomas (CDCIONDIEHINCIPC) Soihtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney I checked with Jim. He doesn?t have a copy of the report. In terms of the "gentleman's agreement? I believe NCIPC DD prepared a response before to that question so I defer to others to answer. It said something along the following lines: ?We have not communicated with the NRA for several years? Thanks, Linda From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:24 PM To: Dahlberg, Linda L. Mercy, James (CDCJONDIEHINCIPCJ Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi all, Another follow up from The Trace: does the CDC still have a ?gentleman's agreement" with the gun lobby to report out, to the lobby, any gun research completed by their grantees, whether that research was actually completed with CDC funds or not? Also, to keep everyone in the loop, I sent Linda 3 separate email with this question, she and Jim are consulting. One of the subjects for my story mentioned that in the 19903, after the CDC Injury Center had producedlfunded a number of studies about gun violence, then-CDC Director David Satcher commissioned a panel of outside experts to review that portfolio of work and make sure it wasn?t biased toward gun control advocacy. The panel ultimately concluded that the studies weren't biased and were in fact extremely well done, and I was wondering if you knew ofa way I could access that report so I could cite it in my article. I would love to get a copy or even the name so I can look it up myself. Thanks you! Courtney From: Dahlberg, Linda L. (CDCIDNDIEHINCIPC) Sent: Wednesday, February 03, 2015 6:10 AM To: Lenard, Courtney Mercy, James Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. {cm} Reimels, Elizabeth Subject: Re: For Review: The Trace-gun violence Hi Courtney. The responses are fine. Thank you, Linda Sent from my BlackBerry From: Lenard, Courtney (CDCJONDIEHJNCIPC) Sent: Wednesday, February 03, 2016 12:49 AM Eastern Standard Time To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Linda, Will you please take a look at the responses and let me know if you are ok with how they read? Deb revised but unfortunately I don't have her exact changes. Looks like mainly she shortened some answers. Thank you! Courtney 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non-research activities. However, firearms are a mechanism of injury, so it is possible to address firearmsrelated violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The RC research agenda - Priorities Jfor Research to Reduce the Threat of Fi'reorm-Reioted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IBM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 {investigator- initiatedj grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: tone study (which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; IA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 3. Did the CDC stop monitoring U.5. gun ownership in 2004, and why? (approvedfreviewed by Division of Reputation Health) The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 1f 1 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 I . . go 6408a] .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27', 2012 Most recent Surveillance Summary: Surveillance for Violent Deaths National 1Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 la1.htm From: Dahlberg, Linda L. Sent: Tuesday, February 02, 2016 3:55 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney - See edits in red below. I didn?t provide an answer for the first question. I will leave that one to someone else. Let me know if you have any questions. Linda From: Lenard, Courtney Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb). Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on (11 8t 03. Thanks much! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non?research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in CDC's appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Reinted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IBM and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making ?rearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries 7. Has the CDC dedicated any funding to guns or gun violence since the Dichey?mendment?was passed? If so . assisted? Following the FY 1997 appropriation language, funded entities conducted some investigator- initiated, peer-reviewed studies on fatal and non- -fata firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 {investigator initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: tone study (which began in 1995} examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non?gun injuries. 15A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; -A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in RDD surveys in general. (making sure this Is Still pit with HRH) Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 ll .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994-2012 MMWR. March 6, 2015 . cde. 8a] .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 031? recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 a 1 him l??l W131- . ..-, I {Tran-.Saving lees and Protecting People from Violence and anu ry From: Dahlberg, Linda L. (CDCXONDIEHJNCIPC) Sent: 9 Feb 2016 21:40:54 +0000 To: Lenard, Courtney Subject: RE: For Review: The Trace-gun violence You?re welcome! From: Lenard, Courtney Sent: Tuesday, February 09, 2016 4:33 PM To: Dahlberg, Linda L. Subject: RE: For Review: The Trace-gun violence Linda, I forgot to thank the millionth time From: Dahlberg, Linda L. Sent: Tuesday, February 09, 2016 8:55 AM To: Lenard, Courtney (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Subject: RE: For Review: The Trace-gun violence Suggest a simple response. ?We have not reached out to them specifically?. From: Lenard, Courtney Sent: Monday, February 08, 2016 6:14 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas (t 59 cdc. Solhtalab, Elizabeth (CDCIONDIEHINCIPC) Cc: Connelly, Erin sedechcgov}; Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCIONDIEHINCIPC) (CTR) Reimels, Elizabeth Subject: RE: For Review: The Tracewgun violence Hi- After providing this, We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out to the NRA in recent years. Here?s a follow up from The Trace: And when you say that you have not reached out to the NRA in recent years, do you mean that you have not informed them of ?rearm?related articles in recent years, or you just haven't reached out to them speci?cally? Has the CDC always alerted stakeholders on gun violence articles? Proposed Response: We have not informed the NRA of firearm-related articles in recent years. As previously mentioned, we routinely alert stakeholder organizations when relevant articles are released. Thanks much! Courtney From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 4:01 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Works for me, although I believe the word ?specifically" was deleted last time. We can save the second part if she comes back again. From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:59 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Subject: RE: For Review: The Trace-gun violence Here?s what we provided to AP, will the ?rst part work? We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out Specifically to the NRA in recent years. Mike Stobbe asked when it startedg?why it stopped, don?t think it is necessary at this point. Providing advance notification to NRA about forthcoming articles was done at the request of the NRA as a part of an effort to improve communication between our two organizations. We do not have documentation about when this started, but believe it was in the early 20005. The Associate Director for SciEnce in the National Center for Injury Prevention and Control provided advance notification of forthcoming articles, but not an advance copy of articles. The practice ended due to staff turnover in both organizations. From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 3:35 PM To: Lenard, Courtney Mercy, James Simon, Thomas (CDCIONDIEHINCIPC) Soihtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney I checked with Jim. He doesn?t have a copy of the report. In terms of the "gentleman's agreement? I believe NCIPC DD prepared a response before to that question so I defer to others to answer. It said something along the following lines: ?We have not communicated with the NRA for several years? Thanks, Linda From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:24 PM To: Dahlberg, Linda L. Mercy, James (CDCJONDIEHINCIPCJ Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi all, Another follow up from The Trace: does the CDC still have a ?gentleman's agreement" with the gun lobby to report out, to the lobby, any gun research completed by their grantees, whether that research was actually completed with CDC funds or not? Also, to keep everyone in the loop, I sent Linda 3 separate email with this question, she and Jim are consulting. One of the subjects for my story mentioned that in the 19903, after the CDC Injury Center had producedlfunded a number of studies about gun violence, then-CDC Director David Satcher commissioned a panel of outside experts to review that portfolio of work and make sure it wasn?t biased toward gun control advocacy. The panel ultimately concluded that the studies weren't biased and were in fact extremely well done, and I was wondering if you knew ofa way I could access that report so I could cite it in my article. I would love to get a copy or even the name so I can look it up myself. Thanks you! Courtney From: Dahlberg, Linda L. (CDCIDNDIEHINCIPC) Sent: Wednesday, February 03, 2015 6:10 AM To: Lenard, Courtney Mercy, James Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. {cm} Reimels, Elizabeth Subject: Re: For Review: The Trace-gun violence Hi Courtney. The responses are fine. Thank you, Linda Sent from my BlackBerry From: Lenard, Courtney (CDCJONDIEHJNCIPC) Sent: Wednesday, February 03, 2016 12:49 AM Eastern Standard Time To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Linda, Will you please take a look at the responses and let me know if you are ok with how they read? Deb revised but unfortunately I don't have her exact changes. Looks like mainly she shortened some answers. Thank you! Courtney 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non-research activities. However, firearms are a mechanism of injury, so it is possible to address firearmsrelated violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The RC research agenda - Priorities Jfor Research to Reduce the Threat of Fi'reorm-Reioted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IBM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 {investigator- initiatedj grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: tone study (which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; IA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 3. Did the CDC stop monitoring U.5. gun ownership in 2004, and why? (approvedfreviewed by Division of Reputation Health) The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 1f 1 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 I . . go 6408a] .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27', 2012 Most recent Surveillance Summary: Surveillance for Violent Deaths National 1Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 la1.htm From: Dahlberg, Linda L. Sent: Tuesday, February 02, 2016 3:55 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney - See edits in red below. I didn?t provide an answer for the first question. I will leave that one to someone else. Let me know if you have any questions. Linda From: Lenard, Courtney Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb). Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on (11 8t 03. Thanks much! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non?research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in CDC's appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Reinted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IBM and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making ?rearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries 7. Has the CDC dedicated any funding to guns or gun violence since the Dichey?mendment?was passed? If so . assisted? Following the FY 1997 appropriation language, funded entities conducted some investigator- initiated, peer-reviewed studies on fatal and non- -fata firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 {investigator initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: tone study (which began in 1995} examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non?gun injuries. 15A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; -A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in RDD surveys in general. (making sure this Is Still pit with HRH) Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 ll .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994-2012 MMWR. March 6, 2015 . cde. 8a] .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 031? recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 a 1 him l??l W131- . ..-, I {Tran-.Saving lees and Protecting People from Violence and anu ry From: Lenard, Courtney Sent: 4 Feb 2015 16:18:54 -0500 To: Dahlberg, Linda L. James Thomas Elizabeth Melissa R. Cc: Connelly, Erin Ga braelle Jennifer Alan J. (CTRi;Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Sounds From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 4:01 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (CDCIONDIEHINCIPC) Subject: RE: For Review: The Trace-gun violence Works for me, although I believe the word ?specifically? was deleted last time. We can save the second part if she comes back again. From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:59 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas (CDCIDNDIEHINCIPC) Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraeile Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth cixn2@cdc.gov> Subject: RE: For Review: The Trace-gun violence Here?s what we provided to AP, will the first part work? We routinely alert stakeholder organizations when reievant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out specifically to the NRA in recent years. Mike Stobbe asked when it startedg?why it stopped, don?t think it is necessary at this point. Providing advance notification to NRA about forthcoming articles was done at the request of the NRA as a part of an effort to improve communication between our two organizations. We do not have documentation about when this started, but believe it was in the early 20005. The Associate Director for Science in the National Center for Injury Prevention and Control provided advance notification of forthcoming articles, but not an advance copy of articles. The practice ended due to staff turnover in both organizations. From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 3:35 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney I checked with Jim. He doesn?t have a copy of the report. In terms of the ?gentleman?s agreement" ?l believe NCIPC 00 prepared a response before to that question sol defer to others to answer. it said something along the following lines: ?We have not communicated with the NRA for several years? Thanks Linda From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:24 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. f0 cdc. ov> Cc: Connelly, Erin (edechcgova; Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi all, Another follow up from The Trace: does the CDC still have a ?gentleman's agreement" with the gun lobby to report out, to the lobby, any gun research completed by their grantees, whether that research was actually completed with CDC funds or not? Also, to keep everyone in the loop, I sent Linda a separate email with this question, she and Jim are consulting. One of the subjects for my story mentioned that in the 19903, after the CDC Injury Center had produced/funded a number of studies aboot gun violence, then?CDC Director David Satcher commissioned a panel of outside experts to review that portfolio of work and make sure it wasn?t biased toward gun control advocacy. The panel ultimately concluded that the studies weren?t biased and were in fact extremely well done, and I was wondering if you knew of a way I could access that report so I could cite it in my article. I would love to get a copy or even the name so I can look it up myself. Thanksyoul Courtney From: Dahlberg, Linda L. Sent: Wednesday, February 03, 2016 6:10 AM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. f0 cdc. ov> Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (cocfonoIEHxNCIPci Subject: Re: For Review: The Trace-gun violence Hi Courtney, The responses are fine. Thank you, Linda Sent from my BlackBerry From: Lenard, Courtney (CDCIDNDIEHINCIPC) Sent: Wednesday, February 03, 2016 12:49 AM Eastern Standard Time To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. (CDCIONDIEHINCIPC) Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCIDNDIEHINCIPC) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Linda, Will you please take a look at the responses and let me know if you are ok with how they read? Deb revised but unfortunately I don?t have her exact changes. Looks like mainly she shortened some answers. Thank you! Courtney 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. i know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non?research activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997', CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut CDC's budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of FirearmnReiated Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm?Reiated Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IOM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm?related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.? 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 (investigator- initiated) grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: 0 one study (which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non?gun injuries. IA 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; IA 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? [apprwedfreviewedgy Batman of Population Health.) The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 . cdc. 0a 1. .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 I .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003-2008 MMWR. January 27, 2012 i? if 1111116 103 alhtm Most recent Sunaeih'once ummarv: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 la] .htm From: Dahlberg, Linda L. Sent: Tuesday, February 02, 2016 3:55 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney See edits in red below. I didn?t provide an answer for the first question. I will leave that one to someone else. Let me know if you have any questions. Linda From: Lenard, Courtney Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James (CDCXONDIEHINCIPQ Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa Ft. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb}. Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on (11 8: C13. Thanks much! Courtney Questions: I. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why'? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in CDC's appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Reicted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IBM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the ?The complexity and frequency of ?rearm violence. combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries 7 Has the CDC dedicated any funding to research involving guns_ or gun violenc_e_ since the Eflckey Amendment was passed? If so, h?m?m: wagging; ef?ng mm Following the FY 1997 appropriation language funded entities conducted some investigator-initiated, peer-reviewed studies on fetal and non fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention and universities awarded R01 {investigator- initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: none study (which began in 1995} examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; -A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? CDC's Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in RDD surveys in general . W?mm ?n?lg?hm?l Firearm Injnries in the United States Prev Med. 2015 Oct;79:5- 14 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27', 2012 103a2 .htm Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 63(880] );1-33 la] .htm Saving Lives and Protecting People from molence and inju ry From: fo=cdc1ou=exchange administrative group lfydibohf235pdlt1/c n=recipie nts/cn=f43 dd520d1854120aa942ac284d c7713-discove rysea mailb Sent: 28 Aug 2018 19:24:48 +0000 To: Lenard, Courtney Amy B. Cc: Connelly, Erin Subject: RE: For Review: The Trace-gun violence How about- I added some edits in red- feel free to delete though Deb Houry, MD, MPH Director National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 4270 Buford Highway, Mail Stop Atlanta, GA 30341 Twitter: Phone: 488-4695 I Fax: [770} 488?4222 From: Lenard, Courtney Sent: Monday, March 21, 2016 4:03 PM To: Houry, Debra E. Peeples, Amy B. Cc: Connelly, Erin Subject: RE: For Review: The Trace-gun violence Hi Deb, Kate Masters has come back with a follow up for you, she is publishing her piece tomorrow on CDC and gun violence research. I don?t think there is anything different to say and suggest repeating pretty much what we have already said to her. Are you ok with this attributed to you? DVP has reviewed. Thank you! Courtney Question for Deb: Does she think that the CDC does enough research on gun vioience and prevention? is it doing everything it possibly can under the current circumstances? Proposed Ressponse: The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence and would like to do more. These are the topical line items that are supported through annual appropriation for both research and non-research activities. CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. While firearm injuries are a mechanism of injury and can be examined in the context of other violence topics, the $10 million in the President?s budget request to Congress would be necessary to pursue the research priorities identi?ed in the research agenda. From: Houry, Debra E. Sent: Tuesday, February 02, 2016 7:01 PM To: Lenard, Courtney Peeples, Amy B. Cc: Connelly, Erin Subject: RE: For Review: The Trace-gun violence See my edits below From: Lenard, Courtney Sent: Tuesday, February 02, 2016 4:27 PM To: Houry, Debra E. Peeples, Amy B. Cc:Connelly, Erin Subject: For Review: The Trace-gun violence Hi Deb, Kate Masters with The Trace requested an interview with you, originally stating she wanted to discuss: "My article is going to be about violence research at the CDC versus the NIH, so most of my questions would center on her approach to running the Center for Injury Controi and Prevention, accompiishments she's made, and priorities she'd to work on.? Based on prior requests she has had with us (Wilmington and gun violence} and with NIH, asked for specific questions that we could address via email. Here they are. Responses have been reviewed/revised with Linda Dahlberg, OPP has also been in the loop. Responses are primarily pulled from our cleared on the issue. I will also get HHS clearance once you review. Thank you! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and nonuresearch activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence {about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence was released by the IOMINRC on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IOM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the IOMIN RC, "The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.? Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, entities conducted some investigator-initiated, peer?reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers (ICRCs), the first cycle of the Academic Centers for Excellence on Youth Violence Prevention and universities awarded R01 (investigator- initiated) grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: a one study (which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. IA 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; IA 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; uA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? Division. of ?Population Health), The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: TIEILES Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 [111116 1 03a2.htm Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 la1.htn1 x+l P?l LEA I?ul'u. I?i EII It." il"1 'l 77.! 1? .ll'v .-. v. Saving lees and Protecting People from Violence and Inju ry From: Dahlberg, Linda L. (CDCXONDIEHXNCIPC) Sent: 4 Feb 2016 20:56:13 +0000 To: Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence These reporters are driving me crazy! From: Reimels, Elizabeth (CDCXONDIEHINCIPC) Sent: Thursday, February 04, 2016 3:53 PM To: Dahlberg, Linda L. Subject: RE: For Review: The Trace-gun violence Made me laugh! From: Dahlberg, Linda L. (CDCIDNDIEHINCIPCJ Sent: Thursday, February 04, 2016 3:40 PM To: Mercy, James Lenard, Courtney (CDCXONDIEHINCIPC) Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin (CDCIONDIEHINCIPQ Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Me either sorry. I was nine years old at the From: Mercy, James Sent: Thursday, February 04, 2016 3:39 PM To: Lenard, Courtney Dahlberg, Linda L. Simon, Thomas {t 59 cdc. Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin sedechcgov}; Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Tracewgun violence I remember the report, but can?t recall the name of it. From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:3? PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Soihtalab, Elizabeth (CDCIONDIEHHNCIPC) Cyril, Melissa R. f0 cdc. ov> Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Thanks Linda and we know the name of the report? For the second, let me look back, that was developed for the AP request. I?ll send around in a From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 3:35 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth [cocxowoiEH/Ncwci Subject: RE: For Review: The Trace-gun violence Hi Courtney - I checked with Jim. He doesn?t have a copy of the report. In terms of the ?gentleman's agreement? ?l believe NCIPC OD prepared a response before to that question - so i defer to others to answer. It said something along the following lines: ?We have not communicated with the NRA for several years" Thanks Linda From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:24 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Subject: RE: For Review: The Tracewgun violence Hi all, Another follow up from The Trace: does the CDC. still have a ?gentleman?s agreement? with the gun lobby to report out, to the lobby, any gun research completed by their grantees. whether that research was actually completed with CDC funds or not? Also, to keep everyone in the loop, I sent Linda a separate email with this question, she and .lim are consulting. One of the subjects for my story mentioned that in the 19903, after the CDC Injury Center had produced/funded a number of studies about gun violence, then?CDC Director David Satcher commissioned a panel of outside experts to review that portfolio of work and make sure it wasn?t biased toward gun control advocacy. The panel ultimately concluded that the studies weren't biased and were in fact extremely well done, and I was wondering if you knew of a way I could access that report so I could cite it in my article. I would love to get a copy or even the name so I can look it up myself. Thanks you! Courtney From: Dahlberg, Linda L. Sent: Wednesday, February 03, 2016 6:10 AM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jen nifer PC) Willia ms, Alan J. (CTR) Reimels, Elizabeth Subject: Re: For Review: The Trace-gun violence Hi Courtney, The responses are fine. Thankyou, Linda Sent from my BlackBerry From: Lenard, Courtney (CDCIDNDIEHINCIPC) Sent: Wednesday, February 03, 2016 12:49 AM Eastern Standard Time To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. (CDCIONDIEHINCIPC) Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCIONDIEHINCIPC) (CT Reimels, Elizabeth (CDCIDNDIEHINCIPC) Subject: RE: For Review: The Trace-gun violence Hi Linda, Will you please take a look at the responses and let me know if you are ok with how they read? Deb revised but unfortunately I don?t have her exact changes. Looks like mainly she shortened some answers. Thank you! Courtney 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence overtime, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda - Priorities for Research to Reduce the Threat of Firearm-Reiatea? Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Reiatea' Viaience was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IOM and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the "The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non~fata firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 (investigator- initiated) grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: none study (which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; IA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? (approved/reviewed by Divisiun-ef Populatia-n Healthl The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 gov! pubmedf261 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 gov/mmwr/ preview! mm 622 Ta 1 .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 Most recent Suryefi'lnnce Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 a] .htm From: Dahlberg, Linda L. Sent: Tuesday, February 02, 2016 3:55 PM To: Lenard, Courtney (CDCXONDIEHINCIPC) Mercy, James Simon, Thomas Solhtalab, Elizabeth (CDCIDNDIEHXNCIPC) Cyril, Melissa Ft. f0 cdc. ov> Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCXONDIEHINCIPC) (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney See edits in red below. I didn?t provide an answer for the first question. I will leave that one to someone else. Let me know if you have any questions. Linda From: Lenard, Courtney Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James (CDCIONDIEHINCIPC) Subject: For Review: The Tracevgun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb). Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on Q1 8t C13. Thanks much! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in CDC's appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Reicted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IBM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the ?The complexity and frequency of ?rearm violence. combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries 7 Has the CDC dedicated any funding to research involving guns_ or gun violenc_e_ since the Eflckey Amendment was passed? If so, h?m?m: wagging; ef?ng mm Following the FY 1997 appropriation language funded entities conducted some investigator-initiated, peer-reviewed studies on fetal and non fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention and universities awarded R01 {investigator- initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: none study (which began in 1995} examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; -A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? CDC's Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in RDD surveys in general . W?mm ?n?lg?hm?l Firearm Injnries in the United States Prev Med. 2015 Oct;79:5- 14 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27', 2012 103a2 .htm Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 63(880] );1-33 la] .htm Saving Lives and Protecting People from molence and inju ry From: Lenard, Courtney Sent: 4 Feb 2016 15:20:28 -0500 To: Dahlberg, Linda L. Subject: RE: For Review: The Trace-gun violence Appreciate you checking! She has come back with another question that I'm not familiar also send to the whole group. does the CDC still have a "gentleman's agreement" with the gun lobby to report out, to the Lobby, any gun research completed by their grantees, whether that research was actually completed with CDC funds or not? From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 1:53 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Subject: RE: For Review: The Trace-gun violence Hi Courtney- I sent Jim 3 message about this. ca n?t find anything other than reference to three investigations GAO, National Academy of Sciences, and HHS Inspector General. 1 also found that Phil Cook was on the independent panel of experts to review our gun violence research portfolio so there was a panel, just don't know if a report is available to send. It was a long time ago Hoping Jim will have some information. Linda From: Lenard, Courtney Sent: Thursday, February 04, 2016 12:20 PM To: Dahlberg, Linda L. Subject: RE: For Review: The Trace-gun violence Not sure about this one i?ll do some digging to see if I can find the report referenced below. From: Lenard, Courtney Sent: Thursday, February 04, 2016 11:09 AM To: Dahlberg, Linda L. Mercy, James (CDCIONDIEHXNCIPCJ Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Good morning, Quick follow up from Kate, do you have a copy of this report or title? One of the subjects for my story mentioned that in the 1990s, after the CDC injury Center had producedffunded a number of studies about gun violence, then-CDC Director David Satcher commissioned a panel of outside experts to review that portfolio of work and make sure it wasn't biased toward gun control advocacy. The panel ultimately concluded that the studies weren't biased and were in fact extremely well done, and I was wondering if you knew of a way I could access that report so I could cite it in my article. I would love to get a copy or even the name so I can look it up myself. Thank you! Courtney From: Dahlberg, Linda L. Sent: Wednesday, February 03, 2016 6:10 AM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCKONDIEHINCIPC) (CTR) Reimels, Elizabeth Subject: Re: For Review: The Trace?gun violence Hi Courtney, The responses are fine. Thank you, Linda Sent from my BiackBerry From: Lenard, Courtney Sent: Wednesday, February 03, 2016 12:49 AM Eastern Standard Time To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. (CDCIONDIEHINCIPC) Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCIONDIEHINCIPC) (CT Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Linda, Will you please take a look at the responses and let me know if you are ok with how they read? Deb revised but unfortunately I don?t have her exact changes. Looks like mainly she shortened some answers. Thank you! Courtney 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. However, firearms are a mechanism of injury, so it is possible to address firearm?related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut CDC's budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of FirearmuReioted Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IDM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured 0r die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-54 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the IOMXN RC, "The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.? 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 {investigator- initiatedj grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: I one study (which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0 A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; I A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0 A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? {-approvedfrewewedby Divisionof Pepelati?e? Health) The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: is 53m ES Firearm injuries in the United States Prev Med. 2015 000795-14 l6133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 . ode. go vim mwr/prev iewf 11111164083 1 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 WWR. July 12, 2013 2? .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27', 2012 I 03512 .htm Most recent Surveillance H?iln?i?ji' Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 2014 la] .htm From: Dahlberg, Linda L. Sent: Tuesday, February 02, 2016 3:55 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cvril, Melissa R. Cc: Connellv, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCXONDIEHKNCIPC) (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney - See edits in red below. ldidn't provide an answer for the first question. I will leave that one to someone else. Let me know if you have any questions. Linda From: Lenard, Courtneyr Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James (CDCJONDIEHINCIPC) Subject: For Review: The Tracevgun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb). Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on Q1 C13. Thanks much! Courtney Questions: 1. Do you feel that the Injury Center would still suffer conseqvaences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but weald it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 20] 3, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda - Priorities Jfor Research to Reduce the Threat of Firearm-Related Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Dbama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IOM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center shOuld be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of ?rearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving or gun violence since the . a - of as s?l 1.3.investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention and universities awarded R01 (investigator- initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: I one study {which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. I A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; - A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0 A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a werking group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in RDD surveys in general. (making sure this is still ok with DPH) Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 I Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 govimmwn?preview,f l/mm? 103 a2.htm Most recent Surveiilmice Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 2014 .cdc. a 1 .htm Courtney N. Lenard, MA Heeafth Conunlmi-zemmn Specials? I Natmna. Gamer for Imuty Prever'lhor'? and (Denim! I Health (Sc-n?nr-mr?cahcm arid Sammie Di?ice I Oi 770 488.313? Monday 8: Friday teieworla and 803.303? Sawing Ltves and Protecting People from Violence and ln}ury From: Lenard, Courtney Sent: 21 Mar 2015 16:06:56 -0400 To: Dahlberg, Linda L. James Thomas Elizabeth Melissa R. Cc: Connelly, Erin ne, Ga braelle Jennifer Alan J. (CTR);Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Got it, thank you Linda! From: Dahlberg, Linda L. Sent: Monday, March 21, 2015 3:10 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney - The response seems fine to me. See additional edits beiow. Linda From: Lenard, Courtney Sent: Monday, March 21, 2016 2:42 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (CDCXONDIEHINCIPC) Subject: RE: For Review: The Trace?gun violence Hi all! Kate Masters has come back again, she is publishing her piece tomorrow on CDC and gun violence research. Again, I don?t think there is anything different to say and suggest repeating what we have already said to her. Are you ok with this? Thank you! Courtney Question for Deb: Does she think that the CBC does enough research on gun vioience and prevention? is it doing everything it possibiy can under the current circumstances? Proposed Rossponse: The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. While firearm injuries are a mechanism of injury and can be examined in the context of other violence topics the $10 million in the President?s budget request to Congress would be necessary to pursue the research priorities identified in the research agenda. - - Ti- antiserum ?ve: early February; l. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resame research on ?rearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but weald it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non-research activities. While firearm injuries are a mechanism of injury and can be examined in the context of other violence topics, the $10 million in the President?s budget request to Congress would be necessary to pursue the research priorities identified in the IOMINRC research agenda. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut CDC ?5 budget by an amount equal to what had been spent on research into gun violence (about million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with RC research agenda Priorities/hr Research to Reduce the Threat ofFirearm-Releted Violence 4. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? There is nothing in the appropriations language that prohibits CDC from conducting research on gun violence. CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of ?rearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The research agenda -- Prioritiesfor Research to Reduce the Threat of'Fireerm? Referred Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that and NRC identi?ed, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making ?rearm?related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the IOMIN RC ?The complexity and frequency of ?rearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC funded investigator?initiated, peer- reviewed studies on fatal and non?fatal ?rearm violence through the Injury Control and Response Centers (1C RC5), the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and through its grant program. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: I one study (which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. - A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-in?icted ?rearm injuries among children and adolescents; - A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; II A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying. CDC has also published a number of papers and reports. Examples are listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004. the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Fireann safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994-2012 MMWR. March 6, 2015 I .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 .cde. 1nmw mm? 103a2.htrn Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 lal .htrn From: Dahlberg, Linda L. Sent: Thursday, March 10, 2016 10:49 AM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin (CDCIONDIEHINCIPQ Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (cot/onoisamcwci (CTR) Reimels, Elizabeth (CDCXONDIEHINCIPC) Subject: RE: For Review: The Trace-gun violence Hi Courtney Not sure what else to say. The story they are proposing was first written by the Washington Post several months ago and has been picked up by other outlets. Dr. Frieden noted in recent conversations with members of Congress that given the President?s request for the CDC to conduct research into the causes and prevention of gun violence, it would be in best interest to have Congress appropriate funds for this work. That would make it clear that Congress wants to fund CDC to do gun violence research and would remove any ambiguity. Dr. Frieden noted that the IOM report conducted a few years ago lists many research avenues that might gain bipartisan support for research. Linda From: Lenard, Courtney (CDCXONDIEHINCIPC) Sent: Thursday, March 10, 2016 10:32 AM To: Dahlberg, Linda L. Mercy, James (CDCIONDIEHINCIPC) Simon, Thomas (CDCIONDIEHINCIPC) Solhtalab. Elizabeth Cyril, Melissa R. f0 cdc. ov> Cc: Connelly, Erin Subject: RE: For Review: The Trace-gun violence Good morning! Kate Masters with The Trace has reached out again with the note below. You can see in the thread all that we have provided in the past. Aside from reiterating again, please let me know if you have any other thoughts on how to respond. Thank you! Comtney Fromm: Thanks again for all the information about the It was definitely helpful and that piece should be up on our site soon. I'm emailing today because my editors and are in the drafting phase of my piece on gun violence research at the CDC, and I wanted to let you know that the basis of the story is that the CDC is avoiding the issue of gun violence and bowing to political pressure by essentially foregoing research on ?rearms, even though there are things the agency could be doing. This is coming from former employees of the CDC, as well as outside gun violence researchers. I wanted to tell you this so there would be no surprise when the article came out, and also because I wanted to give the CDC a chance to respond to what others are saying. That response could be a statement from you, or I would still love to speak with Dr. Henry directly about the lack of gun research at the Injury Center, but I do recommend addressing these statements somehow so that the voice is included in the piece. From: Dahlberg, Linda L. Sent: Tuesday, February 09, 2016 8:55 AM To: Lenard, Courtney (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Suggest a simple response. ?We have not reached out to them specifically?. From: Lenard, Courtney Sent: Monday, February 03, 2016 6:14 PM To: Dahlberg, Linda L. Mercy, James (CDCIONDIEHINCIPC) Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi? After providing this, We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out to the NRA in recent years. Here?s a follow up from The Trace: And when you say that you have not reached out to the NRA in recent years, do you mean that you have not informed them of ?rearm-related articles in recent years, or you just haven't reached out to them speci?cally? Has the CDC always alerted stakeholders on gun violence articles? Proposed ReSponse: We have not informed the NRA of firearm?related articles in recent years. As previously mentioned, we routinely alert stakeholder organizations when relevant articles are released. Thanks much! Courtney From: Dahlberg, Linda L. (CDCIONDIEHJNCIPC) Sent: Thursday, February 04, 2016 4:01 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. {ch) Reimels, Elizabeth Subject: RE: For Review: The Trace?gun violence Works for me, although I believe the word ?specifically? was deleted last time. We can save the second part if she comes back again. From: Lenard, Courtney (CDCJONDJEHINCIPC) Sent: Thursday, February 04, 2016 3:59 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Here?s what we provided to AP, will the first part work? We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out specifically to the NRA in recent years. Mike Stobbe asked when it it stopped, don?t think it is necessary at this point. Providing advance notification to NRA about forthcoming articles was done at the request of the NRA as a part of an effort to improve communication between our two organizations. We do not have documentation about when this started, but believe it was in the early 20005. The Associate Director for Science in the National Center for Injury Prevention and Control provided advance notification of forthcoming articles, but not an advance copy of articles. The practice ended due to staff turnover in both organizations. From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 3:35 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, <'od5 cdc. ov>; Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney I checked with Jim. He doesn't have a copy of the report. In terms of the ?gentleman?s agreement" I believe NCIPC 00 prepared a response before to that question so I defer to others to answer. It said something along the following lines: ?We have not communicated with the NRA for sEveral years" Thanks Linda From: Lenard, Courtney (CDCJONDJEHJNCIPC) Sent: Thursday, February 04, 2016 3:24 PM To: Dahlberg, Linda L. (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas (CDCIONDIEHINCIPC) Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (CDCIONDIEHINCIPC) Subject: RE: For Review: The Trace-gun violence Hi all, Another follow up from The Trace: does the CDC still have a ?gentleman?s agreement" with the gun lobby to report out, to the lobby, any gun research completed by their grantees, whether that research was actually completed with CDC funds or not? Also, to keep everyone in the loop, I sent Linda a separate email with this question, she and Jim are consulting. One of the subjects for my story mentioned that in the 19905. after the CDC Injury Center had producedi?funded a number of studies about gun violence, then-CDC Director David Satcher commissioned a panel of outside experts to review that portfolio of work and make sure it wasn?t biased toward gun control advocacy. The panel ultimately concluded that the studies weren't biased and were in fact extremely well done, and I was wondering if you knew of a way I could access that report so I could cite it in my article. I would love to get a copy or even the name so I can look it up myself. Thanks you! Courtney From: Dahlberg, Linda L. Sent: Wednesday, February 03, 2016 6:10 AM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth (CDCIONDIEHXNCIPC) Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth [cocronoiEH/NCIPC) cixn2@cdc.gov> Subject: Re: For Review: The Trace-gun violence Hi Courtney, The responses are fine. Thank you, Linda Sent from my BlackBerry From: Lenard, Courtney (CDCIDNDIEHINCIPC) Sent: Wednesday, February 03, 2016 12:49 AM Eastern Standard Time To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. (CDCIONDIEHJNCIPC) Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. Reimels, Elizabeth (CDCIUNDIEHINCIPC) Subject: RE: For Review: The Trace-gun violence Hi Linda, Will you please take a look at the responses and let me know if you are ok with how they read? Deb revised but unfortunately I don?t have her exact changes. Looks like mainly she shortened some answers. Thank you! Courtney 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non-research activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The IOM RC research agenda Priorities for Research to Reduce the Threat of Firearm-Related Vioience was released by the on June 5,2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that 10M and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1?64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers (ICRCs), the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01linvestigator~ initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: hone study (which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; IA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? magnetssmetmtisatbi The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 1 him Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 i? .htm Gang Homicides U.S. Cities, 2003-2008 MMWR. January 27, 2012 03 a2 .htm Most recent Lirvef?aiice emissary.- Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 2014 i? a] .htm From: Dahlberg, Linda L. Sent: Tuesday, February 02, 2016 3:55 PM To: Lenard, Courtney cdc. Mercy, James Simon, Thomas (CDCIONDIEHJNCIPC) Solhtalab, Elizabeth Cyril, Melissa R. Q: to cdc. ov> Cc: Connelly, Erin Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan .I. (CTR) Reimels, Elizabeth cixn2@cdc.gov> Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Debi. Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on C11 8: Q3. Thanks much! Courtney Questions: I. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even th0ugh there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why'? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence {about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U5. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in CDC's appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The IOMIN RC research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence ., was released by the IOMINRC on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that 10M and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making ?reann-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of ?rearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries 7. Has the CDC dedicated any funding toresearch invoLVIngguns or gun violegce.? since the - Dickey Amendment was passedFollowing {?it 1997 appropriation language, CDC- funded entities conducted some investigator- -initiated, peer-reviewed studies on fatal and non- -fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention and universities awarded R01 {investigator initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: 0 one study (which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in R00 surveys in general. {making sure this is still oi; with Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27, 2012 03a2.him Most recent Survei?euce Summary.- Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 .cdc. gov/mmwr/previ a 1 .htm {33. .. i. ch?riqirii. furl l'i-j 11 . . -- i inSaving Lives and Protecting People from Violence and Inju ry From: Lenard, Courtney Sent: 3 Feb 2016 13:44:22 {1500 To: Houry, Debra E. Amy B. Cc: Connelly, Erin Subject: Re: For Review: The Trace-gun violence FYI: these have been cleared. From: IIoury, Debra E. Sent: Tuesday. February 02, 2016 08:51 PM To: Lenard, Courtney Peoples, Amy B. Cc: Connolly, Erin (CDCJONDIEIIMCTIPC) Subject: Re: For Review: The Trace-gun violence And assuming this needs to go up for clearance? Ijust want to make sure folks ok with my edits. Sent from my BlackBerry 10 smartphone. From: Houry, Debra E. Sent: Tuesday, February 2, 2016 ?:01 PM To: Lenard, Courtney Peoples, Amy B. Cc: Connolly, Erin Subject: RE: For Review: The Trace-gun violence See my edits below From: Lenard, Courtney (CDCIONDIEHINCIPC) Sent: Tuesday, February 02, 2016 4:27 PM To: Houry, Debra E. Peoples. Amy B. Cc: Connolly, Erin Subject: For Review: The Trace-gun violence Hi Deb, Kate Masters with. The Trace requested an interview with you, originally stating she wanted to discuss: "My article is going to be about violence research at the CDC versus the NIH, so most of?ntv questions would center on her approach to runningr the Centerfor Injury Control and Prevention, accomplishments she?s mode. and priorities she'd still like to work on. Based on prior requests she has had with us {Wilmington and gun violence) and with NIH, I asked for speci?c questions that we could address via email. Here they are. Responses have been reviewedirevised with Linda Dahlberg, OPP has also been in the loop. Responses are primarily pulled from our cleared on the issue. I will also get HHS clearance once you review. Thank you! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to ?rearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. However, ?rearms are a mechanism of injury, so it is possible to address ?reann-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 199? Congress cut budget by an amount equal to what had been spent on research into gun violence (about million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the breast of irearm-Related Viotence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of ?rearm injuries in the U.S. Understanding the patterns, characteristics, and impact of ?rearm violence is an important step toward preventing ?rearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to ?rearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The research agenda Prioritiesfbr Research to Reduce the Threat of FirearmpReiated Violence was released by the on June 5, 2013. It was intended to guide research in the ?eld and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence. but Congress has not approved .it. To pursue many of the research priorities that 10M and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction. of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the RC ?The complexity and frequency of firearm violence. combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." Has the CDC dedicated any funding to research involving guns or gun violence since Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the 199? appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal ?rearm violence through the Injury Control and Response Centers (IC RC the ?rst cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACEs), and universities awarded R01 (investigator-initiated) grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: I one study [which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. I A 1998 study examined the effectiveness of household ?rearm storage methods in reducing unintentional and self?in?icted ?rearm injuries among children and adolescents; I A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; I A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? [approvedheviewed by Division of Population Health) The Behavioral Risk Factor Surveillance System SS) does not currently collect data about ?rearms. Firearms questions were included as optional modules for states to consider between 1995?1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future BRF SS surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 l6133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 a? .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 govr?mmwr/prev iewf [11111640821 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 WWR. January 27, 2012 03 a2.htm Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 Courtneyr N. Lenard, MA Health Communication Specialist I National lCenter for Injuryr Prevention and Control I Health Communication and Science foice I U: "310.438.3733 1 Monday Friday telework: 404.808.3037 Sawing Lives and Protecting People from Violence and Injury From: Lenard, Courtney Sent: 3 Feb 2016 09:10:17 -0500 To: Dahlberg, Linda L. Subject: Re: For Review: The Trace-gun violence Thank youl! From: Dahlberg, Linda L. (CDCEDNDIEHINCIPC) Sent: Wednesday, February 03. 2016 06:09 AM To: Lenard, Courtney JDNDIEHINC Morey, James Simon. Thomas Sothtalab, Elizabeth Cyril, Melissa R. Ce: Connolly. Erin Lane, Gabraelle Middlebrooks, Jennifer Williams. Alan J. (CTR): Reimels, Elizabeth Subject: Re: For Review: The Trace-gun violence Hi Courtney, The responses are ?ne. Thank you, Linda Sent from my Blaecherry From: Lenard, Courtney (CDCJONDIEHWCIPC) Sent: Wednesday, February 03, 20l6 12:49 AM Eastern Standard Time To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhlalab, Elizabeth Cyril, Melissa R. (CDCIONDIEHINCIPC) Ce: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. Reimeis, Elizabeth (CDCIONDIEHKNCIPC) Subject: RE: For Review: The Trace-gun violence Hi Linda, Will you please take a look at the responses and let me know ifyou are ok with how they read? Deb revised but unfortunately I don?t have her exact changes. Looks like mainly she shortened some answers. Thank you! Courtney 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and nonuresearch activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 199? Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of Firearm-Reiated Vioience 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Reiated Viaience was released by the IOMINRC on June 5,2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that 10M and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm?related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.? 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 {investigator- initiated) grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: I one study (which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. IA 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; IA 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; IA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? fepgmvedjrevl?wedhy sesame The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: ES Firearm injuries in the United States Prev Med. 2015 16l33 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006-2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAM. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 I .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27, 2012 govr?m mwrforeview/ 1111116 I 03 a2.htm Most recent VDRS Surveillance ummary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17", 2014 a] .htm From: Dahlberg, Linda L. (CDCIONDIEHINCIPCI Sent: Tuesday, February 02, 2016 3:55 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: FIE: For Review: The Trace-gun violence Hi Courtney See edits in red below. I didn't provide an answer for the first question. I will leave that one to someone else. Let me know it you have any questions. Linda From: Lenard, Courtney (CDCKONDIEHINCIPC) Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth (CDCKONDIEHINCIPC) Cyril, Melissa R. Cc: Connolly, Erin (CDCIONDIEHINCIPC) Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb). Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on Q1 (13. Thanks much! Courtney Questions: 1. Do yen feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making fireami-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the ?The complexity and frequency of ?rearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries. 7. Has the CDC dedicated any funding to research involvmg guns or gun ym_1ence since the hD?tCkey Agendmellt was passed?rdi?? Following the FY 1997 appropriation language, CDC?funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers (ICRCs), the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 (investigator- initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: none study (which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; IA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? CDC's Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in RDD surveys in general. (making Sure this. is-still ok with Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27, 2012 03a2.htm Most recent VDRS Surveillance ammary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 - -i - Saving Lives and Protecting People from Violence and low ry From: Lenard, Courtney Sent: 2 Feb 2015 21:43:07 {1500 To: Houry, Debra E. Amy B. Cc: Connelly, Erin Subject: Re: For Review: The Trace-gun violence Yes, [?11 be sending this up for HHS clearance. From: Iloury, Debra E. Sent: Tuesday. February 02, 2016 08:51 PM To: Lenard, Courtney Peoples, Amy B. Cc: Connolly, Erin Subject: Re: For Review: The Trace-gun violence And assuming this needs to go up for clearance? Ijust want to make sure folks ok with my edits. Sent from my BlackBerry 10 smartphone. From: Houry, Debra E. Sent: Tuesday, February 2, 2016 ?:01 PM To: Lenard, Courtney Peeples, Amy B. Cc: Connelly, Erin Subject: RE: For Review: The Trace-gun violence See my edits below From: Lenard, Courtney (CDCIONDIEHINCIPC) Sent: Tuesday, February 02, 2016 4:27 PM To: Houry, Debra E. Peoples. Amy B. Ce: Connolly, Erin Subject: For Review: The Trace-gun violence Hi Deb, Kate Masters with. The Trace requested an interview with you, originally stating she wanted to discuss: "My article is going to be about research or the CDC versus the NIH, so most of?my questions would center on her opprooeh to rimming the Centerfor Injury Control and Prevention, accomplishments she?s mode. and priorities she'd still to work on. Based on prior requests she has had with us {Wilmington and gun violence) and with NIH, I asked for speci?c questions that we could address via email. Here they are. Responses have been reviewedirevised with Linda Dahlberg, OPP has also been in the loop. Responses are primarily pulled from our cleared on the issue. I will also get HHS clearance once you review. Thank you! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to ?rearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. However, ?rearms are a mechanism of injury, so it is possible to address ?reann-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 199? Congress cut budget by an amount equal to what had been spent on research into gun violence (about million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the breast of irearm-Related Viotence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of ?rearm injuries in the U.S. Understanding the patterns, characteristics, and impact of ?rearm violence is an important step toward preventing ?rearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to ?rearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The research agenda Prioritiesfbr Research to Reduce the Threat of FirearmpReiated Violence was released by the on June 5, 2013. It was intended to guide research in the ?eld and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence. but Congress has not approved .it. To pursue many of the research priorities that 10M and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction. of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the RC ?The complexity and frequency of firearm violence. combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." Has the CDC dedicated any funding to research involving guns or gun violence since Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the 199? appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal ?rearm violence through the Injury Control and Response Centers (IC RC the ?rst cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACEs), and universities awarded R01 (investigator-initiated) grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: I one study [which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. I A 1998 study examined the effectiveness of household ?rearm storage methods in reducing unintentional and self?in?icted ?rearm injuries among children and adolescents; I A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; I A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? [approvedheviewed by Division of Population Health) The Behavioral Risk Factor Surveillance System SS) does not currently collect data about ?rearms. Firearms questions were included as optional modules for states to consider between 1995?1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future BRF SS surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 l6133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 a? .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 govr?mmwr/prev iewf [11111640821 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 WWR. January 27, 2012 03 a2.htm Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 Courtneyr N. Lenard, MA Health Communication Specialist I National lCenter for Injuryr Prevention and Control I Health Communication and Science foice I U: "310.438.3733 1 Monday Friday telework: 404.808.3037 Sawing Lives and Protecting People from Violence and Injury From: Lenard, Courtney Sent: 2 Feb 2016 16:24:34 -0500 To: Solhtalab, Elizabeth Linda L. James Thomas Melissa R. Cc: Connelly, Erin Gabraelle Jennifer Alan J. {CTR};Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Much better From: Solhtalab, Elizabeth Sent: Tuesday, February 02, 2016 4:22 PM To: Lenard, Courtney Dahlberg, Linda L. (CDCIONDIEHXNCIPCJ Mercy, James Simon, Thomas Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence I don?t think that answers the question, since it?s not referencing the past. How about: There is not appropriations language that prohibits CDC from conducting public health research into gun violence, therefore we decline to comment on theoretical consequences. From: Lenard, Courtney Sent: Tuesday, February 02, 2016 4:17 PM To: Dahlberg, Linda L. Mercy, James ; Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. {coc/onoiEHmoPC} Cc: Connolly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCIONDIEHXNCIPC) (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence For Q1, what do you think about this: We will decline to answer this question, you may want to reach out to David Satcher, he was the CDC director during this time. From: Dahlberg, Linda L. (CDCIONDIEHXNCIPC) Sent: Tuesday, February {32, 2016 3:55 PM To: Lenard, Courtney Mercy, James Simon, Thomas (CDCIDNDIEHINCIPC) Solhtalab, Elizabeth (CDCKONDIEHINCIPC) Cyril, Melissa R. Cc: Connolly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace?gun violence Hi Courtney See edits in red below. I didn?t provide an answer for the first question. I will leave that one to someone else. Let me know if you have any questions. Linda From: Lenard, Courtney Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (cocxowoleamcwci Subject: For Review: The Trace?gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb). Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on Q1 8t 03. Thanks much! Courtney Questions: I. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence {about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in CDC's appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged l~64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries. 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, mm "i @8313 mm?m, ??gatisiia? Following the FY 1997 appropriation language, CDC- funded entities conducted some investigator- initiated, peer-reviewed studies on fatal and non- -fata firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention and universities awarded R01 {investigator? initiated) grants. Some of these projects began before FY 1997? and continued throughout their funding period. Examples: Ir one study (which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring US. gun ownership in 2004, and why? Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concernsabout thelength of the current survey and declining response rates in RDD surveys in general. (making sure this. is still olt with LEE Firearm injuries in the United States Prev Med. 2015 002795-14 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 WWR. July 12, 2013 2? 1 .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27', 2012 Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 1111151thth ss630 la] .htm THJ . v. I -, Health CommuniLaTion Specialist 1 National Center f0! Injury F'reveniion and Control I Health Communication and Science Of?ce I 0: 77'0 485.3?33 Mondav 81 Friday ielework.? 404308.303? Saving Lives and Protecting Peopie fromVioIence and Injury From: Lenard, Courtney Sent: 2 Feb 2016 16:02:08 -0500 To: Dahlberg, Linda L. Subject: RE: For Review: The Trace-gun violence Great! I?ll remove the DOJ you! From: Dahlberg, Linda L. (CDCIONDIEHINCIPC) Sent: Tuesday, February 02, 2016 4:06 PM To: Lenard, Courtney Subject: RE: For Review: The Trace-gun violence Just saw the revised response from i'm okay with what they provided below. However, I would strike the sentence in red about contacting DOJ. doesn?t have information on firearm ownership. From: Lenard, Courtney Sent: Tuesday, February 02, 2016 2:20 PM To: Dahlberg, Linda L. Mercy, James Subject: RE: For Review: The Trace-gun violence Thank you, Linda! Please see the revised response below to Q8, provided by the Division of Population Health. From: Dahlberg, Linda L. (CDCJONDIEHINCIPCJ Sent: Tuesday, February 02, 2016 2:03 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Subject: RE: For Review: The Trace-gun violence Hi Courtney I'll send yen a response soon. I have a few meetings unti13:30. Linda From: Lenard, Courtney (CDCJONDIEHINCIPC) Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth (CDCIONDIEHKNCIPC) Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth cixn2@cdc.gov> Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb}. Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on (11 (13. Thanks much! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but w0uld it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The language in appropriation does not prohibit CDC from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. In order to pursue many of the research priorities identified in the report commissioned by CDC, the funding requested in the FY16 President?s Budget would be necessary. 6. Do you feel that the Injury Center should he researching guns and gun violence, that it falls under the jurisdiction of the agency? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? It so, how much money would you say goes toward that kind afresaaohpo?war? CDC has focused on violence, including gun violence, as a public health problem since the early 1980s and continues to support injury surveillance activities, epi?aid investigations, and analyses of injury surveillance and other data to document the public health burden of firearm injuries in the United States. President Obama has included $10 million for CDC to conduct research into the causes and prevention of gun violence in his budget requests to Congress since FY 2014. However, Congress has not included those funds in FY 2014, FY 2015, or FY 2016 appropriation. *Please see below, examples of research. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: You may want to touch base with Department ofJustice to see if they have information on firearms ownership. You can reach them at 202-514-2007. a -, Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 . cdc. 0a1 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .httn Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 govlm a 1 .htm . . . Saving lees and Protecting People from Wolence and Inju ry From: Lenard, Courtney Sent: 2 Feb 2016 16:06:39 -0500 To: Dahlberg, Linda L. James Thomas Elizabeth Melissa R. Cc: Connelly, Erin ne, Gabraelle Jennifer Alan J. {CTR};ReimelS, Elizabeth Subject: RE: For Review: The Trace-gun violence Thank you very much, Linda! I think we can decline to answer the first one. From: Dahlberg, Linda L. Sent: Tuesday, February 02, 2015 3:55 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney - See edits in red below. I didn?t provide an ansWer for the first question. i will leave that one to someone else. Let me know if you have any questions. Linda From: Lenard, Courtney Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth (CDCKONDIEHINCIPC) Cyril, Melissa R. ft} cdc. ov> Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (cocronoiEHmoPc) (CTR) Reimels, Elizabeth (cocrowoiEHrNCIPci Subject: For Review: The Tracegun violence Good afternoon, Kate Masters with The Trace has the questions below (directed towards Deb}. Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on C11 Q3. Thanks much! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in CDC's appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Reicted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IBM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the ?The complexity and frequency of ?rearm violence. combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries 7 Has the CDC dedicated any funding to research involving guns_ or gun violenc_e_ since the Eflckey Amendment was passed? If so, h?m?m: wagging; ef?ng mm Following the FY 1997 appropriation language funded entities conducted some investigator-initiated, peer-reviewed studies on fetal and non fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention and universities awarded R01 {investigator- initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: none study (which began in 1995} examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; -A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? CDC's Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in RDD surveys in general . W?mm ?n?lg?hm?l Firearm Injnries in the United States Prev Med. 2015 Oct;79:5- 14 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27', 2012 103a2 .htm Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 63(880] );1-33 la] .htm Saving Lives and Protecting People from molence and inju ry From: Dahlberg, Linda L. Sent: 2 Feb 2016 19:03:15 +0000 To: Lenard, Courtney James Thomas Elizabeth Melissa R. Cc: Connelly, Erin ne, Gabraelle Jennifer Alan J. {CTR};Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney? I'll send you a response soon. I have a few meetings until 3:30. Linda From: Lenard, Courtney Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below (directed towards Deb). Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on (11 03. Thanks much! Courtney Questions: I. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research. even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The language in appropriation does not prohibit CDC from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts ifthat research continued. 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. Firearms are a mechanism of injury, so it is possible to address firearm?related violence in the context of addressing these topical areas. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. In order to pursue many of the research priorities identified in the report commissioned by CDC, the funding requested in the FY16 President?s Budget would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how yeti-say gees tawerd that kind gamma-year! CDC has focused on violence, including gun violence, as a public health problem since the early 19805 and continues to support injury surveillance activities, epi-aid investigations, and analyses of injury surveillance and other data to document the public health burden of firearm injuries in the United States. President Obama has included $10 million for CDC to conduct research into the causes and prevention of gun violence in his budget requests to Congress since FY 2014. However, Congress has not included those funds in FY 2014, FY 2015, or FY 2016 appropriation. *Please see below, examples of research. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearms in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The predominant reason the questions were discontinued was because of the length of the interview. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. CDC staff asked the state coordinators to consider adding the firearm module to the fixed core in 2014 and 2015, but to date they have not been included. (makingsure this is still bit with DPH) Eng. E5 Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 1mn6230a1 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 ll 111111622721 1 .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 Most recent VDRS Survei?ance mommy: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 1 a 1 .htm Saving Lives and Protecting People from Violence and lnju ry From: Lenard, Courtney Sent: 21 Mar 2016 14:42:15 -D4UO To: Dahlberg, Linda L. James Thomas Elizabeth Melissa R. Cc: Connelly, Erin ne, Ga braelle Jennifer Alan J. {CTR};Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi all! Kate Masters has come back again, she is publishing her piece tomorrow on CDC and gun violence research. Again, I don?t think there is anything different to say and suggest repeating what we have already said to her. Are you ok with this? Thank you! Courtney Question for Deb; Does she think that the CDC does enough research on gun violence and prevention? is it doing everything it possibly can under the current circumstances? Proposed Rossponse: The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. Questionszesponses from early February: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. i know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to tireann violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence. child maltreatment. domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non-research activities. However, firearms are a mechanism ofinjury. so it is possible to address tirearm~related violence in the context of addressing these topical areas and preventing violence from occurring in the ?rst place. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the ?tl'ldS made available to CDC. may be used to ?advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence overtime, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time} and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce. the Threat of frearm -Relc red Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing ?rearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to ?rearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The IOMINRC research agenda Priorities/hr Research to Reduce the. Threat of treasur- Related lf?t?olence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making fireann?related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of ?rearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC?funded entities conducted some investigator?initiated, peer-revieWed studies on fatal and non-fatal ?rearm violence through the Injury Control and Response Centers (ICRCS), the ?rst cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACEs), and universities awarded R01 (investigator initiated) grants. Some of these projects began before 1997' and continued throughout their funding period. Examples: - one study (which began in 1995) examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non?gun injuries. I A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; - A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; - A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? The Behavioral Risk Factor Surveillance System does not currently collect data about ?rearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the BRF SS questionnaire. CDC supports this development and werks with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more infomiation about please visit: g. TI Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 .cdc-. .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27, 2012 03aZ.htm Most recent unet?ence Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 I a l. .htm From: Dahlberg, Linda L. Sent: Thursday, March 10, 2016 10:49 AM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle (CDCIONDIEHINCIPC) Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney - Not sure what else to say. The story they are proposing was first written by the Washington Post several months ago and has been picked up by other outlets. Dr. Frieden noted in recent conversations with members of Congress that given the President?s request for the CDC to conduct research into the causes and prevention of gun violence, it would be in best interest to have Congress appropriate funds for this work. That would make it clear that Congress wants to fund CDC to do gun violence research and would remove any ambiguity. Dr. Frieden noted that the IBM report conducted a few years ago lists many research avenues that might gain bipartisan support for research. Linda From: Lenard, Courtney Sent: Thursday, March 10, 2016 10:32 AM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace?gun violence Good morning! Kate Masters with The Trace has reached out again with the note below. You can see in the thread all that we have provided in the past. Aside from reiterating again, please let me know if you have any other thoughts on how to respond. Thankyou! Courtney From Kate: Thanks again for all the information about the It was de?nitely helpful and that piece should be up on our site soon. I'm emailing today because my editors and are in the drafting phase of my piece on gun violence research at the CDC, and I wanted to let you know that the basis of the story is that the CDC is avoiding the issue of gun violence and bowing to political pressure by essentially foregoing research on ?rearms, even though there are things the agency could be doing. This is coming from former employees of the CDC, as well as outside gun violence researchers. I wanted to tell you this so there would be no surprise when the article came out, and also because [wanted to give the CDC a chance to respond to what others are saying. That response could be a statement from you, or I would still love to speak with Dr. Houry directly about the lack of gun research at the Injury Center, but I do recommend addressing these statements somehow so that the CDC's voice is included in the piece. From: Dahlberg, Linda L. Sent: Tuesday, February {19, 2016 8:55 AM To: Lenard, Courtney MerCy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. ft} cdc. ov> Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (ixn2@cdc.gov> Subject: RE: For Review: The Tracengun violence Suggest a simple response. ?We have not reached out to them specifically?. From: Lenard, Courtney (CDCIONDJEHXNCIPC) Sent: Monday, February 03, 2016 6:14 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (cocronoIEH/Ncwci (CTR) Reimels, Elizabeth (cocxonoiEHxNCiPC) Subject: RE: For Review: The Trace-gun violence Hi- A?er providing this, We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out to the NRA in recent years. Here?s a follow up from The Trace: And when you say that you have not reached out to the NRA in recent years, do you mean that you have not informed them of firearm-related articles in recent years, or you just haven't reached out to them speci?cally? Has the CDC always alerted stakeholders on gun violence articles? Proposed Response: We have not informed the NRA of firearm-related articles in recent years. As previously mentioned, we routinely alert stakeholder organizations when relevant articles are released. Thanks much! Courtney From: Dahlberg, Linda L. (CDCKONDIEHINCIPQ Sent: Thursday, February 04, 2016 4:01 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas Soihtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan .I. (CDCXONDIEHINCIPC) (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Works for me, although I believe the word ?specifically" was deleted last time. We can save the second part if she comes back again. From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:59 PM To: Dahlberg, Linda L. Mercy, James Cc: Connelly, Erin Subject: RE: For Review: The Trace-gun violence Here?s what we provided to AP, will the first part work? We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out specifically to the NRA in recent years. Mike Stobbe asked when it it stopped, don?t think it is necessary at this point. Providing advance notification to NRA ab0ut forthcoming articles was done at the request of the NRA as a part of an effort to improve communication between our two organizations. We do not have dowmentation about when this started, but believe it was in the early 20005. The Associate Director for Science in the National Center for Injury Prevention and Control provided advance notification of forthcoming articles, but not an advance copy of articles. The practice ended due to staff turnover in both organizations. From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 3:35 PM To: Lenard, Courtney Mercy, James Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (CDCIONDIEHINCIPC) Subject: RE: For Review: The Trace-gun violence Hi Courtney I checked with Jim. He doesn't have a copy of the report. In terms of the ?gentleman?s agreement? I believe NCIPC OD prepared a response before to that question so I defer to others to answer. It said something along the following lines: ?We have not communicated with the NRA for several years? Thanks, Linda From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:24 PM To: Dahlberg, Linda L. Mercy, James (CDCJONDIEHINCIPCJ Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi all, Another follow up from The Trace: does the CDC still have a ?gentleman's agreement" with the gun lobby to report out, to the lobby, any gun research completed by their grantees, whether that research was actually completed with CDC funds or not? Also, to keep everyone in the loop, I sent Linda 3 separate email with this question, she and Jim are consulting. One of the subjects for my story mentioned that in the 19903, after the CDC Injury Center had producedlfunded a number of studies about gun violence, then-CDC Director David Satcher commissioned a panel of outside experts to review that portfolio of work and make sure it wasn?t biased toward gun control advocacy. The panel ultimately concluded that the studies weren't biased and were in fact extremely well done, and I was wondering if you knew ofa way I could access that report so I could cite it in my article. I would love to get a copy or even the name so I can look it up myself. Thanks you! Courtney From: Dahlberg, Linda L. (CDCIDNDIEHINCIPC) Sent: Wednesday, February 03, 2015 6:10 AM To: Lenard, Courtney Mercy, James Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. {cm} Reimels, Elizabeth Subject: Re: For Review: The Trace-gun violence Hi Courtney. The responses are fine. Thank you, Linda Sent from my BlackBerry From: Lenard, Courtney (CDCJONDIEHJNCIPC) Sent: Wednesday, February 03, 2016 12:49 AM Eastern Standard Time To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Linda, Will you please take a look at the responses and let me know if you are ok with how they read? Deb revised but unfortunately I don't have her exact changes. Looks like mainly she shortened some answers. Thank you! Courtney 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non-research activities. However, firearms are a mechanism of injury, so it is possible to address firearmsrelated violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Priorities for Research to Reduce the Threat of Firearm-Related Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda ifthere was no intention to use it? The RC research agenda - Priorities Jfor Research to Reduce the Threat of Fi'reorm-Reioted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IBM and NRC identified, this $10 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 {investigator- initiatedj grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: tone study (which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; 0A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; IA longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 3. Did the CDC stop monitoring U.5. gun ownership in 2004, and why? (approvedfreviewed by Division of Reputation Health) The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995-1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury-related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 1f 1 .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 I . . go 6408a] .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27', 2012 Most recent Surveillance Summary: Surveillance for Violent Deaths National 1Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 la1.htm From: Dahlberg, Linda L. Sent: Tuesday, February 02, 2016 3:55 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney - See edits in red below. I didn?t provide an answer for the first question. I will leave that one to someone else. Let me know if you have any questions. Linda From: Lenard, Courtney Sent: Tuesday, February 02, 2016 12:09 PM To: Mercy, James Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Deb). Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on (11 8t 03. Thanks much! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non?research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in CDC's appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm-Reinted Violence was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IBM and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making ?rearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scienti?cally sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries 7. Has the CDC dedicated any funding to guns or gun violence since the Dichey?mendment?was passed? If so . assisted? Following the FY 1997 appropriation language, funded entities conducted some investigator- initiated, peer-reviewed studies on fatal and non- -fata firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 {investigator initiated] grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: tone study (which began in 1995} examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non?gun injuries. 15A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; -A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work, the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions (or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in RDD surveys in general. (making sure this Is Still pit with HRH) Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 ll .htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994-2012 MMWR. March 6, 2015 . cde. 8a] .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 .htm Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 031? recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 a 1 him l??l W131- . ..-, I {Tran-.Saving lees and Protecting People from Violence and anu ry From: Lenard, Courtney Sent: 14 Mar 2016 17:46:48 43400 To: Mercy, James Elizabeth Linda L. Thomas Elizabeth Melissa R. Cc: Connelly, Erin ne, Gabraelle Jennifer Alan J. (CTR) Subject: RE: For Review: The Trace-gun violence Thanks, Jim and Beth! From: Mercy, James Sent: Monday, March 14, 2016 5:43 PM To: Reimels, Elizabeth Lenard, Courtney Dahlberg, Linda L. Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CDCIONDIEHXNCIPC) (CTR) Subject: RE: For Review: The Trace-gun violence Me too From: Reimels, Elizabeth Sent: Monday, March 14, 2016 5:18 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Dahlberg, Linda L. Mercy, James ; Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. (CDCIONDIEHKNCIPC) Cc: Connelly, Erin Lane, Gabraelle (CDCXONDIEHINCIPC) Middlebrooks, Jennifer Williams, Alan J. (CTR) Subject: RE: For Review: The Trace-gun violence Works for me. -E'.eth From: Lenard, Courtney Sent: Monday, March 14, 2016 5:11 PM To: Dahlberg, Linda L. Mercy, James (CDCIONDIEHINCIPC) ; Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Subject: RE: For Review: The Trace-gun violence Hi All! suggests the following response, is everyone comfortable with this? Particularly the last part. CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. More than 11?,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the ?The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.? The President has requested that CDC conduct research into the causes and prevention of gun violence and the IBM Report noted a number of research areas that might have bipartisan support. CDC is ready to conduct that research if funds are appropriated by Congress. Thanks much! Courtney From: Dahlberg, Linda L. (CDCIONDIEHINCIPC) Sent: Thursday, March 10, 2016 10:49 AM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraeile Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Hi Courtney Not sure what else to say. The story they are proposing was first written by the Washington Post several months ago and has been picked up by other outlets. Dr. Frieden noted in recent conversations with members of Congress that given the President?s request for the CDC to conduct research into the causes and prevention of gun violence, it would be in best interest to have Congress appropriate funds for this work. That would make it clear that Congress wants to fund CDC to do gun violence research and would remove any ambiguity. Dr. Frieden noted that the IBM report conducted a few years ago lists many research avenues that might gain bipartisan support for research. Linda From: Lenard, Courtney Sent: Thursday, March 10, 2016 10:32 AM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (cocroonEHrNoPC) Subject: RE: For Review: The Trace-gun violence Suggest a simple response. ?We have not reached out to them specifically". From: Lenard, Courtney Sent: Monday, February 03, 2016 6:14 PM To: Dahlberg, Linda L. (CDCIONDIEHJNCIPQ Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. 4.x f0 cdc. ov> Cc: Connelly, Erin Lane, Gabraelle Subject: RE: For Review: The Trace~gun violence Hi- After providing this, We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out to the NRA in recent years. Here?s a follow up from The Trace: And when you say that you have not reached out to the NRA in recent years, do you mean that you have not informed them of ?rearm-related articles in recent years, or you just haven't reached out to them speci?cally? Has the CDC always alerted stakeholders on gun violence articles? Proposed Response: We have not informed the NRA of firearm-related articles in recent years. As previously mentioned, we routinely alert stakeholder organizations when relevant articles are released. Thanks much! Courtney From: Dahlberg, Linda L. Sent: Thursday, February 04, 2016 4:01 PM To: Lenard, Courtney Mercy, James (iam2@cdc.gova; Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. f0 cdc. ov> Cc: Connelly, Erin (edechcgova; Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) ; Reimels, Elizabeth Subject: RE: For Review: The Trace-gun violence Works for me, although I believe the word ?specifically" was deleted last time. We can save the second part if she comes back again. From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:59 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (cocxowoiEHxNCIPci Subject: RE: For Review: The Trace-gun violence Here's what we provided to AP, will the first part work? We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out specifically to the NRA in recent years. Mike Stobbe asked when it started/why it stopped, don?t think it is necessary at this point. Providing advance notification to NRA about forthcoming articles was done at the request of the NRA as a part of an effort to improve communication between our two organizations. We do not have documentation about when this started, but believe it was in the early 20005. The Associate Director for Science in the National Center for Injury Prevention and Control provided advance notification of forthcoming articles, but not an advance copy of articles. The practice ended due to staff turnover in both organizations. From: Dahlberg, Linda L. (CDCIONDIEHINCIPC) Sent: Thursday, February 04, 2016 3:35 PM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan (CTR) Reimels, Elizabeth Subject: RE: For Review: The Trace?gun violence Hi Courtney - I checked with Jim. He doesn?t have a copy of the report. In terms of the ?gentleman?s agreement" I believe NCIPC 00 prepared a response before to that question so I defer to others to answer. it said something along the following lines: ?We have not communicated with the NRA for several years" Thanks, Linda From: Lenard, Courtney Sent: Thursday, February 04, 2016 3:24 PM To: Dahlberg, Linda L. Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth (cocxoonEH/NCIPC) Subject: RE: For Review: The Trace-gun violence Hi all, Another follow up from The Trace: does the CDC still have a ?gentleman's agreement" with the gun lobby to report out, to the lobby, any gun research completed by their grantees, whether that research was actually completed with CDC funds or not? Also, to keep everyone in the loop, I sent Linda a separate email with this question, she and Jim are consulting. One of the subjects for my story mentioned that in the 1990s, after the CDC Injury Center had producedffunded a number of studies about gun violence, then-CDC Director David Satcher commissioned a panel of outside experts to review that portfolio of work and make sure it wasn't biased toward gun control advocacy. The panel ultimately concluded that the studies weren't biased and were in fact extremely well done, and [was wondering if you knew of a way I could access that report so I could cite it in my article. I would love to get a copy or even the name so I can look it up myself. Thanks you! Courtney From: Dahlberg, Linda L. (CDCIONDIEHKNCIPC) Sent: Wednesday, February 03, 2016 6:10 AM To: Lenard, Courtney Mercy, James Simon, Thomas Solhtalab, Elizabeth Cyril, Melissa R. f0 cdc. ov> Cc: Connelly, Erin Cc: Connelly, Erin Lane, Gabraelle Middlebrooks, Jennifer Williams, Alan J. (CTR) Reimels, Elizabeth Subject: For Review: The Trace-gun violence Good afternoon, Kate Masters with The Trace has the questions below {directed towards Debi. Kate asked us several questions about Wilmington and gun violence back in November. Please edit below and also looking for guidance on C11 81 Q3. Thanks much! Courtney Questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on ?rearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding speci?cally for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through annual appropriation for both research and non-research activities. Firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas. 3. In 2013, the NIH announced a new funding program that called speci?cally for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what?s stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to ?advocate or promote gun control." Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about $2.7 million at the time) and threatened to impose further cuts if that research continued. 4. The Dickey Amendment doesn?t technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the US. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. There is nothing in CDC's appropriation language that prevents the agency from conducting gun violence research. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda - Priorities for Research to Reduce the Threat of Firearm-Reicted Violence - was released by the on June 5,2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Nowis the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that 10M and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 1 17,000 Americans are non-fatally injured or die each year from a gunshot wound, making fireami-rclated injuries among the 5 leading causes of death for people aged l-64 in the United States. Public health research is fundamental to understanding the problem and deyeloping scienti?cally sound solutions. As noted by the ?The complexity and frequency of ?rearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries." 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, may Mit??m?m I??a misses Following the FY 1997 appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 (investigator- initiated] grants. Some of these projects began before FY 199? and continued throughout their funding period. Examples: one study {which began in 1995] examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. 0 A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; I A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? Behavioral Risk Factor Surveillance System which provides state and national data, included questions on firearm safety in the 19905 and early 20005. The last time firearm questions were included in the survey was 2004. The questionnaire is designed by a working group of state coordinators and CDC staff. While CDC coordinates the work; the actual states run the program and have the voting rights to make additions and changes to the survey questionnaire from year to year. The Injury Center submitted a formal application to include the firearm questions on the 2016 survey. The State Coordinators did not approve the inclusion of the firearm questions [or questions pertaining to other topics) citing concerns about the length of the current survey and declining response rates in RDD surveys in general. (makinggsum this 15-511? Climb Firearm injuries in the United States Prev Med. 2015 16133 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006?2007 and 2009?2010 MMWR. August 2, 2013 Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 . cdc. go vim mwr/previewf 1 .htm Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 I .htm Gang Homicides Five US. Cities, 2003?2008 MMWR. January 27, 2012 1111116 I 03512 .htm Most recent SHHFEEHGHCE Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17', 2014 la] .htm Saving LIVES and Protecting People from Violence and Inju ry From: Dahlberg, Linda L. Sent: 5 Oct 2017 10:30:14 -0400 To: Fox, Kate Leslie Thomas Sara S. Cc: Middlebrooks, Jennifer Julie Gabraelle Elizabeth Melissa R. Erin Valerie M. Molly Regina Malia James Courtney Subject: RE: FYI: CNN inquiry on firearms research Attachments: Webster and Wintemute policy review 2015.pdf, Santaella-Tenorio et al review of firearm policies 2016.pdf, Rowhani-Rahbar et al 2016 - Safe storage review.pdf Feel free to respond however you wish. We do have cleared (1803. related to questions (which you have shared with OADC). The state of gun violence research goes beyond work. There have been some recent reviews that might be helpful to them. Perhaps you can share them. From: Fox, Kate Sent: Thursday, October 05, 2017 10:20 AM To: Dorigo, Leslie Dahlberg, Linda L. Simon, Thomas Patterson, Sara S. Cc: Middlebrooks, Jennifer Eschelbach, Julie Lane, Gabraelle Solhtalab, Elizabeth Cyril, Melissa R. Black, Erin Daniel, Valerie M. Kurnit, Molly Regina Richmond?Cram, Malia (CDCIONDIEHINCIPC) Mercy, James Lenard, Courtney Subject: RE: FYI: CNN inquiry on firearms research A couple of updates below to reflect updates on the PB. We could explicitly say that the request was not renewed in the FY 2013 PB, but I?m not sure that it's necessary. From: Dorigo, Leslie Sent: Thursday, October 5, 2017' 10:15 AM To: Dahlberg, Linda L. Simon, Thomas (tgsEJQ-cdcgov}; Patterson, Sara S. Fox, Kate cdc. ova- Cc: Middlebrooks, Jennifer Eschelbach, Julie Lane, Gabraelle ; Solhtalab, Elizabeth Cyril, Melissa R. Black, Erin Daniel, Valerie M. Kurnit, Molly Regina ; Richmond-Crum, Malia Mercy, James Lenard, Courtney Subject: CNN inquiry on firearms research Good morning, We have a request from reporter Susan Scutti at CNN: Questions for CDC: it?s been widely said that the CDC has neglected this area of research since the mid-1990s in response to the 1996 Omnibus Consolidated Appropriations bill for FY 1997 that stated "none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control." Yet, I also know that the NAS released a report, "Priorities for Research to Reduce the threat ofFireamt- related Violence," in June 2013 -- a task requested by the CDC. This report stemmed from President Obama's executive order earlier that year directing federal agencies to improve knowledge of this area. Essentially, then, i am wondering where the state of gun and gun violence research really stands - has gun violence research been stagnant in the A scan ol? pubmed shows some work has been done in recent years. (Basically, then, I am challenging the prevailing notion that nothing has been done - is this true?) What, if anything, came about as a result of the "Priorities for Research? report, which set out an entire research agendathese recommendations? What discussions were had about the report? What insight can you provide about gun violence research since 2013? Do you wish to share any other thoughts about this topic? I?m connecting with (JADE, but I believe our response will be the one cleared by the OD yesterday: Beginning in l99?. CDC has been subject to appropriations language that states that none of the funds made available to (DC may be used to ?advocate or promote gun control." This language was extended to all agencies in FY 2012. The language does not prohibit CDC from collecting public health data on ?rearm violence. Firearm-related injuries are among the 5 leading causes of death for people ages 1-64 in the United States. CDC has and continues to support data collection activities and analyses to document the public health burden of ?rearm injuries in the US. However, I also sent up to OADC what was previously used? when asked about the 10M report or Now Is the Time (appears to have been sent last in mid-January], to see if there's any part that might be used: tt?uitii Examples are included below. Firearm injuries in the United States Prev Med. 2015 Oct:79:5-l4 . m.nilt .eov I'pubmedr'E?l H313 3 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006-2007 and 2009?2010 MMWR. August 2, 2013 Imp . i rm Ix?m m?23 {la 1 Jam Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 6, 2015 . {In Homicide Rates Among Persons Aged 10?24 Years United States, 1981?2010 MMWR. July 12, 2013 1 Jam Most recent VDRS Sarvefllance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 17 States. 2013 MMWR August 19, I (la I .htm'is? cid=as65 1 Gal *l know there are a couple more recent articles we could wanted to see what we?re able to respond with before updating. I?ll keep you posted. Thanks, Leslie Annu. Rev. Public Health 2015.3sz2I-37. Downloaded from masnnualreviewsorg Access provided by Center for Disease Control Information Centenr CDC on l4:r For personal use only. Salts; Further Click here for quick links to Annual Heu-ews content including- - Other art-cles in volume -Top tiled artittes ?Top downloaded articles Out cornerehenslve search Ann". Rev. Public Health 20! 5. 36:2 l4? First published online as a Review in Advance on January 2015 The Annual Health is online at puhlhealtb.annttalreviews.org This article?s Lloi: Copyright 201:? by Animal Reviews. All rights reserved EHCCES of Policies Designed to Keep Firearms from High-Risk ln (livid on] 5 Daniel W. l/?Vebsterl and Garen]. ?lt?Vintemute?2 ICenter for Gun Policy and Research. Bloomberg School of Public Health.johns Hopkins University, Baltimore, Maryland 21205; email: z"lr'iolcnce Precept-ion Research Program: Department of Emergency Medicmc: University of California, Davis, Sacramento, California 9581?; entail: gjwintemute@ucdavis.edu Keywo gun violence, gun policy, gun safety, violence prevention Abstract This article and critiques available evidence from studies pub? lished between 1999 and August 2014 on the effects of policies designed to keep firearms from high?risk individuals in the United States. Some pro- hibitions for high-risk individuals those under domestic violence re- straining orders, violent tnisdemeanants} and procedures for checking for more types of prohibiting conditions are associated with lower rates of vio- lence. Certain laws intended to prevent prohibited persons from accessing ?rearms?rigorous perrnit?to?purchase, Comprehensive background checks, strong regulation and oversight of gun dealers, and requiring gun owners to report lost or stolen ?rearms?are negatively associated with the diversion of guns to criminals. Future research is needed to examine whedter these laws curtail nonlethal gun violence and whether the eifeets of expanding prohibiting conditions for ?rearm possession are modi?ed by the presence of policies to prevent diversion. Annu. Rev, Public Health l?l?jo? I-37. Downloaded from wavwannualreviewsorg Access provided by Center for Disease Control ?lRl?v1If}ur Information Gamer:r CDC on Dem-4116. For personal use only. INTRODUCTION The United States has an unusually high homicide rate for a high-income country?neatly six times higher than average. This discrepancy is observed only for homicides committed by firearms, for which the rate in the United States is nearly 20 times higher than the average of other high? incotne countries (32). Yet the United States is about average in its rate of nonfatal violent crime and aggressive behavior that do not involve ?rearms This disparity suggests mat the availability of ?rearms in the United States, which is far greater than that in other high?income nations, plays an important role in the unusually high US homicide rate. Perhaps even more importantly, the United States stands out in terms olits relatively low standards for legal gun ownership and the weakness of its laws designed to prevent proscribed individuals front accessing ?rearms- Many topics concerning guns in American society are contentious. These include whether widespread gun ownership serves on balance as a protection against violent crime or contributes to more violence, er certain types of guns should be banned, and whether we should restrict legal gun owners from carrying guns?concealed or openly?in public. Yet, there is widespread support for policies designed to prevent high?risk individuals (cg, felons, persons who are subject to a restraining order for domestic violence, individuals with serious mental illnesses) from having ?rearms (4). This support exists among gun owners and nonowners alike and across the spectrum of political party identi?cation Given the lethal capacity of ?rearms and evidence that access to ?rearms signi?cantly increases risk among individuals with a history of violence and criminality (3), policies designed to keep ?rearms front dangerous persons seem logical and have the potential to reduce violence, particularly lethal violence. The fact that a policy is logical or widely supported, ofcoursc, does not mean that it is effective or iust. motivated and resourceful criminals could circumvent laws designed to prevent their access to ?rearms in a nation where gun ownership is widespread. Furthermore, ?rearm sales regulations could, theoretically, have harmful elfects on public safety if their primary impact is to depress ?rearm acquisition among individuals who are at low risk for criminal misuse or suicide and who might incur safety benefits from having a ?rearm. In 2005, I-Iahn et al. published a comprehensive review ofstudies on the effects of?rearm laws that were published between 197?? and March 2001, which concluded that there was insuf?cient evidence to determine the effects of restrictin ?rearm access for members ofhiglt-rislt groups {1 7). More than a decade later, does this judgment stand? The current review summarizes and critiques the available evidence from studies published between 199?) and August Elli-4 on the effects of policies designed to keep ?rearms from high-risk individuals in the United States. It suggests directions for ?Jture research, given that the evidence currently available has shortcomings. The impact of such policies is likelyr to be a function of two factors: how broadly policies identify and disqualify individuals at greatest rislc for committing gun violence and how effective the policies are in preventing ?rearms from being diverted to prohibited individuals or to the underground market 1where criminals often acquire ?rearms. Thus, we have organized this review to consider, ?rst, prohibitions for high?risk individuals, then, accountability measures to prevent guns from being diverted to prohibited persons, and ?nally, studies that simultaneously address both prohibitions for high-risk individuals and diversion prevention. PROI-IIBITING CONDITIONS FOR FIREARNI PURCHASE AN POSSESSION IN THE UNITED STATES Federal law has established the following conditions, among others, that bat an individual from legal purchase or possession ofa ?rearm: being convicted ofany felony or a misdemeanor crime of l'l"rl'o'trr I Annu Rev, Public Health ZUIS 36 2 Downloaded from org Access provided by Center for Disease Control lRl?leflur Information Center:f CDC on 04! Iii-lift. For personal use only. domestic violence; being so bject to a ?nal domestic violence restraining ord er?5 being a fugitive from instice; being adjudicated as mentally defective or involuntarily committed to a mental institution: and being addicted to or an unlawful user of controlled substances. Federal law also establishes [8 years as the minimum legal age for possessing a handgun and 2] years for purchasing a handgun from a federally licensed ?rearm dealer (persons ages 18?20 may purchase handguns from private parties. however}. Although each ofthe prohibiting conditions under federal law is defensible. in that the affected population is at elevated risk for committing violen cc1 available evidence indicates that they would not disqualify the maiorityofindividuals who commit gun violence. For example. in the 3 states with standards for legal gun ownership that essentially mirror or are in some cases weaker. than dmse set under federal law. only 40% ofoifenders imprisoned for crimes committed with a ?rearm were prohibited from possessing the type ofgun they used to commit crimes (42). In diese states and in many others, individuals who are under 21 years of age, who have committed serious crimes that were adiudicated in juvenile courts, or who have been convicted of misdemeanor crimes involving violence. ?rearms. drugs. or alcohol abuse can legally purchase and possess ?rearms Most states do have additional prohiltiting conditions or stricter standards for legal gun own- ership than are manda ted under federal law. Many States have extended ?rearm prohibitions for persons subject to restraining orders for domestic violence to cover those involving datingparmers and temporary restraining orders. Convictions for misdemeanor crimes of violencr:1 extending be- yond domestic partners, lead to ?rearm prohibitions in a few states, as can multiple convictions for alcohol-related offenses occurring within a span of 1?3 years. J'i-lost states now have temporary ?rearm prohibitions for individuals who committed serious crimes adiudicated in juvenile courts. "Fwelve states and the District of Columbia have established 21 as the minimum legal age for purchasing a handgun, even ifthe seller is not a licensed dealer (24). Evidence on the Effects of Prohibiting Firearm Possession by High-Risk Individuals Most of the availahle literature consists of cross-sectional or longitudinal studies of association. 'l?hey have been conducted with widely varying degrees of attention to factors besidEs the policies under study that could have produced the obsen'ed effects. Few have incorporated any assessment of whether the policies were actively enforced. In fairness1 doing so is often dif?cult or impossible. Vigdor 5: Mercy published two studies to estimate the effects of laws designed to disarm perpetrators of domestic violence on rates of intimate partner homicides UPI-Is) We focus on the more recent of these studies because it includes the most data, covering the years 1981 through 3002 for 46 states with complete data. The authors used state and year fixed effects and a 1oroad range ofcovariates to estimate average treatment effects for [2 state laws disqualifying persons convicted of misdemeanor domestic battery from purchasing firearms, 31 state laws with domestic violence restraining order (DVRU) ?rearm restrictions, and 15 state laws authorizing or mandating ?rearm con?scation by police responding to domestic violence calls. The existence of any DURU ?rearm prohibition was associated with an 8% reduction in lP rates, and the seven state DWI-H) laws that prohibited both ?rearm purchase and postsessiou were associated with a 10% reduction in LPl-l rates. Importandy. protective effects ofthese laws were evident only when states had sufficient records in criminal history databases used for background checks. To rule out the possibility that ?rearm laws were confounded by other measm?es to reduce violent crime that could be affecting rigdor .5: Mercy examined whether the laws were associated with changes in stranger homicides and other measures of nonfa tal violent crime, I Firearm Pot'a'ir'rjnr' Htgihfi'ird Prisons we Annu. Rev. Public Health Downloaded from wwannualreviewsorg Access provided by Center For Disease Control - Information Centerf CDC on nouns. For personal use only. and they found no Such association. In contrast with the ?ndings for DVRO restrictions, neither domestic violence misdemeanor prohibitions nor laws allowing or mandating police con?scation of ?rearms from the scenes of domestic violence incidents were associated with changes in IPII rates. Zeoli 8t ?Webster used the same study design to examine the same set of gun laws but used city- level data for the 46 largest US cities Importantly, this study controlled for other policies that were associated with reductions in IPHs. Similar to the findings from Vigdor 8t Mercy, DVRO firearm restrictions were associated with a 19% reduction in IPH rates, but no effects were associated with domestic violence misdemeanor restrictions or firearm confiscation laws. One challenge to developing valid estimates of the effects of laws establishing prohibiting conditions for ?rearm possession is the absence of data on whether an offender had the prohibiting condition targeted by the laws under study. A few studies are exceptions. Using data from two cohorts in California that attempted to purchase a handgun from a licensed ?rearm dealer, ?fright et al. (59) estimated the effects of denying felons the ability to legally purchase ?rearms: 2,470 individuals who had one or more prior felony arrests but no felony convictions were approved for purchase, and 170 were denied when attempting to purchase handguns due to prior felony convictions (59). After controlling for prior criminal history, age, sex, and race, those who were approved to purchase a handgun were 21% more likely to be subsequently arrested for a crime involving a gun [relative risk (RR) 1.21, 95% confidence interval (CI) 1.08-1.36] and 24% more likely to be arrested for a violent crime (RR 1.24, 95% CI 1.11?1.39) than would have been expected had their attempt to purchase a handgun been denied based on felons? likelihood of reoffense. Of course, these ?ndings likely suffer from selection bias and may not generalize to the larger population of felons. Felons who attempt to purchase handguns from licensed ?rearm dealers may have fewer connections with suppliers in undergrormd markets than is the case for most felons and therefore may be a lower risk for violent o?'ending. In 1991, a California law went into elfect that extended firearm prohibitions to persons con~ victed of misdemeanor crimes of violence. i-Vinteniute and colleagues collected criminal history data on a retrospective, population-based cohort of persons younger than 35 years of age who sought to purchase a handgun in California in 1991 but were denied as a result of this new dis- quali?cation (57). To estimate the elfect of the law, investigators contrasted criminal offending in the newly denied cohort with that ofa comparison group of persons younger than 35 years of age who had been convicted of a violent misdemeanor during the 10 years prior to legally purchasing handguns in California in 1989 or 1990, just before the new law went into effect. After adjusting for differences in age, sex, and prior criminal history, those approved for handgun purchases prior to the new law were 29% more likely to be arrested for new gun and/or violent crimes during the three years following the attempted purchase than were persons denied from purchasing a hand- gun based on the new law (relative hazard 1.29, 95% CI As would he expected if handgun purchase denial, and not some other factor, had reduced violent offending, investigators saw no difference between the groups in their risk for new offenses that did not involve firearms or violence. Malyel (26) examined the effects ofstate laws that prohibited juveniles {ages <13 years of age) from possessing handguns on juveniles? involvement in homicides as victims and arrestees during 1970?1999. Juvenile handgun prohibitions were unrelated to juvenile involvement in homicides in regression analyses. Many of the juvenile handgun prohibitions were enacred during the early 1990s, a time when juvenile homicide rates were peaking after surging in the late 1980's and just before a steep decline in juveniie homicides from 1994 to 1999. These dramatic changes in juvenile homicides were believed to be driven by forces that were di?icult to measure changes in drug markets, gang involvement, changes in social norms) (5) and were likely to be uneven across the ?Elder I interstate Annu. Rev, Public Health 2015.369 Downloaded from wavwannuaireviewsorg Access pnivided by Center for Disease Control Information Center! CDC on 04! 16. For personal use only. EU states (1 Marvel?s attempt to account for social forces that were not directly measured and that were unique to each state (state?speci?c linear terms to control for very nonlinear changes) was likely to be inadequate to avoid biases from omitted variables. Even ifMan'el's null ?ndings are valid, they may not be surprising. Risks that juveniles face when carrying handguns may not have changed the passage ofjuvenile handgun prohibitions. Prior to such prohibitions. juveniles could still be charged with possessing a gun outside the home without a permit to carry a concealed ?rearm. Using state-level data for 50 states anti the District of Columbia for the period [979?1998, Rosengart and colleagues (33) estimated the effects ot'statc laws that set age 21 as the minimum age for legal purchase and possession of a handgun on homicide and suicide victimization for victims under age .10. Handgun purchase and possession prohibitions for individuals under age I were not associated with risks for ?rearm?related homicides and suicides. The authors noted two limitations ofd?ie study, which may partly explain the null ?ndings: First, only three purchase laws and one possession law had at least ?ve years of postantendrnent enactment data. which limits the statistical power of the study; and second, the models are based on the assumption that the effect of each law was immediate and constant when more gradual effects may be more realistic. Laws restricting ?rearm access by individuals deemed to be a threat to others or to themselves as a result ofa serious mental illness have been in place for many decades. But the first rigorous study ofthe effects ofsuch policies on violence was published in 20 I 3. Swanson and colleagues obtained data for more than 23,000 individuals hospitalized in Connecrjcut for Schizophrenia, bipolar disorder, or tnaior depressive disorder during an eight?year period (2002?2309) and merged these records with criminal iustice records for violent crime Roughly 40% of this group was found to be disquali?ed from legally purchasing or possessing ?rearms in Connecticut due to mental health adjudication, criminal offense, or both. Regression analysis. which controlled for individual risk factors. found that having a ?rearm?disqualifying condition was associated with a increased odds ofviolent offending [odds ratio (OR) Lot), 95% CI 1524.68]. However, having a disqualifying mental health condition during the period when the state was submitting relevant records to the FEl?s National Instant Check System was associated with a reduced likelihood of violent offending by a factor areas (OR one, 95% CI FIREARNI SALES ACCOUN I ABILITY POLICIES DESIGNED TO PREVENT DIVERSION OF GUNS TO PROHIBITED PERSONS Federal Firearm Laws Laws prohibiting ?rearm sales to and possession by highsrisk persons may have limited impact on violence without complementary laws and regulations that provide suf?ciently strong deterrents to illegal ?rearm transfers. The Federal Firearms Act of [938 and the Gun Control Act of 1958 created a rudimentary structure for accountability in the ?rearm industry by requiring those in the business til-selling ?rearms to obtain a federal ?rearm license and by limiting interstate sales of ?rearms to federal ?rearm licensees (FFLs) (63). The GCA required ?rearms manufactured in or imported into the United States to have serial numbers imprinted on them and imposed rectil'leieijpin requirements that would allow law enforcement to trace ?rearm transfers involving licensed manufacturers, wholesalers, retailers. and retail purchasers. The GCA required individuals purchasing ?rearms from FFLs to sign a form stating that they were not convicted felons or otherwise disquali?ed under federal law. Prohibited individuals could be prosecuted for ?lying and buying,? but gun dealers had no obligation to verify that a purchaser was not proscribed from possessing ?rearms. Under the GCA, ?rearm transfers by private gun owners are not regulated, I Pot'n'it'rjr'rr High-Hiri- Ferrari's Annu. Rev. Public Health Downloaded from wwannualreviewsorg Access pmvided by Center For Disease Conlrol - 113411160:r Information Cenlerf CDC on moms. For personal use only. although the GCA made it a crime to transfer a ?rearm to someone known to be proscribed from possessing ?rearms a felon). The Brady Handgun Violence Prevention Act of 1994 mandated background checks to deter? mine whether individuals seeking to purchase ?rearms from licensed gun dealers were prohibited from possessing ?rearms. During the initial or interim phase of the law?s implementation, the background check requirement applied only to sales of handguns and included a ?ve-day waiting period between a purchase application and delivery to approved purchasers. In December 1998, the law was fully implemented for all ?rearms, but the ?ve-day waiting period was replaced with the NICS. From 1994- through 2010, NICS received more than 118 million ?rearm purchase applications, and 2.1 million of those requests were denied either by the FBI or by state or local law enforcement agencies processing the applications (16). The Firearm Owners Protection Act (FOPA) was signed into federal law in 1985. The pro? visions of this law substantially weakened the GCA by raising the legal standard for prosecuting gun dealers who violated ?rearm sales laws. Prosecutors had the burden of proving not only that a violation had occurred, but that the violation was willful. Penalties for ?rearm sales laws viola- tions were reduced, and law compliance inspections of licensed ?rearm dealers were limited. This high standard for taking legal action against licensed ?rearm dealers makes it easier for scof?aw or negligent gun dealers to divert or allow the diversion of large numbers of guns to criminals without incurring corrective action. Separate provisions of the FOPA raised the bar for classify- ing someone as ?in the business of selling ?rearms? and thus Facilitated the unregulated sale of ?rearms by private parties who sell a large number of ?rearms without a formal business. These sales proceed in most states with purchasers remaining anonymous, without background checks, anda?or without record keeping. The FOPA also speci?cally prohibited the federal government from establishing a registry of firearm purchasers. This limitation materially affects the ability of the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATP) to trace ?rearm sales using the records of woof-business ?rearm dealers. The FOPA is not the only federal policy that has reduced retailer accountability that might otheiwisc prevent the diversion of guns to prohibited persons. Congress passed an amendment to an appropriations bill in 20133 that exempted the ATF's crime gun trace data from Freedom of Information Act requests, whether from public agencies or from researchers. These Tiahrt Amendments, so known in reference to their sponsor Representative Todd Tiahrt (Republican from Kansas), also mandated that information from the background checks for gun pur? chasers be destroyed within 2-1- hours of the checks completion and prevented the drillE from requiring ?rearm dealers to perform physical inventories during compliance audits. Provisions added to the law in subsequent years prohibited the subpoena of the crime gun trace data for use in local or state license revocations, civil lawsuits, or other administrative proceedings unless ?led by the ATP. Prior to the passage of this legislation, researchers used data from the ATF tracing of ?rearms recovered by police from criminals and crime scenes and made the startling ?nding that 1% of licensed ?rearm dealers accounted for more than half-of the crime guns traced by the ATF in the late 199% (36). This concentration of crime gun sales among a small number of rctai lers persisted even when ?rearm sales volume was taken into account. For these retailers, crime gun sales were not just frequent; they were diSproportionate In some instancEs, the names of gun dealers connected with the most crime guns were released to the public (28). Cities highly affected by ?rearm violence began to rely on the crime gun trace data to identify gun dealers to target for undercover stings and lawsuits (51). The Protection of Lawful Commerce in Arms Act (PLCAA) was enacted in 2005 in response to lawsuits brought against gun dealers and manufacturers on the basis of claims that, among I interstate Annu. Rev, Public Health 205.36.? Downloaded from wwannualreviewsorg Access provided by Center for Disease Control lRl?vllfiur Information Dealer:f CDC on Iii-ll o. For personal use only. other things, negligent sales practices by licensed ?rearm dealers were enabling criminals to arm themselves and contributing to gun violence. The PCLAA protected gun makers and retailers against lawsuits "resulting from the criminal or unlawful misuse of a quali?ed product by the person or a third party.? Numerous lawsuits brought against the ?rearm industry were dismissed on the basis of the PCLAA. (38). Evidence on Federal Firearm Laws? Ability to Prevent Diversions to Criminals and to Reduce Violence Considerable evidence has demonstrated that criminals and ?rearm traf?ckers regularly exploit weaknesses in federal ?rearm laws. Adi?state survey of licensed retailers selling at least 50 ?rearms annually estimated that these retailers experienced 33,800 attempted surrogate (straw) purchases, and attempted undocumented purchases, per year (54). The most conunonly discussed weakness is the Brady Act?s exemption of background checks and record keeping for ?rearm transfers by private gun owners. This omission hinders the ability oflaw enforcement to hold a gun owner accountable ifhe or she transfers a ?rearm to someone who is prohibited from owning guns. Nearly 3 out of if] gun crime offenders participating in a national survey ofstatc prison inmates conducted in 2004 reported that they obtained their guns from a friend, family member, or the underground gun market (50). Firearm transactions between strangers without background checks or record keeping can be observed directly at gun shows in states that do not close the Brady Act loophole for private gun sales (52). Some unlicensed vendors at these events sell a substantial number of ?rearms Such that it appears to be more of a livelihood than a hobby (53). It is important to emphasize that gun shows make up a small portion of the secondary gun market. In fact, the importance ofthe private?seller exemption to the Brady Law in providing criminals and gun traf?ckers relatively low?risk access to ?rearms and customers is best exempli?ed by the enormous growth in Internet sites established to facilitate ?rearm sales The number of guns for sale by a private seller on the popular website Annslistcom grew more than sixfold (from 12,294 to 83,204} ovcra 20-month period from December 20] I to August 2013. New York City of?cials contracted with an investigative ?rm to call 125 private Sellers of ?rearms identi?ed on ten websites to see if they would sell their ?rearms when the caller said that he/she ?probably couldn't pass a background check.? percent verbally agreed to sell the ?rearm anyway (9). Certainly, actual criminals are using die Internet and lax absent regulation of sales by private sellers to obtain their guns Ludwig 8: Cook estimated the effects of the ?rst phase ofthe Brady Act using data from 1985 through [99? with a difference-indifferences approach. They compared changes in homicide and suicide rates following the Brady Act between the 32 states directly affected by the law (B rady states} with changes in those outcomes for the [8 states that had preexisting state background check requirements (It Clo-Brady states). Although rates of ?reann-involvetl homicides in the United States declined following the law's implementation, differences in the reductions experienced in Brady states did not differ signi?cantly from declines experienced in non-Brady states. There was also no overall Bra dy-related change in suicide rates. The authors mention several plausible reasons for the null ?ndings: (rt) The law exempted sales by private gun owners; (.9) many homicide o?'ende rs do not meet any of the disqualifying conditions prior to offense and therefore are not affected by the law (1 and probably of lesser importance, records for background checks during the time period of the study were incomplete. These authors and others have also noted that the states affected by the law had been source states for guns used in. crime elsewhere. in creasing restrictions in the Brady states could therefore have reduced homicides in the non-Brady states I Pat?n'icrjr'n' Htgih?'ir? Prisons Annu. Rev. Public Health Downloaded from waywannualreviewsorg Access provided by Center For Disease Control - Information Centen? CDC on moms. For personal use only. The FOPA may have introduced another important weakness. Firearm?related homicide rates increased dramatically, particularly among youth, in the years immediately following the enact? ment of the FOPA, fueled by the emergence of turbulent crack cocaine markets and a surge in gun carrying among youth (13). Many of the increasing number of guns recovered from youth connected to the illegal drug trade had likely been diverted from legal commerce. The effects of the FOPA on the diversion of guns to criminals and on gun violence have not been formally studied. Some evidence indicates that federal laws govcming licensed firearm dealers, principally the FOPA, hinder the ability to hold scofflaw dealers accountable. A study of federal ?rearm traf?cking investigations in die late 1990s found that corrupt or negligent licensed deal? ers were the leading channel for guns diverted to criminals, in some cases accounting for more than 10,000 guns Anthony Braga, a leading researcher studying illegal gun traf?cking who helped the ATP conduct this study, and Peter Gagliardi, a former ATP agent, wrote that federal prosecutors were able to charge a defendant with one of these violations in fewer than 33% of the cases involving dealing without a license and fewer than 45% of straw purchasing cases This is in spite of the fact that ATP gun-traf?cking investigators reported that gun dealing and record-keeping violations occurred in most cases accepted for prosecution. Braga Gagliardi also underscored the difficulty in getting prosecutors to bring cases against scoli'law gun dealers and traf?ckers after the FUPA weakened penalties for violating the record-keeping laws necessary for preventing ?rearm diversions. These roadblocks had important practical e?'ects. Drawing on data from 1996 through 2000, National Economic Research Associates identi?ed 12 licensed gun dealers, each ofwhich had sold at least 200 crime guns for which traces provided evidence suggesting gun traf?cking. There were 54,694 Such guns in total. 0f the 35 dealers with more than SUD traces of guns with one or more traf?cking indicators, 32 were still open for business through the end of 2003 (3G). Prosecutions ofgun dealers are very rare, and imprisonment for gun traf?cking is even rarer Standardized measurement and tracking of the diversion of guns to criminals are challenging. Researchers and gun-trafficking investigators at the ATP have routinely used crime gun trace data and indicators of traf?cking or diversion. The most commonly used indicator of gun diversion has been an unusually short interval?ranging from less than 1 year to less than 3 years?between a gun?s retail sale and its subsequent recovery by police from criminal suspects or crime scenes, a metric known as time?to-crime (FTC). A short TTC is considered an indicator of diversion, especially when the criminal possessor is someone different from the purchaser of record. Other indicators include the gun having originated from a retail sale in another state or having an obliterated serial number. Kleek 8t 1Wrong challenged the use of short TTC intervals and out-of-state origins as indica- tors of gun tra flicking and argued that many of the flagged guns are likely stolen (22). Braga and colleagues refute these claims and defend the use of short TTC and out-of?state origins as indi? carers of illegal gun diversion Concerns about biased results from selective tracing of crime guns can also be minimized by limiting analyses to jurisdictions and times where comprehensive gun-tracing policies are in place. A case study from Nlilwaukee, Tla?k'isconsin, suggests that public transParency with crime gun trace data could encourage greater vigilance by gun dealers to prevent gun diversion and that die Tiahrt Amendments may reduce incentives for gun dealers to prevent diversions. working with pre?Tiahrt trace data obtained from the ATF and post?Tiahrt data supplied by Milwaukee Police Department, 1?Webster and colleagues analyzed trends in the number of crime guns deemed likely to have been diverted that were recovered by police between 1996 and 2006 (48). In May 1999, it was publicly reported that a local gun shop, Badger Guns and Ammo, had sold more guns later I interstate Annu. Rev, Public Health 205.36.? Downloaded from Access pnwided by Center for Disease Control lRl?lefJul Information Center! CDC on Dem-4116. For personal use only. traced to crime than had any other gun store in the nation. Within days of this release, the gun store?s owners announced voluntary meaSures to reduce the likelihood that the guns sold by the store would get into the hands oi'erimjnals. During the months iust following this announcement, the number of guns sold by the store that were subsequently recovered within a year of sale by police from someone other than the purchaser of record dropped abruptly by Wits with minimal replacement by other dealers (46). But the implementation of the Tiahrt Amendments in 2005 was associated with a Millie increase in short sale-to-critnc guns sold by the gun store in question, with no comparable increase for other gun dealers Law enforcement?researcher partnerships should examine whether the Tiahrt Amendments had similar eliccrs in other US cities and whether the effects are muted in states that have their own laws for gun dealer regulation dint are notably tougher dian federal laws. Prior studiea have shown that la wsuits brought against gun dealers hicilitating bla tantly illegal straw purchases signi?cantly reduced the diversion of guns to criminals {45, 51). Now that the threat oilawsuits against gun dealers is likely to have been reduced by the PLCAA, research should examine whether gin) diversions shortly following retail sales have increased. Effects of State Gun Laws on the Diversion of Guns to Criminals and Criminal Access to Guns il?he wea knot-is in federal gun laws dEscrib-ed above and snirirnarized previously by Bra ga 5: Ga gliardi (10) underscores the importance of studying the eli'ects of state laws governing ?rearm sales. Seventeen states require individuals in the business of selling ?rearms to obtain licenses from state or local law enforcement agencies. Only 12 of these states and the District of Columbia also allow law enforcement to inspect gun dealers? records. however. which is a minimum requirement for firearm sales law compliance oversight (39). The number ol?stalcs that have a more comprehensive set of laws and enforcement practices to promote accountability by federally licensed lire-arm dealers?licensing. record?keeping requirements, allowing audits of records, mandatory prom pt reporting of ?rearm theft or loss. and conducting regular compliance audits-is dwindling to a handful (47). Seventeen states and the District of Columbia have some requirement in place to regulate private sales of handguns, including mandatory purchaser background checks. 'I?hirteen of these states have some form of permit?to?purchase 11") policies for handguns; however, these systems vary gready in ways dint are likely to aHIeL't their ability to curtail gun diversions and reduce vio- lence. Two states allow permit seekers to apply through the mail or online, whereas all but one of the others require in?person applications with applicants being photographed and ?ngerprinted. Permits to purchase are valid for as long as 11] years in Illinois and Maryland and for as short as 10 days in Massachusetts and Michigan. Several states that issue permits that are valid for longer time periods have separate presale requirements for background checks, which is important be? cause a signi?cant percentage of those who pass a background check and purchase ?rearms legally become prohibited within a Few years (58). Three states (Massachusetts. New Jersey, and New York) allow local law enforcement agencies issuing the permits to use discretion and to deny an applicant who does not have any explicitly stated disqualifying conditions (20). State laws governing background check processes for ?rearm purchasers also d'di'er with respect to the records that are checked. All states check the however, 19 states process background checks by state or local law enforcement agencies, which can access additional records ltept by those agencies that may not be available in the NICS. The types and number of records that are available and used For checks for firearm transfers also vary considerably across states and over time I Pal'rrirrjirr' Persons Annu. Rev. Public Health Downloaded from wavwannualreviewsorg Access pmvided by Center For Disease Control - IRMOI Information Centen? CDC on 041? l4f to. For personal use only. 30 Beginning in the late 19905, the ATP developed a Youth Crime Gun Interdiction Initiative (YCGII) to promote comprehensive crime gun tracing in cities around the United States and the use of the data in understanding and combating illegal gun traf?cking (35). About 70% of crime gun traces are for guns that originated from a retail sale in the same state in which the gun was recovered in crime. A much lower than average share of crime guns that originated from within?state retail sales suggests that the state is preventing diversions to criminals. 1Webster et al. analyzed crime gun trace data from the ?rst 25 YCGH cities to examine associations between a state?s gun sales regulations and the proportion of its crime guns that originated from retail sales within the state (49). The share of crime guns that originated from in-state retail sales in states with both policies and handgun registration was, on average, 3? percentage points lower relative to the comparison states lacking either policy, after controlling for differences in gun ownership, proximity to population centers in other states, the prevalence of guns recovered from drug arrests (because illegal drugs and guns travel together across state lines), and in?state migration. In a recent national study, this combination of policies, along with a comprehensive background check requirement, was also associated with fewer crime guns having a short TTC. Pierce and colleagues categorized California separately because its policies for regulating firearm sales are at least as rigorous as those in many states with FTP laws. The number ofshort TTC years) traced crime guns bought in state per 100,000 gun owners was four times higher in states that lacked FTP or handgun registration than in California or states that had both policies. These differences between crime gun sales rates and across these gun sales law categories were even more pronounced for guns diverted to criminals across state lines (31). Economists have examined the flow of guns purchased in one state and recovered following their use in crime in another state as a function of the difference in the stringency of gun laws in the source (exporting) state and the destination (importing) state, while controlling for other factors. Using a simple additive index of 10 gun laws identi?ed by Mayors Against Illegal Guns as important to preventing gun traflicking,' Knight (23) found that weaker gun laws in source states increased the export of crime guns, and stronger gun laws in destination states increased the import ofcrime guns. Firearm use in crime, as measured by the percentage of robberies committed with a ?rearm, increased in states with relatively strong gun laws when nearby states had relatively weak gun laws. lidost strongly associated with preventing the export of crime guns were laws requiring gun owners to report lost or stolen ?rearms to law enforcement, those that provided local diScretion to adopt gun laws stronger than those adopted at the state level (much of this eifect may be due to Chicago's longtime ban of handguns), and state statutes speci?cally prohibiting straw purchases (23). Kahane {21) conducted a study using much ofthe data and theoretical underpinnings as Knight did but incorporated measures relevant to the demand for guns by criminals within a state gang members and police per capita). His ?ndings were similar to Knight?s on measures of the relative strength of gun laws in aggregate. With respect to the effects of speci?c laws, both studies found strong protective effects of mandatory theft and loss reporting. But Kahane?s ?ndings differed from Knight?s because he did not ?nd that local discretion to regulate gun sales was protective against exporting crime guns and did ?nd that laws requiring background checks for lThe state laws examined established criminal violations for straw purchases, falsifying information on purchase applications, and ?rearms dealers failure to conduct background checks for ?rearm transfers; required background checks for all private handgun transfers or for all ?rearms transferred at gun shows, P'l'l??s for handguns, anti mandatory prompt reporting of lost or stolen ?rearms to law enforcement; allowed law enforcement inspections of ?rearms dealers; prohibited gun possession for violent misdeineanants; anti allowed law enforcement discretion in issuing permits for concealed carry of ?rearms. f?f?eftn?rr I 1V furniture Annu Rev, Public Health EDIE 36 2 Downloaded from mannualreviews org Access pmvided by Center for Disease Control lRl?lefJur Information (Denier:r CDC on l4i'l o. For personal use only. sales by private gun owners and allowing law enforcement discretion in issuing permits to carry concealed firearms were protective (21). W'ebster and colleagues studied state differences in exporting guns to criminals in other states and found that PTP laws for handguns, when law enforcement retained discretion to deny applications ifdecmed to be in the interest of public safety, were strongly associated with lower per capita exporting of crime guns. Nondiseretionary PTP laws that required purchasers to be [in gerprin ted, other requirements for background checks for private sales, mandatory reporting of theft or loss of ?rearms, and junk gun bans were also independently associated with fewer guns exported per capita. These analyses controlled for gun ownership, proximity to states with stronger gun laws, borders with lCanada or Mexico, and out?of?state migration (50). in another study, researchers used data front crime gun traces from 2000 to ZGUZ in 5-i- US cities with comprehensive critne gun trace policies to examine associations between the number ofguns likely diverted (TTC <1 year and the criminal possessor ofthe gun was not the purchaser of record) and gun sales laws. Strong gun dealer regulations and oversight, required purchaser background checks for handgun sales by private owners, and FTP laws with law enforcement discretion were each independently associated with fewer diversions to criminals. Discretionary FTP laws were not independently associated with levels ofg'un diversions when gun ownership levels were controlled for Findings from these studies are generally consistent with economic theories relevant to reg- ulation and market forces (12, 34-, 35). Comprehensive regulations that should promote ?rearm seller and purchaser accountability rigorous systems, comprehensive background checks, and mandatory theft and loss reporting?appear to curtail diversions of guns to criminals, but they also lead to criminals importing guns from states with weaker gun laws. States with the strongest gun sales regulations experienced reduced availability of guns for criminal use, despite the in?ux of guns front other states where regulations were weaker (49). These ?ndings suggest that the real price of guns for criminals in states with the strongest gun laws is elevated by these states? gun policies and that criminals' demand for guns is at least somewhat elastic. This conclusion is consistent with data front an in-depth study of Chicago?s underground gun market prior to the city?s handgun ban being overturned by the US Supreme Court. i-Vhilc thousands of guns are recovered hy the Chicago Police Department each year, those guns are recovered from a small fractiOn of the city?s 2.7 millicm population. and a survey of adult arrestees found that only 1 in 5 male arrestees?-i-4% of whom reported current or past gang membershipwreported ever owning a Through hundreds of interviews with a broad range of actors in the undergrotmd economy in a high?crime Chicago neighborhood, researchers found that trusted suppliers of ?rearms were in short supply, and gang leaders rationed gun access among their members. There were substantial transaction costs (search time, risk encountered connecting with a supplier or purchaser). and prices paid for typically low-quality hand guns were twice as high as would be found in advertisements for private sales in states with weaker gun laws than those in. Illinois. Effects on Violence of Laws Designed to Prevent the Diversion of Guns to Prohibited Persons There are few rigorous studies of the effects of US gun policies designed to prevent the diversion of guns to prohibited persons. Most published research has examined asmciations between the presence of various state gun policies and rates of homicide or odter violent crimes after control? ling for numerous potential eonfounders. Most studies, however, do not estimate policy effects on the basis of changes in outcomes following changes in policy using fixed effects regression models. I Firearm Pat'rrit?rjiir' Higlhfiire Prisons Annu. Rev. Public Health Downloaded from wavwannualreviewsorg Access provided by Center For Disease Control - Information Centen? CDC on For personal use only. Because the most relevant gun laws PTP handgun laws, gun dealer regulations, compre? hensive background checks) have changed very little for decades, the studies are principally cross? sectional. For example, in a state-level panel study, Irvin et al. examined the association between sta te laws and regulations governing ?rearm dealers and ?rearm homicide rates (19). Although the data examined spanned 1995?2010, the policies did not change over the study period. Regression analyses controlled for social and demographic characteristics, gun ownership, rates of burglaries and drug crimes (trends in these crimes would not be expected to be affected directly by ?rearm policies), and a global scale of gun law restrictiveness. State licensing requirements and laws requiring or allowing inspections or audits of gun dealers were independently associated with signi?cantly lower ?rearm homicide rates, and these two policies combined were associated with ?rearm homicide rates that we re 51% lower than would be expected without the policies. Although a measure of the strictness of gun laws was included in the regression models, it is likely that this factor would not completely control for confOunding with the most important gun laws handgun laws, comprehensive background checks) that are correlated with dealer regulations. Fleegler and colleagues analyzed the association between state ?rearm laws?measured as quintilcs along an overall gun law strength scale developed by the Brady Campaign to Prevent Gun Violence?and ?rearm mortality using annual data for the years 2007-2010 (15). Poisson regression analyses controlled for population composition by age, racez?ed'tnicity, sex, poverty, unemployment, educational attainment, population density, and rates of non?rearm homicide and noniirearm suicide. Compared with states in the lowest quintile on gun regulations, states in the highest quintile had ?rearm homicide and ?rearm suicide rates roughly 40% lower than would be predicted. But the only single category of gun laws that was signi?cantly associated with ?rearm homicide and ?rearm suicide rates was for laws strengthening background checks. This subscale was weighted mostly by the presence and strength of PTP handgun laws. In addition, almost all the observed effect was on ?rearm suicide, though the laws under study were directed at interpersonal violence. Independent effects of the total ?rearm regulation score were eliminated when the regression analyses controlled for gun ownership levels. Fleeglcr and colleagues interpret the ?ndings to indicate that ?rearm regulation effects on ?rearm homicide and suicide were mediated by the laws depressing population gun ownership. Bur interpreting cross?sectional associations between gin laws, gun ownership, and ?rearm violence is dili'icult (55). 130pulati0n gun ownership levels affect the probability of certain gun laws being enacted and few gun laws are designed, or are likely, to have signi?cant effects on population gun ownership (discretionary PTP laws are a likely exception). Thus, the absence of ?rearm regulations? associations with ?rearm homicide and ?rearm suicide when gun ownership was controlled for could mean that gun ownership levels affect ?rearm homicide and suicide rates, and gun laws provide no protective bene?ts and are only spuriously associated with lower ?rearm mortality. This and other ?aws in the Fleegler study leave much uncertainty about the utility of its ?ndings (55). Moorhousc 8t iVanner examined associations between the restrictiveness ofa state?s gun laws in 1998 and crime rates in 1999 and ZUUI (29). Although the policies were measured prior to the outcomea, this study examined cross?sectional associations rather than changes in crime in response to changes in policies. Using similar covariates as did Fleegler et al. but adding per capita income, arrest rates, and average sentences for criminal convictions, but not controlling for gun ownership, Moorhouse 8t ?t?u?anner report no association between the Open Society Institute's global score for each state?s gun laws and any of the violent crimes examined (murder, rape, robbery, assaults). I interstate Annu. Rev. Public Health Downloaded from wwannualreviewsorg Access provided by Center For Disease Control - minor Information Centen? CDC on mums. For personal use only. The reasons for the discrepant ?ndings between the report by Fleegler et al. and the report by MoorhOuse 8t Wanner [and similar prior studies ?nding no associations between gun control and violent crime (14, 25)] are not obvious. Here we focus on dilierences between the outcome measures and how gun regulations were measured. Moo rhouse 3t Wanner examined violent crimes that, all but murder, typically do not involve use of a ?rearm. In contrast, Fleegler et al. and Irvin et al. focused exclusively on lethal violence committed with ?rearms. it is not surprising that outcomes that exclusively measure ?rearm violence would be more closely correlated with ?rearm policies than would outcomes where most incidents do not involve a ?rearm. The measures ofgun policies used in each study are also problematic. These studies and many others used scales purporting to measure die restrictiveness of gun laws. These scales generally reflect the political priorities of gun control advocates rather than a scienti?cally valid measure of a construct. The scales are often not weighted to reflect the size of the e?ect each element is expected to have. Furthermore, using such a blunt measure does not allow researchers to examine whether the effectiveness of certain policies prohibitions for violent misdemeanan ts) depends on the presence ofother policies comprehensive background checks). For example, an index made up of largely ineliective policies and 3 e?ective policies is likely to produce null ?ndings. Findings from global measures of gun laws also prevent inferences about the citizens of any single policy. lOne of the stronger studies to consider both the type and the breadth of disquali?cations for ?rearm postsession as well as the strength of regulations designed to prevent transfers to prohibited persons is ibidttEs 8c Hempstead?s study of the effects of state gun policies on suicide rates for males In a SD?state panel study covering 1995?2 004, they found that an index of behavioral {versus criminal) prohibitions relevant to risk for suicide restrictions for mental illness, domestic violence, alcohol and drug convictions) and a measure that cotnbined PTP requirements and minimum purchase age 21 were each associated with lower suicide rates. There was no association between criminal prohibitions and suicides. These analyses controlled for social and economic variables, alcohol consumption, and a proxy for ?rearm ownership. The researchers used state and year ?xed eliccts to control for time-invariant omitted variables speci?c to states and omitted variables over time nationally. Although there has been relatively little change in key state policies designed to prevent guns being diverted to prohibited persons in recent decadEs, there have been some expansions to prohibiting conditions and improvements in the databases used to determine ?rearm purchaser eligibility. Sen Paniamapirom examined state?level associations between variations in the types of records for prohibiting conditions that were accessed for pregun?sale background checks and ?rearm deaths for the period 1996?2005 Analyses controlled for changes in population demographics, poverty, unemployment, divorce, hunting licenses (a proxy for gun ownership), alcohol consumption, whether a state required background checks prior to the Brady Act, year and region ?xed eliects, and a lagged value of the outcome variable for 1990. h?lore extensive background checks were associated with lower rates of homicide overall, ?rearm homicide, and ?rearm suicide. Expanded checks for domestic violence restraining orders, fugitive status, and mental illness disquali?ers were each independently associated with lower rates of ?rearm homi- cides and all homicides. Expanded checks for mental illness disquali?cations and fugitive status were each associated with lower rates of ?rearm suicides and all suicidEs. The magnitude of the estimated effects was greatest among outcomes for ?rearm homicide. The size of these estimated effects, however, seems questionably large. For example, restraining order laws are principally "The analyses were limited to males because the vast majority of ?rearm suicides are by males. I Forum; i?afiri'er?at' High?Rial: Ferraro." Annu. Rev, Public Health 205.362 I-37. Downloaded from maennualreviewsorg Access pmvided by Center for Disease Control lRl?viIqur Information Cenlenr CDC on lane. For personal use only. applicable to domestic violence. which accounts For less than 10% ofmurtlers, yet background checks for restraining orders were associated with a 13% lower risk for ?rearm homicides. The study?s exclusive focus on categories of background checks without controlling for other policies is likely to have inflated estimates ofthe ctlects olbackground checks. For the research reviewed above. IJ'tf: type of ?rearm policy most consistently associated with curtailing the diversion of guns to criminals and for which some evidence indicates protective effects against gun violence is FTP for handguns. Most states with FTP laws have had them in place for many decades. The most recent change was Missouri?s repeal of its FTP handgun law. i?Vebster ct al. studied the effects ol'this policy on lethal violence with a SU-statc panel study using data For the period 1999?2 012 (43). Regression analyses cono'ollcd for stare and year ?xed effects and changes in unemployment. poverty, policing levels, incarceration, liurglaiy rates (as a general measure ulcrime), and policies concerning the ease ofgetting concealed weapons permits, junk gun bans, and so?ealled ?Stand Your Ground? laws. l-lomicide rates based on vital records and murder rates based on police reports showed diverging trends inu nediately following the FTP repeal; rates rose sharplyin Missouri but declined in the rest olthe nation. Missouri?s PTP repeal was associated with 3 increase in murder rates over 5 years Following the policy change and a 2 5% increase in ?rearm homicide rates. Additional evidence bolstered causal inference benveen the policy change and increased murders: Increases in ?rearm homicide rates were widespread and relatively even across metropolitan counties in the state (ruling out the possibility that the increase was due to some changein one large there was no policy-related change in non?rearrn homicides; and there was a twofold increase in short TTC guns and a relatively large Shift from outwo?state sources of crime guns to within?state crime guns immediately following the repeal. CONCLUSION The weaknesses in US federal ?rearm policies are well documented and result in many high-risk individuals having access to and using ?rearms to commit violent crimes. Roughly ball or more of those who commit gun crimes do not meet any of the prohibiting conditions under federal law. Wieak Jfederal laws and declining resources for federal gun law enforcement limit the ATF's ability to curtail illegal ?rearm traf?ckin g. The enactment ofthe Brady Handgun Violence Preventi on Act was a step in the direccion of increased accountability to prevent prohibited persons EFIZHTI obtaining ?rearms, but it did not have a signi?cant impact on population homicide or suicide rates during the ?rst four years it was in place. Yet on a more micro level, it appears that criminals who attempt to purchase ?rearms from licensed gun dealers and are denied are less likely to engage in violent crime. Expansions in the types of background checks performed may also have protective e?'ecrs against lethal violence. Some expansions in the conditions that disqualify someone from legally possessing ?rearms?restraining orders for domestic violence and convictions for misdemeanor crimes ofviol encc?seem to reduce violence. lthers (cg, minimum age For purchase or poss easion misdemeanors for domestic violence) have not in?uenced violent crime. Mounting evidence indicates that certain laws intended to increase the accountability of?rearm sellers to avoid risky transfers of ?rearms are effective in curtailin the diversion of guns to crim? inals, in particular the more rigorous FTP handgun laws, comprehensive background checks, strong regulation and oversight of gun dealers, and laws requiring owners to re? port lost or stolen ?rearms. Evidence that lower levels of guns being diverted to criminals will translate into less gun violence is less robust, but it appears that rigorous FTP handgun laws are protective against homicides and suicides. Future research should examine whether these laws also curtail nonlethal gun violence. Laws mandating con?iprehensive background check requirements I Annu Rev Public Health ZUIS 3e 2 I-37 Downloaded ?om annualresiews org Access pnwided by Center for Disease Control Information Centeri CDC on Dem-1116. For personal use only. for ?rearm purchasers through means other than PTP laws should be studied with respect to both their enforcement as well as their impact on violence. Such studies should consider the elieets of complementary policies such as penalties for failure to comply with ?rearm sales laws, explicit prohibitions on straw purchases, and mandatory loss and theft reporting. Finally, it is surprising that prior studies have not systematically examined ifand how policy e?eets are modi?ed by the presence of other policies. For example, the impact ol'a law expanding firearm prohibitions to violent misdemeanants Ina},r depend on whether the state has a robust system of laws in place to prevent diversions. Similarly, the impact ofantitliversion laws such as comprehensive background checks should depend on the breadth of the prohibitions For high?risk individuals. Given the importance of gun violence to public safety in the United States, greater invesunent in and corn? rnitrnent to rigorous research are needed to answer these and other important tluestit'ms relevant to the prevention of gun violence. DISCLOSURE STATENIEINT The audiots are not aware of any af?liations, memberships, funding, or ?nancial holdings that might be perceived as after-ring the objectivity of dais renew. LITERATURE CITED 1. Abbey A, Donohuel} 1H, Zhung A. 201 l. The impact of right-toucan?y laws and the NRC report: lessons for the empirical evaluation of law and policy. Am. Lani Eran. Reta 13:565~632 3 . dun. For Gun 5:1 F. Found, ZIHH. S'rliirrg Crime: ilmid?ii affirm Sister Fuel Criminals. Washington, DC: Am. For Gun Found. 1. Andres AR.He1npsteatl K. Jill I. 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Firearms. 1999. Yuma Crime Grin Iaterriittian initiative. Crime Cm: Repairs: Tine Mega! Panto Firearms .Mari'er in Smith. 1ii'ir'ashington, DC: US. Dep. Trcas. . U.S. Bur. Alcoht'il, Toh. Firearms. 2131.111. Chmmeirc in Firear?mria tire States. 1lilirrashington, DC: US. Dep. Tre as. . U.S. Bur. .?r'ticr'ihol, Trih. Firearms. 21.11111. Foiiotving tire Gnu: En?rring Fcrir?rai Inn?s Against Firearms Trajjiirking. 1i'ii?ashington, DC: US. Dcp. Treas. VernickJS, Rutltow L, Salmon DA. 2011?. Availability of litigation as a public health tool for ?rearm injury prevention: comparison of guns, vaccines, and motor vehicles. Am. J. Paaiir Hana; 9219913? Vernick JS, 1Veh5ter Bulzacchelli MT, MairJS. 211116. Regulation of ?rearm dealers in the United States: an analysis oi'statc law and opportunities for improvement]. Law ?ied. Erato? 263?25 Vigdor ER, Mercy JA. 211113. Dis-arming hatterers: the impact of laws restricting access to ?rearms by domestic violence oli'enders. In Gan Paiig': E?i?rrs on Crime and Wartime, Ludwig, (look, pp. 151?2 114. ?Washington, DC: Brookings Inst. Vigdor ER, MerchA. 21106. Do laws restricting access to lirearlns by domestic violence olieiiders prevent intimate partner homicides? Eva}. Ree. 311:313?46 K531, 'W'ebster 2013. Legal status and source 01' ol'l'cnclers? ?rearms in states with the least stringent criteria for gun ownership. in}. Prev. 19:26?31 ?Water I 11" interstate Annu. Rev. Public Health Downloaded from wwannualreviewsorg Access provided by Center For Disease Control - lRl?w?l?vr lnfonnation Centen? CDC on 041? 14-:r 16. For personal use only. 43. 46. 43. 49. 1Webster Cril'asi CK Vernick ?15. 2014. Elfeets of the repeal of Missouri?s handgun purchaser licensing law on homicides]. Ulnar; Health 91203402. Erratum: Uzi-lam Health 915084501 . W?ebster VernickJS, eels. 2013. Resisting Violence in America: Informing Policy with Evidence and Analyser. Baltimore, MD: Johns Hopkins Univ. Press 1lullv?ebster DW, Verniek JS. 2013. Sparring responsible ?rearms sales practices through litigation: the impact of New York City?s lawsuits against gun dealers on interstate gun traf?cking. See Ref. 44, pp. 12 3? 32 1Webster DEV, 1v?ernick J5, Bulzaechelli MT. 2006. Effects ol'a gun dealer?s change in sales practices on the supply of guns to criminals]. Urban Health 03 :77'8?8? Verniek IS, Bulzaechelli MT. 200?). Effects of state?level ?rearm seller accountability policies on firearms trafficking. 7. Urban ?with 86525?3? 1laTernick J5, Bulzacehelli MT, Vittes KA. 2012. Recent federal gun laws, gun dealer ac- countahilitv and the diversion of guns to criminals in Milwaukee. Urban Health 89:8?4?7 1Webster VernickJS, Hepburn LM. 2001. The relationship between licensing, registration and other state gun sales laws and the source state of crime guns. .laj. Prev. Bil?39 . 1i.llvl'elisrer Vernick JS, McGintp FF, Alcorn T. 201 3. Preventing the diversion of guns to criminals through elfeetive ?rearm sales laws. See Ref. 44., pp. 109?22 . ?Webster Zeoli AM. Bulzacchelli MT. Vernick JS. 2006. Elfects of police stings of gun dealers on the supply?r ofnew guns to criminals. faj. Prev. l2:225~30 . 2007'. Gun shows across a multistate American gun market: observational evidence of the effects of regulatory policies. In}. Prev. 13:150?56 . 1 Jll'inreunite 20119. fun-ale Grin Shows: Imer Goes on ?7.5ch Everybody Tilt-inlet iVoboa'ylr Sacra? mento, CA: Violence Prev. Res. Progr. . 1ivii-Tintemute 2013. Frequency of and responses to illegal activity related to commerce in ?rearms: Iindings from the Firearms Licensee Survey. Iiy'. Prev. 19412?40 . ?Wintemute 2013. Responding to the crisis of ?rearm violence in the United States: comment on ?Firearm Legislation and Firearm?Related Fatalities in the United into-a. Med. 173:740? 42 . 1W?iniaeirrnite Cook ?Fright MA. 2005. Risk factors among handgun retailers for frequent and disproportionate sales ofguns used in violent and fireannurelated crimes. by. Prev. 1 1:35 L63 . l-Vintemute ?Wright MA, Drake C, Beaumont 2001. Subsequent criminal activity among violent misdemeanants who seek to purchase handguns. jAMld 235 :1019v2t?i . W'right MA. l.v?l?iriteniute 2010. Felonious or violent criminal activity.r that prohibits gun ownership among prior purchasers of handguns. if. Trauma 8?:352?64 . 1i.llr?right MA, Rivara PP. 1999. Flfectiveness of denial of handgun purchase to persons believed to he at high risk for ?rearm violence. Am. Health 09:38?90 . Zeoli AMI. TWebster 2010. Effects of domestic violence policies. alcohol taxes and police stalling levels on intimate partner homicide in large 1.1.3. cities. liy?. Prev. 16:90?95 . Zimring FE. 19-158. is gun control likely to reduce violent killings? Univ. Chicago Law Rev. 35:?21?3? . Ziniring FF. Firearms and federal law: the Gun Control Act of 1933.}. Legal Stud. 41133?93 tauire.amrnaft'cvirwr.org I Fn'canw f?afia'cr?ar Hfgh?Rirf: Ferraro." 'qu Ml Annu. Rev, Public Health 2015.369 Downloaded from wwannuaireviewsorg Aecees provided by Center for Disease Control lRl?viUur Information Denier:f CDC on UNI-lilo. For personal use only. Contents Symposium: Strategies to Prevent Gun Violence Commentary: Evidence to Guide Gun Violence Prevention in America Danie! PV. W?ebrrer The Epidemiology of Firearm Violence in the Twentvairst Century United States Gar-ea} 5 Effects of Policies Designed to Keep Firearms from Hi gin?Risk Individuals Daniel IV. Webster and Germ}. 21 Cure Violence: A Public Health Model to Reduce Gun Violence Jeffrey A. Hurts, Caterina Caner} Lindmy Barre-dole, end?'reirrv R. Potter A . H39 Focused Deterrence and the Prevention ofViolent Gun Injuries: Practice, Theoretical Principles, and Scienti?c Evidence Aarbauv?. Stage midDat-Tr'dL. ?fronted?- "i'i Epidemiology and Biostatistics llas Epidemiology Become Infatuated W?ith Methods? A .l-Iistorical Perspective on the Place ofMethods During the Classical (1945?1965) Phase of Epidenu'ology Alfredo Mambia . . . 69 Statistical Foundations for Nlodel?Based Adjustanents Sander Greenland and Neil Pom-r: The Elusiveness of Population?W'ide High Blood Pressure Control Parr! K. {Metro-a 199 The Epidemiology of Firearm Violence in the Twenty-First Centurir United States Grove Moments 5 Focused Deterrence and the Prevention ofViolent Gun Iniuries: Practice, Theoretical Principles, and Scienti?c Evidence AnrborryA. Bragatmd DevidL. {Welded 1J1 Annual Review of Public Health Volume 35, 2015 Annu. Rev. Public Health 2015.36z21-3T. Downloaded from Access provided by Center For Disease Conlrol - Information Cenlerl CDC on D4ll4ll?. For personal use only. Unintentional Home Injuries Across the Life Span: Problems and Solutions Andree C. Gielen, Eileen i'lr?l. M'Deneld, and Wendy Shields . 231 Sleep as a Potential Fundamental Contributor to Disparities in Cardiovascular Health Chandra L. fuck-ten, Redlirze, {arid Karen .M. Emmett: 417 Translating Evidence into Population Health Improvement: Strategies and Barriers Steven H. Woolf: fawn Q. Parnell, Serial: Simon, Emiijr B. Zimmerman, Gabriela Cenilverar, Antler Haley, and Robert P. Fields 463 Environmental and Occupational Health Fitness of the US NieelnerP.Piunle131 Food System Policy, Public Health, and Human Rights in the United States Kerry L. Shannan, Brent F. Kine, Shaw?! E. .MeKenzie, and Halter! S. Lawrence Regulating Chemicals: Law, Science, and the Unbearable Burdens of Regulation Ellen K. Silleergelil, Daniele llr?laneliiali, and Carl F. Greener 175 The Haves, the Have?Nets, and the Health oFFneryone: The Relationship Between Social Inequality and Environmental Qualit},F Lara Curbing, Rachel Marelle?Fmteb, Aladeline Wander, and M's-Intel Patter 193 The Impact of Toxins on the Developing Brain Brute P. Lanpbeiir 21 Unintentional Home Injuries Across the Life Span: Problems and Solutions Andrea C. Gielen, Eileen ll/I. iWrDeneld, and Wendy Shields . . 231 Public Health Practice Cross-Sector Partnerships and Public Health: Challenges and Opportunities for Addressing Obesity and Noncommunicable Diseases Through Engagement with the Private Sector Lee M. Jebnsren and Diane T. Finegaad . 255 Deciphering the Imperative: Translating Public Health Quality Improvement into Organizational Performance Management Gains Leslie Mr. Valerie A. Yeager, and john il/Iaran 2 l3 Contents Annu. Rev. Public Health 2015.36z21-3T. Downloaded from Access provided by Center For Disease Comm] - Information Cenlen? CDC on D4fl4a?l?. For personal use only. Identifying the Effects of Environmental and Policy Change Interventions on Healthy Eating Deborah}. Bowen, Wendy E. Remington, and Shirley AA. Hereford 289 Lessons from Complex Interventions to Improve Health Peneiope Home 307 Trade Policy and Public Health Sharon FrieI, [Joey Hattersl'tgr, and Rm}: Townsend . .. 325 Uses of Electronic Health Records for Public Health Surveillance to Advance Public Health Greene 5. Birebeod, iMjeboe! Mommas, and Norm R. Ebola 345 ?What Is Health Resilience and How Can We Build It? Katherine Way}; Darrin Donate, and Nreoie Lorie 361 Effects of Policies Designed to Keep Firearms from High-Risk Individuals Dorrie! 14/. Webster and Goren]. Wintemete . 21 Cure Violence: A Public Health Nlodel to Reduce Gun Violence A. Bern, Chlorine Garters Roman, Lindsay Bornoiek, ond?o?emy R. Porter . .39 Focused Deterrence and the Prevention of Violent Gun Injuries: Practice, Theoretical Principles, and Scienti?c Evidence Anthony A. Brogo and David L. 55 Regulating Chemicals: Law, Science, and the Unbearable Burdens of Regulation Elfen K. Siibergeld, Daniele i?l/Iemdrioli, one! Cor! F. Cronor ITS The Response of the US Centers for Disease Control and Prevention to the Obesity Epidemic Wi?iom H. Diem 575 Social Environment and Behavior Immigration as a Social Determinant of Health Heide Castaneda, Serb .M. Holmes, Doniei S. Aldrin?Elena DeTi-inidod Young, Naomi Beyet'er, and James Querodo 375 Mobile Text Messaging for Health: A Systematic Review of Reviews Amends K. Hoff, Heather Cole-Lewis, rmdj?oy MI. Bernhard: 393 Sleep as a Potential Fundamental Contributor to Disparities in Cardiovascular Health Chandra L. forkron, 33mm Redfine, and Karen ill/I. Emmonr 417 Co men Lt Annu. Rev. Public Health 2015.36z21-3T. Downloaded from Access provided by Center For Disease Comm] - Information Cenleti CDC on [Mild-i115. For personal use only. 1? Stress and Type 2 Diabetes: A Review of How Stress Contributes to the Development ofTvpe 2 Diabetes Show Karol}: arid M?aoaraie irmaii . . .. . . . Translating Evidence into Population Health Improvement: Strategies and Barriers Steven H. Woolf Eaton Q. Parnell, Sarah Mr. .S'imoa, Emiiv B. Zimmerman, Gabriela Camberos, A?tiffi' Haiev, and Robert P. Fields Using New Technologies to Improve the Prevention and Management of Chronic Conditions in Populations Brim: Oideaimrg, C. Barr Taylor, Adrienne O'Neil, Fiona Corker, and Linda D. Cameron Commentary: Evidence to Guide Gun Violence Prevention in America Danie! Webster The Haves, the Have-Nots, and the Health of Everyone: The Relationship Between Social Inequality and Environmental Quality Lair: Cashing, Racbei il/ioreiio-Froscia, alfadeiine Wander, and Pastor . . . Cross?Sector Partnerships and Public Health: Challenges and Opportunities for Addressing Obesity and Noneommunicable Diseases Through Engagement with the Private Sector Lee forearm?! and Diane T. Fiaegood . Lessons from Complex Interventions to Improve Health Peneiope Hattie ?vVhat Is Health Resilience and How Can ?We Build It? Katharine Wow: Dania Donate, and Nitoie Lorie Health Services Assessing and Changing Organizational Social Contexts for Effective Mental Health Services Charlies Giisson and Natimaiei Policyr Dilemmas in Latino Health Care and Implementation of the Affordable Care Act ?iexander N. Ortega, Hector P. Rodrigaea, and Art-taro Vargas Tax-Exempt Hospitals and Community Bene?t: New Directions in Policy and Practice Daniel B. Rabin, Simone R. Siagb, and Gary}. Young The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction Andrew Koioday, David T. Coartwrigbt, Catherine S. Hmong, Peter Kreirier, john L. Eadie, Thomas Clark, and G. CaieiJAiexaader . . .. . . Contents 193 255 3'3? 361 5'3? 525 545 .559 Annu. Rev. Public Health 2015.36z21-3T. Downloaded from Access provided by Cenler For Disease Comm] - Information Cenleti CDC on [Mild-i115. For personal use only. he Response of the US Centers for Disease Control and Prevention to the Obesity Epidemic H. Diets . . 5 75 Mobile Text Messaging for Health: A Systematic Review of Re?ews Amanda K. Heather Cele?Lewis, and?iv EM. Bernhardt 393 Using New Technologies to Improve the Prevention and Management of Chronic Conditions in Populations Brim: Oldenburg, C. Beer Trailer, Adrienne O?Neil, Fiona: Corker, and Linda D. Cameron 483 Indexes Cumulative Index of Contributing Authors, Volumes 27?36 . 597 Cumulative Index of Article Titles, Volumes 603 Errata An online log ofcorrections to Amine! Review of Public Health articles mayr be found at Ca men Lt xi Epidemiologic Fteviews Vol. 38, 2015 The Author 2016. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. DUI: 10.1093iepirevimxvt112 All rights reserved. For permissions. please e-mail: joumal5.permissions@oupcom. Advance Access publication; Febmary 10. 2016 What Do We Know About the Association Between Firearm Legislation and Firearm-Related Injuries? Julian Santaella~Tenorio*, Magdalena Gerda, Andres Villaveces, and Sandro Galea Correspondence to Dr. Julian SanlaelIa-Tenorio. Departmental Epidemiology. Mailman School of Public Health. Columbia University. 122 West 163th Street. Floom 515. New York. NY 10(132 le-mail: Accepted for publication September 4. so i 5. Firearms account for a substantial proportion of external causes of death, injury, and disability across the world. Legislation to regulate firearms has often been passed with the intent of reducing problems related to their use. However, lack of clarity around which interventions are effective remains a major challenge for policy development. Aiming to meet this challenge; we systematically reviewed studies exploring the associations between firearm? related laws and firearm homicides. suicides, and unintentional injuriesideaths. We restricted our search to studies published from 1950 to 2014. Evidence from 130 studies in 10 countries suggests that in certain nations the simu ~ taneous implementation of laws targeting multiple firearms restrictions is associated with reductions in firearm deaths. Laws restricting the purchase of leg; background checks) and access to safer storage} firearms are also associated with lower rates of intimate partner homicides and firearm unintentional deaths in children. re- spectively. Limitations of studies include challenges inherent to theirecological design. their execution. and the lack of robustness of findings to model specifications. High quality research on the association between the implemen- tation or repeal of firearm legislation (rather than the evaluation of existing laws) and firearm injuries would lead to a better understanding of what interventions are likely to work given local contexts. This information is key to move this field forward and for the development of effective policies that may counteract the burden that firearm injuries pose on populations. death; firearms; homicide; legislation; suicide; weapons; wounds and injuries Abbreviations: NCHS. National Center for Health Statistics: NFA. National Firearms Agreement; Uniform Grime Fleports. 14D Epidemioi Fiev 9 ipnzw no ruoiumonog 1n run]; popcijjumoq Epidemiologic Fteviews Advance Access published January 13, 2016 Epidemiologtc Fteviews 10.1093fepirevfmav?ue The Author 2016. Published by Oxford University Press on behalf of the Johns Hopi-tins Bloomberg School of Public Health. All rights reserved. For please e-marl: journalsnennissrons@oup.com. Effectiveness of Interventions to Promote Safe Firearm Storage Ali Rowhani-Flahbar*, Joseph A. Simonetti, and Frederick P. Rivera Correspondence to Dr. Ali Howhani?Flahbar. Box 35?236. Department of Epidemiology. School of Public Health. University of Washington, Seattle, WA 93195 (e-mail: rowhani @uwedu]. Accepted for publication July 2015. Despite supportive evidence for an association between safe firearm storage and lower risk of ?rearm injury. the effectiveness of interventions that promote such practices remains unclear. Guided by the Preferred Reporting Items for Systematic Fleviews and Meta-Analyses checklist. we conducted a systematic review of ran? domized and quasi-experimental controlled studies of safe firearm storage interventions using a prespecified search of 9 electronic databases with no restrictions on language. year. or location from inception through May 2015. Study selection and data extraction were independently performed by 2 investigators. The Cochrane Col- laboration's domain-specific tool for assessing risk of bias was used to evaluate the quality of included studies. Seven clinic- and community-based studies published in 2000?201 2 using counseling with or without safety device provision met the inciusion criteria. All 3 studies that provided a safety device significantly improved firearm storage practices. while 3 of 4 studies that provided no safety device failed to show an effect. Heterogeneity of studies pre- cluded conducting a meta-analysis. We discuss methodological considerations, gaps in the literature, and recom- mendations for conducting future studies. Although additional studies are needed, the totality of evidence suggests that counseling augmented by device provision can effectively encourage individuals to store their firearms safely. firearms; program evaluation; safety Abbreviations: DVRD. domestic violence restraining order; IPH. intimate partner homicide; IPV. intimate partner violence. INTRODUCTION According to the Centers for Disease Control and Preven- tion. about 118.000 Americans including 13,000 individuals younger than 20 years of age sustained fatal or nonfatal fire? arm injuries in 2013 Such injuries lead to substantial mortality. and physical morbidity, and high costs resulting front medical expenses, reduced productivity. and diminished quality of life Gun ownership is an in? dependent risk Factor for ?rearm injury and estimates indicate that guns are present in about one third of US house.? holds {17, Iii}. only a few interventions aimed at limiting ?rearm ownership have been tested (1 9?21 and such prevention strategies remain socially and politically conferr- tious. Some studies have also suggested that gun owners prefer not to be asked to remove ?rearms from their homes 22. 23 i. Notably, more than one halfof'US households store a gun unlocked andr?or loaded (17. 24}. which provides an opportu- nity to pursue other strategies to prevent ?rearm injuries. Sai'e storage. including methods such as keeping guns unloaded. locked. and separate from locked ammunition. has been widely endorsed as a ?rearm 1njury prevention strategy by medical professional societies {25?27). Several [ireann advocacy orga? nizations have also encouraged form of safety practices as an integral element of responsible gun ownership (28-30}. Importantly. adult patients and parents of pediatric patients do not seem to be bothered by conversations about guns [22. 23. 3 I J, and the concept of safe ?rearm storage has enjoyed broad public support Case?control and cross?sectional studies among children and adults have consistently shown a lower risk of self?in?icted ?rearm injuries and deaths in households that practice safe storage compared with those in which guns are stored un- locked andior loaded {9?1 I. 13. 15, 33. 34}. although some of those studies were limited by insuf?cient statistical power 1t}. 34]. In addition. a study of'a nationally representative sample of suicide decedents found that individuals living in households with safe storage practices were less likely to commit suicide using a firearm This ?nding is notable because ofthe importance of speci?cally preventi ngjirertrm? refuted suicide attempts since the case fatality of those is greater than that of other methods such as suffocation 9mg Ensuring no tinuqrj 3(1) 1:12pm 1 'g noticing to rum; pnpnujumor] From: Dahlberg, Linda L. Sent: 1 Aug 2016 20:35:14 +0000 To: Belser-Vega, Elizabeth (CDCIONDIEHINCIPCJ Subject: RE: - GAO You?re welcome. From: Belser-Vega, Elizabeth Sent: Monday, August 01, 2016 4:35 PM To: Dahlberg, Linda L. Subject: RE: - GAO Thank you very much! From: Dahlberg, Linda L. (CDCIONDIEHINCIPCJ Sent: Monday, August 01, 2016 4:34 PM To: Belser-Vega, Elizabeth Subject: RE: - GAD Thanks so much Linda! Malia forwarded it all to me last week and I sent it up right away. I will let you know if i hear anything else from them. You did a fantasticjob on Thursday! I really appreciate all your help on this. Elizabeth From: Dahlberg, Linda L. Sent: Monday, August 01, 2016 11:29 AM To: Doyle, Nadine Cc: Belser-?v?ega, Elizabeth Subject: FW: FEU - GAO From: Dahlberg, Linda L. Sent: Thursday, July 28, 2016 4:30 PM To: Richmond-Crum, Malia Subject: RE: - GAD Thanks so much Linda! Malia forwarded it all to me last week and I sent it up right away. I will let you know if i hear anything else from them. You did a fantasticjob on Thursday! I really appreciate all your help on this. Elizabeth From: Dahlberg, Linda L. (CDCIONDIEHINCIPC) Sent: Monday, August 01, 2016 11:29 AM To: Doyle, Nadine Subject: - GAD Hi Malia Here?s follow-up materials to send up to the Center, including the response to C14 about the impact of the Dickey amendment (attached) and the summary report from the Federal Partner Meeting (also attached). Federal Partner Meeting (summary report attached) CDC and the CDC Foundation co-sponsored a two-day convening of stakeholders partners from multiple federal agencies in Washington, DC on February 19-20, 2014. Representatives from the Departments of Education, HHS, and met in Washington, D.C. to discuss current efforts and future opportunities associated with firearm violence prevention research. The meeting objectives were to: 1. Discuss approaches for strengthening data to understand patterns and characteristics of firearm violence and to address research questions 2. Discuss ways to ensure that the research carried out by the different agencies is complementary and builds upon individual and collective 3. Identify opportunities to collaborate on current or future efforts Systematic reviews (firearm laws and safe storage) -- attached - Santaella?Tenorio et al. What do we know about the association between firearm legislation and firearm-related injuries? Epidemiologic Reviews, 2016; 38:140-157. 1- Ali Rowhani-Rahbar et al. Effectiveness of interventions to promote safe firearm storage. Epidemiologic Reviews, 2015; CDC paper: I Fowler K, Dahlberg LL, Haileyesus T, Annest JL, Bacon S. Firearm injuries in the United States. Preventive Medicine 2015; 79:544. (attached) Paper on the pilot study related to lethal means counseling and safe storage of medications and firearms - Runyan, E. Becker, A, Brandspigel, 5., Barber, (2., Trudeau, A., 8: Novins, D. (2016). Lethal Means Counseling for Parents of Youth Seeking Emergency Care for Suicidality. Washf Emerg Med, 17(1), 8?14. doi: 10.5811]westjem.2015.11.28590 (attached) IDM Papers: The papers were presented during the Means of Violence Workshop held December 18, 2014 and are included as "attachments? to the Workshop Summary Report. Direct links to the paper are below Direct Links to the Papers: Firearmspif. Suicide?l-Eomicidepdf. Linda L. Dahlberg, Senior Advisor to the Director Division of Violence Prevention 4220 Buford Highway, NE., MS-F64 Atlanta, GA 30341 Tel: 770-488-4496 Fax: 770-488-4349 Email: From: Dahlberg, Linda L. (CDCXONDIEHJNCIPC) Sent: 1 Aug 2016 17:11:46 +0000 To: Belser-Vega, Elizabeth Subject: RE: GAO Attachments: GAO Request- Firearm Safety and Public Health.docx Sure here you go. From: Belser-Vega, Elizabeth Sent: Monday, August 01, 2016 11:48 AM To: Dahlberg, Linda L. Subject: RE: - GAO Would you mind sharing your notes with me that you used for the call? i won?t send them anywhere or use them for anything, ijust want to reread what you said for my own long term FA knowledge. From: Dahlberg, Linda L. Sent: Monday, August 01, 2016 11:46 AM To: Belser?Vega, Elizabeth Subject: RE: - GAO Thanks so much Linda! Malia forwarded it all to me last week and I sent it up right away. I will let you know if I hear anything else from them. You did a fantasticjob on Thursday! I really appreciate all your help on this. Elizabeth From: Dahlberg, Linda L. (CDCIONDIEHJNCIPCJ Sent: Monday, August 01, 2016 11:29 AM To: Doyle, Nadine <11ny cdc. oy> Cc: Belser-Vega, Elizabeth Subject: GAO Hi Malia Here?s follow-up materials to send up to the Center, including the response to (14 about the impact of the Dickey amendment (attached) and the summary report from the Federal Partner Meeting {also attached). Federal Partner Meeting {summary report attached) CDC and the CDC Foundation co-sponsored a two?day convening of stakeholders partners from multiple federal agencies in Washington, DC on February 19-20, 2014. Representatives from the Departments of Education, HHS, and met in Washington, D.C. to discuss current efforts and future opportunities associated with firearm violence prevention research. The meeting objectives were to: 1. Discuss approaches for strengthening data to understand patterns and characteristics of ?rearm violence and to address research questions 2. Discuss ways to ensure that the research carried out by the different agencies is complementary and builds upon individual and collective 3. Identify opportunities to collaborate on current or future efforts Systematic reviews (firearm laws and safe storage) -- attached I- Santaella-Tenorio et al. What do we know about the association between firearm legislation and firearm-related injuries? Epidemioiogic Reviews, 2016; 38:140?157. . Ali RowhaninRahbar et al. Effectiveness of interventions to promote safe firearm storage. Epidemioiogic Reviews, 2016; CDC paper: I Fowler K, Dahlberg LL, Hailevesus T, Annest JL, Bacon 5. Firearm injuries in the United States. Preventive Medicine 2015; 79:5?14. (attached) Paper on the pilot study related to lethal means counseling and safe storage of medications and firearms - Bunyan, C. W., Becker, A, Brandspigel, 5., Barber, (3., Trudeau, A, 8: Novins, D. (2016). Lethal Means Counseling for Parents of Youth Seeking Emergency Care for Suicidalitv. Westi Emerg Med, 17(1), 8-14. doi: 10.5811fwestjem2015.11.23590 {attached} IDM Papers: The papers were presented during the Means of Violence Workshop held December 18, 2014 and are included as "attachments" to the Workshop Summary Report. Direct links to the paper are below Direct Links to the Papers: SuiciderHomicidepdf. Linda L. Dahlberg, Senior Advisor to the Director Division of Violence Prevention 4770 Buford Highway, NE., MS-F64 Atlanta, GA 30341 Tel: 770-488-4496 Fax: 770-438-4349 Email: ldahlberg@cdc.g? cochEn From: Richmond-Crum, Malia Sent: 29 Jul 2015 08:15:15 -O400 To: Dahlberg, Linda L. Subject: RE: - GAO Thanks Linda! We?ll forward these resources. Malia From: Dahlberg, Linda L. Sent: Thursday, July 28, 2016 4:30 PM To: Richmond-Crum, Malia Cc: Dahlberg, Linda L. Subject: - GAD Hi Malia Here?s follow-up materials to send up to the Center, including the response to C14 about the impact of the Dickey amendment (attached) and the summary report from the Federal Partner Meeting {also attached). Federal Partner Meeting {summary report attached) CDC and the CDC Foundation co-sponsored a two-day convening of stakeholders partners from multiple federal agencies in Washington, DC on February 19-20, 2014. Representatives from the Departments of Education, HHS, and met in Washington, D.C. to discuss current efforts and future opportunities associated with firearm violence prevention research. The meeting objectives were to: 1. Discuss approaches for strengthening data to understand patterns and characteristics of firearm violence and to address research questions 2. Discuss ways to ensure that the research carried out by the different agencies is complementary and builds upon individual and collective 3. Identify opportunities to collaborate on current or future efforts Systematic reviews (firearm laws and safe storage) -- attached I Santaella-Tenorio et al. What do we know about the association between firearm legislation and firearm-related injuries? Epidemioiogic Reviews, 2016; 33:140-157. I Ali Rowhani-Rahbar et al. Effectiveness of interventions to promote safe firearm storage. Epidemioiogic Reviews, 2016; CDC paper: I Fowler K, Dahlberg LL, Haileyesus T, Annest JL, Bacon 5. Firearm injuries in the United States. Preventive Medicine 2015; i9:5?14. (attached) Paper on the pilot study related to lethal means counseling and safe storage of medications and firearms I Runyan, C. W., Becker, A., Brandspigel, 5., Barber, (3., Trudeau, A, St Novins, D. (2016). Lethal Means Counseling for Parents of Youth Seeking Emergency Care for Suicidality. WestJ Emerg Med, 8?14. doi: 10.53111westjem2015.11.28590 {attached} IOM Papers: The papers were presented during the Means of Violence Workshop held December 18, 2014 and are included as ?attachments" to the Workshop Summary Report. Direct links to the paper are below Direct Links to the Papers: rms- Suicide~Homicide.pdf. Linda L. Dahlberg, Senior Advisor to the Director Division of Violence Prevention 4770 Buford Highway, NE., MS-F64 Atlanta, GA 30341 Tel: 770-488-4495 Fax: 770-488-4349 Email: coc@/7 moonwalk! horelmw: nae-pic Fromm. andmlury From: Simon, Thomas Sent: 23 Feb 2018 17:13:54 +0000 To: Roby, Sarah Subject: RE: Gun violence research by the government hasn't been funded in two decades. But that may soon change. I'm glad. From: Roby, Sarah Sent: Friday, February 23, 2018 9:29 AM To: Simon, Thomas Subject: Re: Gun violence research by the government hasn't been funded in two decades. But that may soon change. Hi Tom, Thank you so much for sending this. It renewed my optimism for the day Sarah From: Simon, Thomas Sent: Friday, February 23, 2018 8:47:32 AM To: Sileno, Samantha Dennehy, Heather Roby, Sarah Richmond-Crum, Malia Black, Erin Subject: FW: Gun violence research by the government hasn't been funded in two decades. But that may soon change. FYI From: DIANA Sent: Thursday, February 22, 2018 1:04 PM To: Simon, Thomas Subject: FW: Gun violence research by the government hasn't been funded in two decades. But that may soon change. This would be huge if it came to fruition! Diana H. Fishbein, Professor, Department of Human Development and Family Studies Director. Program for Translational Research on Adversity and Neurodevelopment The State University 213 Health and Human Development Building University Park. PA 10802 5314-8654377 And Director, National Prevention Science Coalition to Improve Lives From: Bobby Vassar [mailtgj (.13 H6) Sent: Thursday, February 22, 2018 12:25 PM To: DIANA FISHBEIN romanjohn@norc.org; Michael Greene (b rs; Subject: Gun violence research by the government hasn?t been funded in two decades. But that may soon change. This seems encouraging! From: The Washington Post Sent: Thursday, February 22, 2018 9:32 AM To: Bobby Vassar Subject: The Health 202: Gun violence reSEarch by the government hasn't been funded in two decades. But that rna soon then e. VIEW ON WEB El El Analysis on Washington's health-care debate. Not on the list? Sign up here. PowerPost The Health 201 Your health policy appointment ?Share ?Share aTipsiFeedback Gun violence research by the qovernment hasn't be two decades. But that may soon change. BY PAIGE WINFIELD CUNNINGHAM with Paulina Firozi THE PROGNOSIS town hall on gun violcnoc, annotated Is the latest school shooting enough to convince Congress to violence research again? Democrats are hoping it just might bi In the wake of the Parkland, Fla, tragedy that left 17 dead at a local Republicans are generally resisting passing stricter gun control laws of their resolve is starting to crack as President Trump and GOP lav an openness to strengthening background checks or gun violence r: laws. One of them is Sen. Marco Rubio who gartiwgated in and emotional CNN town hall last night on gun violence in which he the minimum age for buying a rifle and stated he is reconsidering hi: capacity magazines. And student displays such as thelie?in grotests teenagers staged White House this week have given gun-safety advocates fresh ho 1.. You are reading The Health 202, our must- read newsletter on health policy. Not a regular subscriber? All?1 OOF, OLFCH Fake Pereocet pills that are actually fentanyl. (Tommyr Famerchnues/see Bureau of Investigation via AHH: Drug overdose deaths declined in 14 states in the 12- month period before July 2017, according to new provisional data from CDC reported by Stateline. While drug deaths have been climbing steadily every year, in nearly every state, the new data is a potentially hopeful sign that policies aimed at the opioid epidemic may be working, Christine Vestal writes. "The reported drop in overdose deaths occurred in Wyoming, Utah, Washington, Alaska, Montana, Mississippi, Kansas, Rhode island, Oregon, California, Tennessee, Massachusetts, Arizona and Hawaii," Christine writes. "That compares with declines in only three states Nebraska, Washington and Wyoming reported for an earlier 12-month period that ended in January the CDC only made death data available once a year and it was 12 to 14 months behind. In a fast-moving opioid scourge, epidemiologists say the increased frequency of overdose death reporting is a welcome improvement." A resident of the Puerto Nueyo neighborhood in San Juan, Puerto Rico walks through ?ood water during the passage of Hurricane Maria. Images) 00F: Calls to suicide hotlines in Puerto Rico have almost tripled in the months since Hurricane Maria. Starting in November and lasting through January, a crisis hotline on the island received 3,050 calls from people who said they had attempted suicide, a 246 percent increase compared with the same period last year, Vox?s Alexia Fernandez Campbell reports. Even more people -- about 9,645 -- called the hotline to report suicidal thoughts, an 83 percentjump from the same time last year. The suicide rate is the highest it has been in four years, Alexia writes, citing data reported by Puerto Rico's Department of Health and El Nueyo Dia, Puerto Rico?s largest newspaper. ?it's hard to tell how much of the spike is directly related to the aftermath of Hurricane Marla. But the likely connection is difficult to ignore,? Alexia writes. Julio Santana Mari?o, a professor at Universidad Carlos Albizu in Puerto Rico, El Nuevo Dia the common risk factors for suicide were compounded in the aftermath of the storm. "It's normal for there to be family conflicts, but when you add the stress of more than five months without power, without food, living patterns change it makes it harder for people to manage daily life," Santana Mari?o said. The Duck Valley Indian Reservation in Nevada. Darin Oswald for The Washington Post] OUCH: Robert Weaver, Trump's nominee to lead the Indian Health Service, has withdrawn his name from consideration after a series of Wall Street Journal articles reporting that he'd embellished some of his previous professional experience and left a former employer in financial disarray. ?Mr. Weaver is no longer the Administration's nominee for Director of the Indian Health Service," an HHS spokeswoman told WSJ yesterday. The paper reported that while Weaver said he maintained leadership positions at a hospital, former colleagues and supervisors claimed he served as a registration clerk. Weaver, who is a member of the Quapaw tribe, was nominated forthe position in October. TRUMP TEMPERATURE President Trump. Photo-"Manuel Bales {Tenetal --Trump has been prodding Congress to pass a "Right to Try" law making experimental medications available to terminally ill patients, CNBC reports. A lawmaker working closely on the issue said last week the president asked him point blank, "How close are you to getting this done?" A top priority for a number of conservative groups, Trump called for a Right to Try law in his State of the Union address last month. These laws, which 38 states have enacted, allow patients to take experimental medications outside of clinical trials as long as the therapies have undergone preliminary safety testing. Here's our Health 202 on Right to Try. IE1 STATE SCAN will New Jersey Gov. Phil Murphy signs legislation setting aside about $15 million for family planning and women's health. Finite-"Michael Catalini] --Yesterday New Jersey Gov. Phil Murphy, a Democrat, signed his first law in office, restoring $7.5 million for women?s health and family planning that was vetoed by former Republican Gov. Chris Christie. ?Today we are saying in a clear voice that New Jersey will once again stand for the right things,? Murphy told a crowd that included Planned Parenthood President Cecile Richards, per the Associated Press. ?New Jersey will once again stand up for women?s health." The funding, which Christie slashed eight years ago, went to health providers, including Planned Parenthood, but couldn't be used for abortions. While Christie said he opposed the legislation because it circumvented the regular budget process, Democrats who control the state legislature said it's needed for preventive care, including breast and cervical cancer screenings. "The eight?year wait to restore the funding was a pointed theme," the AP writes. "Murphy thanked a host of lawmakers for passing the legislation and focused at one point on sponsor Senate Majority Leader Loretta Weinberg, who introduced the bill each year of Christie's term." ?if there?s a motto that we can ascribe to you I think it is this: If at ?rst you don?t succeed try, try, try and try, try, try and try and try again," he said. few more good reads from The Post and beyond: Florida House Declines Debate On Assault Rifles, Calls Porn A 'Health Risk' The lawmakers voted H-353 against opening up debate on the bill that would ban assault weapons and large?capacity magazines, leaving it in committees that aren't scheduled to meet during this session. NPR Read more a HEALTH ON THE HILL Beyond 'Obamacare': New liberal plan on health care overhaul A major liberal policy group is raising the ante on the health care debate with a new plan that builds on Medicare to guarantee coverage for all. Called ?Medicare Extra for All,? the proposal to be released Thursday by the Center for American Progress gives politically energized Democrats more options to achieve a long-sought goal. Associated Press - Read more tr} MEDICAL MISSIVES It's OK to Use Nasal Spray Flu Vaccine Again, US Panel Says It's OK for doctors to start using a kid-friendly nasal spray flu vaccine again, a federal panel said Wednesday. Associated Press - Read more Stud Seeks to End Antide ressant Debate-The Dru 5 Do Work A vast research study that sought to settle a long- standing debate about whether or not anti-depressant drugs really work has found they are indeed effective . in relieving acute depression in adults. Reuters - Read more OPIOID OPTICS Mexican cartels pushing more heroin after U.S. states relax marijuana laws Mexican growers and cartels ?nd traf?cking heroin more profitable than marijuana as some states allow marijuana use. USA Today - Read more a DAY BOOK Coming Up - The Joint House and Senate Veterans' Affairs Committees hold a hearing on the legislative presentation of the Disabled American Veterans on March 1. SUGAR RUSH Unpacking America's perceptions about mass shootings and gun control: r/lif, r, J: Unpacking America's perceptions about mass shootings and gun control Trump's meeting with Florida school shooting survivors, in three minutes: Trump?s meeting with Fla. school shooting survivors. in three minutes Fred Guttenberg, whose daughter Jaime was killed in last week's shooting, called Sen. Marco Rubio's (R-Fla.) comments at a CNN town hall "pathetically weakz" Imp- AFT UESTION Can you look at me and tell me you will do something about guns? STUDENTS 0F STONEMAN DEMANQ ACTION Parent of Fla. shooting victim slams Rubia for 'pathctioaliy weak" comments Andrew Pollack, whose daughter died in the high school shooting in Florida said ?we, as a country, failed our children:" 0 t, Father of Fiat. shooting victim: ?We. as a country. failed our Share The Health 202: Twitter ?Facebook Trouble reading? Click hereto view in your browser You received this email because you signed up for The Health 202 or because it is included In your subscription For additional free newsletters or to manage your newsletters, click here. We respect your gyrivac . If you believe that this email has been sent to you in error or you no longer wish to receive email from The Washington Post, click here. Contact us for help. 2017 The Washington Post, 12301 St NW, Washington 20071 A Bobby ?The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little.? DR, 1933 From: Peeples, Amy B. Sent: 17 Mar 2016 19:03:42 -0400 To: Bonzo, Sandra E. Debra E. Cc: lkeda, Robin Subject: Re: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Interesting indeed! Thankyou! Amy 404-259-678? From: Bonzo, Sandra E. Sent: Thursday, March 17, 2016 12:05 PM To: Houry, Debra E. Peeples, Amy B. (CDCIDNDIEHXNCIPC) Cc: Ikeda, Robin Subject: FW: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research May be a coincidence but compare questions in the attached letter to the questions from Kate Masters in early February. From: Jones, Kamara (DSXASPAI Sent: Tuesday, March 15, 2016 4:00 PM To: Robinson, Michael Burden, Bernadette OS - Interviews Beeton, Jonathan Broido, Tara Gianelli, Diane Migliaccio, Kate (HHSIDASH) Cc: Lenard, Courtney Harben, Kathy Bryant, LaKia R. Subject: RE: CDC Interview (email) request from The Trace: gun violence DEADLINE: 03-14-16 Do we know the exact date when the piece will be published? From: Robinson, Michael] Sent: Monday, March 14, 2016 6:01 PM To: Burden, Bernadette DS - Interviews; Beeton, Jonathan Broido, Tara Gianelli, Diane Migliaccio, Kate Cc: Lenard, Courtney Harben, Kathy Bryant, LaKia B. [CDC/ooroaoc] Subject: Re: CDC Interview {email} request from The Trace: gun violence DEADLINE: 03-14-16 0k From: Burden, Bernadette Sent: Monday, March 14, 2016 5:44:37 PM To: 05 - Interviews; Robinson, Michael] Cc: Lenard, Courtney Harben, Kathy Bryant, LaKia R. (CDCIODIOADCJ Subject: FW: CDC Interview {email} request from The Trace: gun violence DEADLINE: 03-14-16 ASPA Media Interview Request Template Reporter: Kate Masters Organization: The Trace Phone Subject: gun violence Deadline: 03-14-16 Spokesperson: emailed response only. Kate Masters with The Trace has a follow up, please see her several previous requests in the thread below in addition the proposed CDC response. Her deadline is today. From Kate: Thanks again for all the information about the it was definitely helpful and that piece should be up on our site soon. l?rn emailing today because my editors and are in the drafting phase of my piece on gun violence research at the CDC, and wanted to let you know that the basis of the story is that the CDC is avoiding the issue of gun violence and bowing to political pressure by essentially foregoing research on firearms, even though there are things the agency could be doing. This is coming from former employees of the CDC, as well as outside gun violence researchers. wanted to tell you this so there would be no surprise when the article came out, and also because wanted to give the CDC a chance to respond to what others are saying. That response could be a statement from you, or would still love to speak with Dr. Haury directly about the lack of gun research at the injury Center, but i do recommend addressing these statements somehow so that the CDC ?5 voice is included in the piece. Proposed Response: CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm-related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the IOMINRC, "The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.? The President has requested that CDC conduct research into the causes and prevention of gun violence and the ICWI Report noted a number of research areas that might have bipartisan support. CDC is ready to conduct that research if funds are appropriated by Congress. Thanks in advance, Bernadette Burden Senior Public Affairs Specialist News Media Branch Division of Public Affairs (404)639?3286 From: Robinson, Michael Sent: Friday, February 12, 2016 11:22 AM To: Lenard, Courtney Blackmore, Rebecca (HHSIASFR) Medvedev, Bree Cabezas, Miriam Beeton, Jonathan Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette ; Fine, Amanda <3manda.fine@nih.gov> Bubject: RE: CDC Interview (email) request from The Trace: gun violence OR From: Lenard, Courtney Sent: Friday, February 12, 2016 11:16 AM To: Robinson, Michael Blackmore, Rebecca Medvedev, Bree Cabezas, Miriam Beeton, Jonathan Broido, Tara Colson, Angela Gianelli, Diane Migliaccio, Kate Cabezas, Miriam (HHSIASFR) Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette Fine, Amanda Subject: RE: CDC Interview [email] request from The Trace: gun violence Good morning, Deadline is COB today. Thank you! Courtney From: Robinson, Michael Sent: Thursday, February 11,2016 4:50 PM To: Lenard, Courtney Blackmore, Rebecca (HHSIASFR) Medvedev, Bree Cabezas, Miriam Cc: Connelly, Erin (CDCXONDIEHINCIPC) Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette Fine, Amanda Subject: RE: CDC Interview (email) request from The Trace: gun violence Hi ?Adding ASFR What?s the deadline for this info? Best, From: Lenard, Courtney Sent: Thursday, February 11, 2016 4:48 PM To: Robinson, Michael.) OS Interviews; Cabezas, Miriam Beeton, Jonathan Broido, Tara Colson, Angela Glanelli, Diane Migliaccio, Kate Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette Fine, Amanda (NIHIDD) Subject: RE: CDC Interview (email) request from The Trace: gun violence Good afternoon, Another follow up from Kate with The Trace: I also know that the President requested the full $23.5 million required to place in all 50 states and the District of Columbia in his budget request. asked the White House why that decision was made and why the was prioritized this year, and they told me to check with the CDC. So do you guys have any information on why that request was made and why it was important to the administration? Proposed Response: The President's budget request for has been for $23.5m for several years (since the FY14 request). Expansion of to all 50 states and DC has been a priority for the administration since FY14. Although CDC has seen incremental increases (including most recently in FY 16) and will be able to expand the program this year, the request will allow CDC to expand the program further to truly have a national program (all 50 states and DC). is the only stateubased surveillance system that pools information from multiple data sources into a usable, anonymous data base. It covers all types of violent deaths including homicides, suicides, and child maltreatment fatalities in all settings and for all age groups. Thanks much! Courtney From: Robinson, Michael Sent: Thursday, February 04, 2016 4:21 PM To: Lenard, Courtney OS Interviews Cabezas, Miriam (HHSIASFR) Beeton, Jonathan Broido, Tara Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy (CDCIODIOADC) Burden, Bernadette Fine, Amanda (NIHXOD) Subject: RE: CDC Interview (email) request from The Trace: gun violence 0k From: Lenard, Courtney (CDCEDNDIEHXNCIPCJ Sent: Thursday, February 04, 2016 4:19 PM To: Robinson, Michael OS IntervieWS; Cabezas, Miriam Beeton, Jonathan Broido, Tara Colson, Angela Gianelli, Diane Migliaccio, Kate Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette [coQoojomcL Fine, Amanda Subject: RE: CDC Interview [email] request from The Trace: gun violence Good afternoon, We have a follow up from Kate: does the CDC still have a "gentleman's agreement" with the gun lobby to report out, to the lobby, any gun research completed by their grantees, whether that research was actually completed with CDC funds or not? Proposed response, this question came up in the AP interview from a few months ago and this is what we said: We routinely alert stakeholder organizations when relevant articles are released, including organizations such as the NRA, who are interested in firearm related violence. We have not reached out to the NBA in recent years. Thanks much! Courtney From: Robinson, Michael] Sent: Wednesday, February 03, 2016 1:2? PM To: 05 - Interviews Lenard, Courtney Cabezas, Miriam Beeton, Jonathan Broido, Tara (HHSIOASH) Colson, Angela Gianelli, Diane (DASH) Migliaccio, Kate Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy (CDCIODXOADC) Burden, Bernadette Fine, Amanda Subject: FW: CDC Interview (email) request from The Trace: gun violence 0k is new] From: Lenard, Courtney Sent: Wednesday, February 03, 2015 1:05 PM To: US Interviews Cc: Connelly, Erin Dorigo, Leslie Lane, Gabraelle Harben, Kathy Burden, Bernadette Fine, Amanda (NIHIDD) Subject: CDC Interview {email} request from The Trace: gun violence ASPA Media Interview Request Outlet: The Trace Reporter: Kate Masters Phone: [57116434275 Subject: gun violence research Deadline: today Spokesperson: email response attributed to Deb Houry, MD, MPH, director, Injury Center Expected place of publication (print, online, broadcast): print Expected date of publicationfairing: nf'a Expected prominence front page, Sunday, eveninglmorning show, etc}: n/a Background: She requested to interview Deb Houry. "My articie is going to be about violence research at the CDC versus the so most of my questions would center on her approach to running the Center for injury Control and Prevention, accomplishments she's made, and priorities she'd like to work on.? Actual questions: 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? If so, how much money would you say goes toward that kind of research per year? 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? 1. Do you feel that the Injury Center would still suffer consequences from Congress for doing any type of gun violence research, even though there's growing political pressure to repeal the Dickey Amendment and allow the CDC to resume research on firearms? And if so, why? There is not appropriations language that prohibits CDC from conducting public health research into gun violence. 2. I know that Congress has repeatedly refused to allocate funding specifically for gun violence research, but would it be feasible for the CDC to reallocate some of its overall budget to go to gun research? The Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. CDC currently conducts and funds research on a variety of related topics, Including youth violence, child maltreatment, domestic violence and sexual violence. These are the topical line items that are supported through CDC's annual appropriation for both research and non?research activities. However, firearms are a mechanism of injury, so it is possible to address firearm-related violence in the context of addressing these topical areas and preventing violence from occurring in the first place. 3. In 2013, the NIH announced a new funding program that called specifically for research projects on gun violence. How was the NIH able to do that, given that it's also subject to federal limitations on gun research? And what's stopping the CDC from doing something similar? Beginning in FY 1997, CDC has been subject to appropriations language that states that none of the funds made available to CDC may be used to "advocate or promote gun control.? Similar appropriations language was extended to all HHS agencies, including NIH, beginning in FY 2012. The appropriations language does not prohibit the CDC or the NIH from conducting public health research into gun violence. CDC limited its research on gun violence over time, not because it was legally prohibited, but rather, because in 1997 Congress cut budget by an amount equal to what had been spent on research into gun violence (about million at the time} and threatened to impose further cuts if that research continued. Should we receive appropriations, we are ready to support research in this area in line with research agenda Prioritiesfor Research to Reduce the Threat of Firearm-Related Violence 4. The Dickey Amendment doesn't technically ban gun violence research, so are there any projects or research on gun violence that the CDC could be doing without violating the language of the amendment? CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. As noted above, the Injury Center has very limited discretionary funding to dedicate to firearm violence research and prevention. 5. Whatever happened to the 2013 research agenda on gun violence that the CDC commissioned from the Institute of Medicine? Have any of those research goals been addressed? If not, why commission a research agenda if there was no intention to use it? The RC research agenda Priorities for Research to Reduce the Threat of Firearm- Reiated Vioience - was released by the on June 5, 2013. It was intended to guide research in the field and has been referenced in various funding solicitations by other agencies. Individual researchers may also be pursuing some of the research priorities on their own. Every year since the release of Now is the Time, President Obama has included a $10 million request in his budget to research the causes and prevention of gun violence, but Congress has not approved it. To pursue many of the research priorities that IUM and NRC identified, this 510 million would be necessary. 6. Do you feel that the Injury Center should be researching guns and gun violence, that it falls under the jurisdiction of the agency? More than 117,000 Americans are non-fatally injured or die each year from a gunshot wound, making firearm?related injuries among the 5 leading causes of death for people aged 1-64 in the United States. Public health research is fundamental to understanding the problem and developing scientifically sound solutions. As noted by the "The complexity and frequency of firearm violence, combined with its impact on the health and safety of Americans, suggest that a public health approach should be incorporated into the strategies used to prevent future harm and injuries.? 7. Has the CDC dedicated any funding to research involving guns or gun violence since the Dickey Amendment was passed? if so, how much money would you say goes toward that kind of research per year? Following the FY 199? appropriation language, CDC-funded entities conducted some investigator-initiated, peer-reviewed studies on fatal and non-fatal firearm violence through the Injury Control and Response Centers the first cycle of the Academic Centers for Excellence on Youth Violence Prevention (ACES), and universities awarded R01 (investigator-initiated) grants. Some of these projects began before FY 1997 and continued throughout their funding period. Examples: I- one study (which began in 1995} examined the risk factors for gun use and gun injury among young males in neighborhoods with high rates of homicide and determined the characteristics and processes of interpersonal interactions where gun injuries occur compared to non-gun injuries. A 1998 study examined the effectiveness of household firearm storage methods in reducing unintentional and self-inflicted firearm injuries among children and adolescents; - A 1999 study examined the risks for retaliatory shootings and the role of gangs, drugs, and alcohol to inform future opportunities for prevention; 0 A longitudinal study initiated in 2001 examined intentional injury among urban youth, which included questions regarding gun carrying and reasons for gun carrying; and CDC has also published a number of papers and reports. Examples listed below. 8. Did the CDC stop monitoring U.S. gun ownership in 2004, and why? The Behavioral Risk Factor Surveillance System does not currently collect data about firearms. Firearms questions were included as optional modules for states to consider between 1995?1999 and a subset of questions were included on the core survey in 2001, 2002, and 2004. In 2004, the state coordinators decided to retain only the question on seat belts in the survey and dropped the other injury?related topics from the survey. The injury questions had been on the survey for a number of years and there was interest at the time in pursuing other public health topics. Each year, coordinators from state and territorial health departments decide which questions to include on the questionnaire. CDC supports this development and works with the state coordinators to balance state and federal public health needs in an effort to ensure a standardized, valid, and reliable questionnaire and data collection process. Also, state health departments can decide to include additional questions. Firearm safety questions are currently under consideration for future surveys. For more information about please visit: Firearm injuries in the United States Prev Med. 2015 000795-14 Firearm Homicides and Suicides in Major Metropolitan Areas United States, 2006? 2007 and 2009-2010 MMWR. August 2, 2013 I m6230a 1.htm Violence in the United States: Status, Challenges, and Opportunities JAMA. Attached Suicide Trends Among Persons Aged 10?24 Years United States, 1994?2012 MMWR. March 5, 2015 Homicide Rates Among Persons Aged 10?24 Years United States, 1931?2010 MMWR. July 12, 2013 Gang Homicides Five U.S. Cities, 2003?2008 MMWR. January 27, 2012 Most recent Surveillance Summary: Surveillance for Violent Deaths National Violent Death Reporting System, 16 States, 2010 MMWR. January 17, 2014 1.htm From: Houry, Debra E. Sent: Wednesday, March 16, 2016 2:18 PM To: Ikeda, Robin Bonzo, Sandra E. Cc: Peoples, Amy B. Subject: FW: Letter from Senate HSGAC Ranking Member Carper regarding gun violence research Fyi- received today 000 will begin working on it Deb Houry, MD, MPH Director National Center for Injury Prevention and Control, Centers for Disease Control and Prevention 4770 Buford Highway, Mail Stop Atlanta, GA 30341 Twitter: Phone: [770] 488-4696 Fax; (770) 488-4222 From: Morris, Dena Sent: Wednesday, March 16, 2015 1:59 PM To: Frieden, Thomas (Tom) (CDCJIOD) Schuchat, Anne MD Villar, Carmen 5. Berger, Sherri ; Daniel, Katherine Lyon ; Houry, Debra E. Subject: Re: Research on firearms injury I think I am ready. I was going to say that our team's contribution was to push for the creation of a center. From VEB to having the ?rst permanent director took 12 years. It wasn't easy but bringing about change is never easy, and injury control has always been an uphill battle. These are lives at risk that we are ?ghting for. People in Injury control who make a difference always bring together science and passion. I think it's compassion and social justice. The problems the center is working on today are still incredibly important and the center now makes me proud of everyone who has contributed and everyone still working there. What should 1 point out and what should I add? On Thu. Sep 28, 2017 at 10:22 AM Mercy, James {'am2 diode. ov> wrote: Wow. so beautiful. Are you ready for the panel next week? From: Mark Rosenberg Sent: Thursday, September 28, 2017 10:15 AM To: Mercy, James Subject: Re: Research on ?rearms injury We are in Maine on rocks overlooking an incredible ocean. On Thu, Sep 28, 2017 at 9:10 AM Mercy, James wrote: Hi Mark, I sent from my personal e-mail. Where have you been we've missed you at the core training classes. Jim From: Mark Rosenberg Sent: Wednesday, September 27, 2017 5:10 PM To: Mercy, James (CDCIONDIEHJNCIPO g James A. Mercy {imerev??agmaileom? Subject: Fwd: Research on ?rearms injury Jim, Please use this expanded email to respond. Can you ?ll this in with any details and let me know where I am off or wrong. I am trying to ?gure out how the Dickey amendment and the clash with Congress set research back, speci?cally the research that was being done by this select group of researchers: Garen Wintemute, Phil Cook, Steve Teret, David Hemenway, Daniel Webster, and you. Here is an outline of what I remember: Steve Teret-?was one of the ?rst in public health to start looking at guns from the perspective of injury control (as taught by Sue Baker); as a lawyer, brought in the legal community to look at the public health perspective. The public health perspective of modifying the "agent" of injury led him to look at smart guns. He mentored and taught a group of key researchers including Garen Wintemute, Daniel Webster, Jens Ludwig. He also spoke up about CDC's timidity or outright ban on letting researchers use CDC ?Jnds to attend meetings where other people were talking about what could have been construed as gun Control." Steve gradually moved away from gun research to running the HOpkins Injury Control research center, then to becoming a vice-dean and an administrator. David H_emenway-- I don't think David had done much in the area of gun violence research per se before the congressional attack, but he actually got a big boost from getting the money that we asked George Soros to give us at CDC for gun research, when CDC told us it was too hot to handle. We originally worked with the Robert Wood Johnson Foundation who wanted to restore the research money that Congress had taken away from gun violence prevention research. But they had a board member who was an NRA advocate and he vetoed the proposal by the president and staff of RWJ F. Hemenway eveloped a very strong focus on the public health approach, and gun suicide. Focused on demographic and epi analysis. Phil Cook--started looking at suicide, and economics of gun traf?cking, emphasizing the grey market impacts of restricting access to legal sales. Phil was an economist with a strong interest in public policy and the impact of policies when implemented. Garen Wintemute??he had been looking at how criminals acquire guns, especially saturday night specials, cheap handguns, and had done some work on mapping the handgun industry. He published this in a report that I think was called Ring of Fire. He did not let the drying up of CDC funding stop his research. It is not clear that it even slowed him down. If anything, it probably re-energized him and led to his re- doubling his efforts. He starting looking at large data sets in California that would let him look at how different laws that were passed in California were impacting gun deaths and injuries and how restricting access to firearms by persons who violated extant laws would reduce or affect firearm injuries. Daniel Webster--I don't think he was actually doing gun Violence research in 1996 but he certainly started doing research in subsequent years. His main focus has been on evaluating the impact of different policies, like shall-issue laws that made access to ?rearms by high-risk persons easier. He has worked to show flaws in papers published by pro-gun ?researchers." He is focusing on the impact of laws designed to keep firearms out of the hands of people who break the law. Mark From: Mercy, James Sent: 28 Sep 2017 14:22:35 +0000 To: Mark Rosenberg Subject: RE: Research on firearms injury Wow, so beautiful, Are you ready for the panel next week? From: Mark Rosenberg Sent: Thursday, Soptember 28, 201? 10:15 AM To: Mercy, James Subject: Re: Research on firearms injury We are in Maine on rocks overlookin an incredible ocean. On Thu, Sep 28, 201? at 9: 10 AM Mercy, James <13m2?c?cdogov> wrote: Hi Mark, I sent from my personal e?mail. Where have you been we?ve missed you at the core training classes. Jim From: Mark Rosenberg Sent: Wednesday, September 2017 5:10 PM To: Mercy, James James A. Mercy Subject: Fwd: Research on firearms injuryr Jim, Please use this eXpanded email to respond. Can you ?ll this in with any details and let me know where I am off or wrong. I am trying to ?gure out how the Dickey amendment and the clash with Congress set research back, specifically the research that was being done by this select group of researchers: Garen Winternute, Phil Cook, Steve Teret, David Hemenway, Daniel Webster, and you. Here is an outline of what I remember: Steve Teret--was one of the ?rst in public health to start looking at guns from the perspective of injury control (as taught by Sue Baker); as a lawyer, brought in the legal community to look at the public health perspective. The public health perspective of modifying the "agent? of injury led him to look at smart guns. He mentored and taught a group of key researchers including Garen Wintemute, Daniel Webster, Jens Ludwig. He also spoke up about timidity or outright ban on letting researchers use CDC funds to attend meetings where other people were talking about what could have been construed as gun Control." Steve gradually moved away from gun research to running the HOpkins Injury Control research center, then to becoming a vice-dean and an administrator. David Hemenwa I don't think David had done much in the area of gun violence research per se before the congressional attack, but he actually got a big boost from getting the money that we asked George Soros to give us at CDC for gun research, when CDC told us it was too hot to handle. We originally worked with the Robert Wood Johnson Foundation who wanted to restore the research money that Congress had taken away from gun violence prevention research. But they had a board member who was an NRA advocate and he vetoed the proposal by the president and staff of RWJ F. Hemenway eveloped a very strong focus on the public health approach, and gun suicide. Focused on demographic and epi analysis. Phil Cook-?started looking at suicide, and economics of gun trafficking, emphasizing the grey market impacts of restricting access to legal sales. Phil was an economist with a strong interest in public policy and the impact of policies when implemented. Garen Wintemute?-he had been looking at how criminals acquire guns, especially saturday night specials, cheap handguns, and had done some work on mapping the handgun industry. He published this in a report that I think was called Ring of Fire. He did not let the drying up of CDC funding stop his research. It is not clear that it even slowed him down. If anything, it probably re-energized him and led to his re- doubling his efforts. He startng looking at large data sets in California that would let him look at how different laws that were passed in California were impacting gun deaths and injuries and how restricting access to ?rearms by persons who violated extant laws would reduce or affect firearm injuries. Daniel Webster-J don't think he was actually doing gun violence research in 1996 but he certainly started doing research in subsequent years. His main focus has been on evaluating the impact of different policies, like shall?issue laws that made access to ?rearms by high?risk persons easier. He has worked to show ?aws in papers published by pro-gun "researchers.? He is focusing on the impact of laws designed to keep ?rearms out of the hands of people who break the law. Mark From: Foti, Sent: 15 Jun 2016 20:49:54 -U4OO To: Houry, Debra E. Dena Subject: Re: Schatz key take aways if helpful for tomorrow for Dr Frieden Thanks! From: Houry. Debra E. Sent: Wednesday, June IS, 20] 6 08:46 PM Eastom Standard Time To: Foti, Morris. Dona Subject: Schatz key lake aways iflielpful For tomorrow for Dr Friodcn Met with Aimee his health LA- she's a pediatrician so gets public health! injury prevention Falls- big interest of the Senator- they had been briefed by American College of Prev Med re the CPT code we have been working with them on- this CPT code was recently rejected by we will be resubmitting this month. They may be interested in sending letter of support to AMA re this (of note, HI has one of the lowest rates of falls in US- has good community based Tai Chi program] Suicide- advocates recently met with them- i mentioned the FY17 request and what our vision for work in suicide would be {community level interventions in states and tribal communities; implementing evidence based approaches; expanding nationallyi- she said they are extremely interested in suicide and would like to support our efforts FV- she brought this up esp with AMA resolution this week re lifting Dickey amendment. I talked about the work we were doing [child injury papers, optional ERFSS module, ICRC projects) but talked about the importance of report language andf or appropriation. She wants to have a follow up discussion on this to see how they can help move this forward From: Houry, Debra E. Sent: 19 Apr 2016 12:38:52 +0000 To: Mercy, James Subject: RE: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353690 Got it- let me check in with opp and see if it?s been submitted yet or not From: Mercy, James Sent: Tuesday, April 19, 2016 8:03 AM To: Houry, Debra E. Subject: FW: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353690 Deb, I?m a little concerned about how the answer to #9 has evolved. As it is now it?s not really accurate. Jim From: Reimels, Elizabeth Sent: Monday, April 18, 2016 9:48 AM To: Solhtalab, Elizabeth Cc: Belser-Vega, Elizabeth Patterson, Sara S. Mercy, James Subject: FW: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353690 Hello! This is looking really good, but we have some concerns about some of the edits that were made. The response to number 9, for example, jumps out at us as being incorrect and misleading now. In response to Linda?s comment on the response to question 3, it would be good to add an introductory sentence to the that distinguishes as a surveillance system that is called out in Now is the Time, but is not part of the request. Can we still provide feedback on this version? Thanks! From: Dahlberg, Linda L. Sent: Monday, April 18, 2016 9:02 AM To: Mercy, James Reimels, Elizabeth Subject: FW: Support for Gun Violence Research Senator Thomas Carper - Folder 2353690 From: Solhtalab, Elizabeth Sent: Monday, April 18, 2016 8:15 AM To: Dahlberg, Linda L. (CDCIDNDIEHINCIPCJ DVP Policy Requests (CDC) (dyppolicyrequests@cdc.goy> Cc: Belser?Vega, Elizabeth Cyril, Melissa R. Patterson, Sara S. Cc: Solhtalab, Elizabeth Subject: FW: URGENT FOR APPROVAL: Support for Gun Violence Research - Senator Thomas Carper Folder 2353690 Importance: High Deb think Dr. Frieden is waiting for you to say that you are OK with the response for #6 and then he will clear. It was the only concern/question that he raised. Sara?Attached is what we expect to be the final. Lauren Lauren Hoffmann, MA. ES Lead, High Pro?le Action Team, Division of issues Management. Analysis and Coordination Office of Chief of Staff Of?ce of the Director Centers for Disease Control and Prevention 1600 Clifton Road, NE, Atlanta, GA 30333 I Office: 404?639?2126 I Mobile: 404?541399? I E?mail: cgf5@cdc.gov Forecast. Coordinate. Communicate. From: Frieden, Thomas (Tom) Sent: Friday, April 15, 2016 6:13 PM To: Payne, Rebecca L. Cc: Villar, Carmen S. Hoffmann, Lauren (c f5 cdc. ov>; Richards, Bridget Lubar, Debra Subject: RE: URGENT FOR APPROVAL: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353690 I'm ok it if Deb is From: Payne, Rebecca L. Sent: Friday, April 15, 2016 5:03 PM To: Frieden, Thomas {Tom} Cc: Villar, Carmen S. (CDCIODIOCQ Hoffmann, Lauren (c f5 cdc. ov>; Richards, Bridget Subject: RE: URGENT FOR APPROVAL: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353690 Re funding we are being consistent with past statements and responses. The language you are asking about is consistent with responses we've sent to Congress via other inquiries. Our funded research in various violence related topic areas may touch on firearms even if it's not the full scope of the research. For example, the evaluation of Safe Streets, a violence interrupter program in Baltimore, would touch on firearm access and use Even though the program isn?t directly addressing firearms. +Deb in case this raises additional questions From: Payne, Rebecca L. Sent: Friday, April 15, 2016 4:47 PM To: Frieden, Thomas {Tom} Subject: RE: URGENT FOR APPROVAL: Support for Gun Violence Research Senator Thomas Carper Folder 2353630 The appendices are in the end of the word doc but pasted the full doc below as well we are checking on the funding The Honorable Thomas R. Carper Ranking Member, Committee on Homeland Security and Governmental Affairs United States Senate Washington, DC 20510 Dear Senator Carper: Thank you for your letter regarding the status of the Centers for Disease Control and Prevention?s (CDC) research into the causes and prevention of gun violence. CDC appreciates your concerns and those of the Committee on Homeland Security and Governmental Affairs, and is committed to protecting the health, safety, and security of the American people. Enclosed, please ?nd detailed responses to the speci?c questions outlined in your letter. We appreciate the Committee?s interest in this important public health isSue. If you have additional questions or concerns, please contact Cristi Schwarcz in the CDC Washington Of?ce at or (202) 245-0600. Sincerely, Thomas R. Frieden, MD, MPH Director, CDC Enclosure Centers for Disease Control and Prevention (CDC) Response to the Senate Committee on Homeland Security and Governmental Affairs regarding Gun Violence Research 1. Please describe the CDC's policy toward scienti?c research into the causes and prevention of gun violence. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. While National Center for Injury Prevention and Control (NCIPC) has no speci?c program dedicated to firearm violence research and prevention, ?rearms are a mechanism (cause) of injury. Therefore, CDC addresses firearm?related violence prevention in the context of addressing related areas, including youth violence, child maltreatment, domestic violence, and sexual violence. These areas coincide with topical line items that are supported through annual appropriation for research and non-research activities. The Fiscal Year (FY) 2017 President?s Budget includes $10 million to dedicate to gun violence prevention research. 2. Has the CDC or the Department of Health and Human Services' (HHS) Of?ce of the General Counsel conducted any analysis of the Dickey Amendment, including the types of gun violence research that are still permissible? If so, please provide this analysis. In 1997, after the Dickey Amendment was passed, CDC interpreted the amendment as prohibiting impermissible lobbying related to advocating or promoting gun control. CDC also interpreted the amendment to mean that activities that supported the collection of firearm injury-related data and engagement in scienti?c, public health research directed to preventing injuries from violence and ?rearms were still permissible. More recently, in January 2013, the President issued a Presidential Memorandum, ?Engaging in Public Health Research on the Causes and Prevention of Gun Violence? (Presidential Memorandum). This Presidential directive outlines the types of gun violence research that are permissible, including conducting or sponsoring research into the causes of gun violence and ways to prevent it, identifying the most pressing research questions with the greatest potential public health impact, and assessing existing public health interventions to prevent gun violence. The President?s plan to reduce gun violence, ?Now is the Time,? also states that the language in the Dickey Amendment, limiting the use of appropriated funds to ?advocate or promote gun control,? does not bar CDC from conducting research on the causes of gun violence, noting speci?cally that ?research on gun violence is not advocacy.? 3. In the aftermath of the shooting at Sandy Hook Elementary School in December 2012, President Obama issued a memorandum directing the Secretary of Health and Human Services (HHS), through the Director of the CDC and other agencies within HHS, to conduct or sponsor research into the causes of gun violence and the ways to prevent it. Please describe the efforts CDC has taken in response to this memorandum. In January 2013, in response to the President?s memorandum, CDC asked the Institute of Medicine (IOM), in collaboration with the National Research Council (NRC), to convene a committee to engage diverse stakeholders and identify the most pressing .research questions on gun violence, including those with the greatest potential public health impact. The released their report, which is available at chonszO BfPrio?tics- for-Rcsearch-to-Rcducc-thc- On June 5, 20l3. In addition, the CDC Foundation, in collaboration with CDC, commissioned the to develop and disseminate three supplemental discussion papers focusing on youth possession and acquisition of ?reamis, the relationship between alcohol and ?rearm violence, and ?rearm access by persons at risk of banning themselves or others. These papers, available at ediaf Fi less? Acti vitv?f?iZUFi lesx?Globalf 20 I 4-DEC- lSfYouth-Acouisition-Carrvin g-Fircarms-USpdf, iarF i U201 4- DEC - lilfAlcohoLF f, and vitv?MJEUFi obalf201 4-DEC- were released in late 2014. In February 2014, CDC met with a number of Executive Branch agencies, including representatives from HHS and the Department of Justice, to discuss approaches for strengthening data to understand patterns and characteristics of ?rearm violence, address research questions identi?ed in the report, ensure that research carried out by the different agencies is complementary and builds upon individual and collective and determine opportunities to collaborate on current or future efforts. For examples of CDC investigations, analyses of surveillance, and other data to document the public health burden of ?rearm injuries, see Appendix A. In FY 2015, with increased appropriations, CDC expanded the National Violent Death Reporting System from 18 to 32 participating states. In FY16, utilizing increased appropriation million), CDC plans to expand the to an additional four to seven states. is a state-based surveillance system that pools information about the ?who, when, where, and how? from data on violent deaths to provide insights on ?why? they occur. It gives states and communities a clearer understanding of violent deaths to guide local decisions about efforts to prevent violence and track progress over time. Findings from have resulted in tailored interventions, including increased veterans services to prevent suicide, ensuring child witnesses of domestic violence homicides are linked to social services, and screening older adults for depression. 4. In April 2013, the National Center for Injury Prevention and Control asked the Institute of Medicine to recommend a research agenda on the public health aspects of ?rearm-related violence. Please describe the actions the CDC plans to take in response to the ?ndings of the Institute of Medicine report issued in June 2013. The President?s FY 2017 Budget request includes $10 million in funding for gun violence prevention research. These funds would enable CDC to pursue research priorities identi?ed in the report. Should funding become available; CDC will pursue research activities that align with the priorities identi?ed in the IOMINRC report; Prioritiesfor Research to Reduce the Threat 0 Firearm-Related Violence (available at This includes understanding the characteristics of ?rearm violence patterns of access and use among children and youth, and among high?risk raciallethnic minority populations; ruralfurban differences in firearm-related violence); the risk and protective factors for homicide and suicide ?rearm violence alcohol. other situational or environmental factors; the factors in?uencing non-fatal firearm violence); and the effectiveness of interventions to prevent firearm violence (cg; safe storage practices; whether existing evidence?based approaches and policies for preventing interpersonal violence are effective in reducing ?rearm-related deaths and injuries). 5. From 1996 to the present; please describe notable examples of research conducted or funded by the including research by or through the National Center for Injury Prevention and Control, related to understanding gun violence. For a list of projects funded through the research grant programs; the Injury Control Research Centers (1C RC and the ?rst cycle ofthe Academic Centers of Excellence for Youth Violence Prevention (ACE). please see Appendix B. 5a. Please also provide all instances when the CDC included requests for gun violence research in its research proposal solicitation materials. Firearm-related research priorities were included in funding solicitations from 1996-2001 within the context of addressing assaultive behavior among youth, suicidal behavior. intimate partner violence and sexual violence. The funding solicitations for the and ACEs were broad and did not include specific priorities for fireann-related research. For a list ofthese funding announcements; please see Appendix C. 6. For each year from FY1996 to FY2015, what portion of the CDC's budget, including the budget of the National Center for Injury Prevention and Central. has been devoted to gun violence research? In FY 1997', Congress redirected $2.6 million from gun violence prevention activities to traumatic brain injury. CDC. addresses firearm?related violence prevention in the context of other violence-related areas. including youth violence. child maltreatment; domestic violence. and sexual violence. These areas coincide with topical line items that are supported through CDC is annual appropriation research and non-research activities. As previously noted; CDC has requested $10 million to dedicate to gun violence prevention research in the FY 2017 President?s Budget. Because firearms are a cause of injuries in these related areas; CDC has awarded research grants that address firearms as part of their scope; based on a competitive process. Proposals are evaluated for scientific and technical merit by an external peer review group, in accordance with CDC peer review policy and procedures. using stated review criteria. Since awards are competitive; the funding levels for firearm-related activities from 1997 thr0ugh 2015 have ranged from about $100,000 to just over $1 million. Comparisons to the total NCIPC budget or total CDC budget are not informative because the agency?s budget structure and scope have changed dramatic-ally in the past 20 years. Each year, CDC's Division of Violence Prevention solicits investigator-initiated research via an Grant Program Announcement. The language in these announcements signals to grant-seeking public health researchers the research priorities of the CDC and its Division of Violence Prevention. Please describe any Division of Violence Prevention's R01 Grant Program Announcements related to gun violence research put forward from 1996 to the present. Firearm-related research priorities were included in funding solicitations from 1996-2001 within the context of addressing assaultive behavior among youth, suicidal behavior, intimate partner violence, and sexual violence. All R?lapplications were evaluated for scienti?c and technical merit by an external peer review group, in accordance with CDC peer review policy and procedures, using stated review criteria. Following initial peer review, recommended applications received a second level of review. A variety of factors were considered in making funding decisions, such as scienti?c and technical merit of the proposed project as determined by scienti?c peer review, availability of funds, and relevance of the proposed projects to program priorities. The research solicitations during these years focused on enhancing the understanding of social, economic, and environmental factors that may impact the frequency and severity of these forms of violence. The research solicitations also focused on enhancing evaluations of policies, programs, or other interventions that may reduce morbidity, mortality, and disabilities associated with suicidal behavior, assaultive violence, firearm- related injuries, intimate partner violence, and sexual violence. Researchers proposed ?rearm?related research projects in the Injury Control Research Center (ICRC) grants and in the ?rst cycle of funding for the Academic Centers of Excellence for Youth Violence Prevention (ACES) during this period. The funding solicitations for the ICRCs and ACEs were broad and did not include specific priorities for ?rearm?related research. See Appendix C. The funding priorities for the R01 investigator-initiated research grants from 2002-2012 emphasized dissemination research and effectiveness research, particularly the effectiveness of primary prevention strategies to prevent child maltreatment, intimate partner violence, sexual violence, youth violence, and suicidal behavior. The research objectives outlined in Funding Opportunity Announcements are based on priorities in the NCIPC Research Agenda. 8. The National Violent Death Reporting System collects and combines data from multiple sources to provide states and communities with a more complete record of the circumstances surrounding violent deaths. Participation from all 50 states would signi?cantly increase the amount of data available to the National Violent Death Reporting System and, thereby, improve its effectiveness. In how many states has the National Violent Death Reporting System been implemented? has been implemented in 32 states, and with the FY2016 appropriations increase, the system will expand to include an additional four to seven states. The funding announcement was recently released, and states? applications are due to CDC on May 27. Final funding decisions will be made by September. CDC has requested an increase of $7.6 million in FY 2017 in order to support nationwide. 8a. How many states have applied to be included in this system? Over the years, 41 states have applied to the funding opportunity announcements. This year, 18 states and Washington, DC, are eligible to apply. The remaining 32 states are funded for multiple years. Therefore, they are not eligible to apply this year. 8b. What circumstances have prevented all state applicants from being added to the National Violent Death Reporting System? Currently, does not include all state applicants because levels of funding are not sufficient to support every state. Therefore, all prior funding opportunity announcements for have been competitive. Based on objective reviews, criteria for not funding prior applicants include lack of an injury prevention (or other suitable public health) infrastructure to provide adequate staf?ng and resources, inability to develop or demonstrate partnerships with data providers (vital registrars, coronersfmedical examiners, or law enforcement) required for problems with grantiapplieation writing, andz?or state legislation that restricts sharing of data required for The FY 2017" President?s Budget includes $23.5 million in funding for the National Violent Death Reporting System. With the total request of $23.5 million, CDC will be able to complete the expansion to all 50 states and Washington, DC. CDC expects that all states will apply for funding should full funding be provided to support a national system. In FY 2016 and FY 2017, to prepare for additional expansion, CDC and our partners will continue to work with unfunded states to determine barriers related to collecting violent death data and develop strategies to address identified barriers. CDC has and will continue to collaborate with partners to provide training to previously unfunded states to offer guidance for implementing the system and for facilitating collaboration between previously un?Jnded states and experienced states. 9. Has the CDC previously entered into any agreements with the National Ri?e Association offering to provide advanced notice of any publication on the subject of gun violence? If so, please provide a description of any such agreements as well as communications and documents memorializing the agreements. CDC routinely informs stakeholder organizations, including the National Ri?e Association, when articles of interest, such as articles on ?rearm?related violence, are released. 10. From 1996 to the present, has the CDC instructed any employee or researcher to not conduct scienti?c research on gun violence? Has the CDC instructed any employees or researchers to re-write reports submitted for publication to avoid using any variation of the word "gun"? CDC has not instructed employees or researchers to refrain from scienti?c research on gun violence. To ensure scientific integrity, technical accuracy, consistency with appropriations language, and usefulness to the intended audience, CDC has a standard agency review process for any manuscript or report produced by CDC scientists. Agency review is not speci?c to any topic area. In the course of reviewing manuscripts or reports on firearm violence, CDC has asked employees to use correct terminology?for example, to say ?died as a result of a ?rearm- related injury" vs. ?died from a ?rearm" in the same way as one would write ?died as a result of a motor-vehicle crash" vs. ?died from a car.? 11. What remedies are available to CDC researchers who believe their scienti?c research has been inappropriately suppressed or discouraged? Please describe any review or appeals processes and include a list of the of?ces or review boards who would address any such concerns. CDC is committed to a transparent research process and works to conduct scienti?c research in a manner that increases our knowledge of public health and ensures scientific quality and integrity. As diligent stewards of the public funds entrusted to us, CDC programs work to ensure that our scienti?c efforts meet established public health goals. Working with their leadership, scientists and subject matter experts ensure accuracy, validity, and appropriateness of results and findings and follow best practices to assure scienti?c quality and integrity. CDC scientists are required to complete scienti?c integrity and quality training. CDC has established an organizational framework that supports its scientists through the Associate Director for Science (ADS) structure. Through the ADS structure, CDC scientists can consult with their manager, leader, or ADS in their immediate program if they have concerns about research decisions. The ADS in the immediate program may escalate the matter to ADSs serving at higher organizational levels within the agency, as needed. Scientists may also escalate the matter to an ADS serving at higher organizational levels if they are in disagreement with the ADS in their immediate program or believe their research has been inappropriately discouraged. To enhance the agency?s strategic approach to scientific research, CDC also has established the Excellence in Science Committee (EISC). The EISC provides a forum for information exchange among ADSs. As an advocate for scienti?c quality and integrity, the EISC serves as a consulting body for science-related issues and makes recommendations when appropriate. Appendix A Examples of CDC ?rearm-related surveillance activities and analyses Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Preventive Medicine 2015; 79:5-14. Sullivan EM, Annest JL, Simon TR, Luo F, Dahlberg L. Suicide trends among persons aged 10? 24 years United States, 1994?2012. Morbidity and Mortality Weekly Report 2015; Kegler SR, Mercy JA. Firearm homicides and suicides in major metropolitan areas?United States, 2006-2007 and 2009-2010. Morbidity and Mortality Weekly Report 2013; 602. Sullivan, E., Annest, J. L., Luo, F., Simon, T. R., Dahlberg, L. L. Suicide among adults aged 35?64 years?United States, 1999?2010. Morbidity and Mortality Weekly Report, 2013, Ferdon CD, Dahlberg LL, Kegler S. Homicide rates among persons aged 10-24 years United States, 1981-2010. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, 2013, Egley A, Logan J, McDaniel D. Gang Homicides Five US. Cities, 2003?2008. Morbidity and Mortality Weekly Report, 2012; Appendix - CDC ?rearm-related research projects Projects listed below were funded through the research grant programs, the Injury Control Research Centers (ICRC) and the first cycle of the Academic Centers of Excellence for Youth Violence Prevention (ACE). Jeffrey Fagan Situational Contexts of Gun and Non-Gun Injuries R49HR01 1995-1997 Jeffrey Fagan Lethal Non-Lethal Adolescent Violence: Social, Economic, Neighborhood 1996-1998 David McDowall Injury Prevention Effects of Violence Interventions R49HR01 1996?1998 David Grossman Firearm Storage Device Evaluation R49HR01 1998?2000 David Hemenway Adult Firearms Survey ICRC 1998-2001 (Harvard) Daniel Webster Understanding risks for retaliatory shootings and opportunities for prevention ICRC 1999-2000 (Hopkins) Daniel Webster Estimating the effects of laws setting minimum legal age for handgun purchase and possession on youth suicide and homicide ACE 2000-2005 David Hemenvvay Evaluation of State-Level Firearms Policies ICRC 2001?2006 (Harvard) Appendix - Research solicitations A synopsis of ?rearm-related funding announcements, from 1996-2001, within the context of addressing assaultive behavior among youth, suicidal behavior, intimate partner violence and sexual violence, is provided below. 1996 CE96-011 Grants for Violence-Related Injury Prevention Research Grant applicants should concentrate on the need to reduce morbidity, mortality, and disabilities caused by suicidal behavior, assaultive behavior among youth, and family and intimate partner violence. 1.1niurv from Suicidal and Assaultive Behavior Enhancing our understanding ofsociai, economic, and environmental factors that may a?ect suicidalr behavior: 0 Study how choice of method (firearm, overdosing, etc.) in planning or attempting suicidal behavior is in?uenced by cultural, social, or environmental factors. I Conduct research to determine the nature of suicide risk among gay and lesbian persons in comparison to the general population. I Evaluate policies, programs, or interventions that may reduce suicidal behavior via the modification of social, economic, or environmental ciICumstances. . Assess the effectiveness of interventions that attempt to remove access to lethal means in reducing injury and severity of injury from suicidal behavior. Enhancing our understanding oftne importance ofsociai and economic factors that in?uence assaultive behavior among youth 0 Study why many socioeconomically disadvantaged youth do not engage in assaultive behavior despite their socioeconomic status. 1' Undertake research to increase our understanding of relationships between poverty and assaultive behavior among youth. I Study how unequal access to criminal justice, health care, and educational systems is related to assaultive behavior. I Evaluate policies, programs, or interventions that may reduce assaultive behavior among youth via the modi?cation of social or economic circumstances. 2. Family and Intimate Violence Prevention Address and define the needs ofmothers and children where intimate violence occurs. I Undertake research to determine effective interventions for mothers and children in families with ongoing violence - Conduct studies to determine which mothers and children are most likely to be helped by interventions designed for families with ongoing violence . Examine variables related to mothers, children, and families that may predict intervention effectiveness 0 Conduct studies related to the impact of children witnessing violence in their families. Define the incidence or prevalence ofjitnctionai limitations and among women as a resuit of intimate partner violence. - Quantify injuries sustained (nature and severity) and subsequent short and long-term (1-year) functional limitations and disability Ir Quantify the use of acute care, mental health, rehabilitation, and social services 0 Identify risk factors for adverse outcomes 1998 CE98-029 Grants for Violence-Related Injury Prevention Research Grant applicants should concentrate on the need to reduce morbidity, mortality, and disabilities caused by suicidal behavior, ?rearm-related injury, sexual violence, or intimate partner violence. I. Injury prevention research addressing emerging issues in suicidal behavior - Conduct research to develop and improve measurement instruments for the identi?cation and study of suicides and suicide attempts in surveys, research studies, and surveillance systems. 0 Conduct research designed to improve understanding of the nature of suicide risk among emerging high?risk populations such as young African American males. - Conduct research that further illuminates understanding of the contribution of potential risk factors for suicide Such as impulsivity, sexual orientation, and hopelessness. 2. Injury prevention research addressing injuries among children and adolescents - Conduct research to improve understanding of the motivations and deterrents for weapon carrying behavior among adolescents at high risk for ?rearm-related injuries. I Conduct research that estimates injury risk associated with ?rearm storage or carriage practices. 0 Conduct research that addresses the effects of ?rearm safety training and education programs on ?rearm storage and carriage practices. 3. Injury prevention research addressing sexual vioience or intimate partner violence 0 Conduct research to address the impact of welfare and welfare-to-work programs on women [and their children) who experience intimate partner violence. II Conduct research to determine the effectiveness of prevention programs for adolescent males at risk for perpetration of sexual violence or intimate partner violence or intervention programs for perpetrators of sexual violence or intimate partner violence. I Conduct research on risk factors for perpetration of sexual violence. 1999 CE99-055 Extramural Grants for Violence-Related Injury Evaluation Research The purposes of this program are to: evaluate the effectiveness andfor cost effectiveness of interventions and policies designed to reduce morbidity, mortality, and disabilities caused by suicidal behavior, ?rearm-related injury, sexual violence, or intimate partner violence. 1. In the area of suicide, there is particular interest in projects to evaluate suicide prevention interventions for general or high risk populations and projects to evaluate services provided in various settings such as a managed care setting. 2. In the area of firearm injuries, there is particular interest in projects evaluating prevention programs and policies that offer promise in preventing firearm injuries among children and adolescents safe storage of ?rearms in homes, safe gun technology, curricula to promote gun safety for children and adolescents). 3. In the areas of sexual violence and intimate partner violence, there is particular interest in evaluation research to determine the effectiveness of: I Prevention programs for adolescent males at risk for perpetration of sexual violence or intimate partner violence; or I Intervention programs for perpetrators of sexual violence or intimate partner violence. 2001 CEOl-{ll? Grants for Violence-Related Injury Prevention Research Research is sought to better understand the etiology of violence and its consequences, to determine how best to prevent violence-related injury among different segments of the population and in different settings, and how best to reduce the severity of the emotional and physical consequences of violence. 1. Improve understanding ofthe etiology of'violence interpersonal youth violence, child abuse, intimate partner violence, suicide, and sexual assault) and its consequences through research that addresses: I The independent, additive, interactive, and sequential effects of socioeconomic, and environmental risk and protective factors. I Factors that have differential effects on the onset, persistence, escalation, de-escalation, or desistance of violent offending at different ages. I Factors that increase the severity of the emotional and physical consequences of violence and suicidal behavior. I The effect of social and economic risk and protective factors such as poverty, social contagion, social norms, and social capital on interpersonal violence. I The effect of social, and environmental factors not directly related to mental health on suicide. I The risks and bene?ts of ?rearm access or carrying. Improve understanding of the relationships between different types of violence. of particular concern are: I The relationship between intimate partner violence victimization and perpetration to child abuse. I The effects of exposure to child abuse and intimate partner violence on suicidal behavior. I The effects of witnessing violence as a child in the home and community on violent behavior during adolescence and adulthood. Design and test preventive in terventionsjor intimate partner violence, sexual violence, suicidal behavior, and child abuse. Evaluate the ?-zasibilitv and impact of screening and intervention methods in the acute medical care settingforyouth interpensonal violence, child abuse, suicidal ideation. and intimate partner violence. Advance our unders tanding of the effectiveness of interventions to preventuvouth violence by evaluating: I The long-term impact of promising interventions. I Multifaceted interventions to prevent youth violence. I The effect youth-violence-prevention strategies in diverse cultural and social settings. The cost effectiveness of promising interventions 2015 CE15-001 Research Grants for Preventing Violence and Violence-Related Injury NCIPC is soliciting investigator-initiated research that will help expand and advance knowledge in three areas: (1) how best to disseminate, implement, and translate evidence-based primary prevention strategies, programs and policies designed to reduce youth violence; (2) what works to prevent violence by rigorously evaluating primary prevention strategies, programs, and policies; and (3) research to determine ways to effectively prevent serious and lethal interpersonal and self-directed violence. The following research objectives are the focus of this announcement: I. Research in prevent youth violence: - research to accelerate the adoption of evidence-based strategies, programs, and policies to prevent youth violence. There is particular interest in research that examines how models that have shown preventive effects on violence outcomes at the community level Communities That Care, Cardiff Violence Prevention Program) can be adopted for use in high risk communities. Prevention models that bring together different sectors within communities to make data driven decisions about the set of evidence?based prevention activities that are most appropriate for the local community and then en3ure implementation of those strategies have the potential to reduce risk for violence at the community level. Additional research is needed to help communities understand the capacity needed to implement these models, how the models can be appropriately adopted, and the effects of modifications on violence outcomes. a Effectiveness research to determine which community-level and societal-level strategies, programs, and policies effectively prevent youth violence. This includes studies to assess the effectiveness of economic development schemes business improvement districts) and other efforts to improve the physical, social, and economic characteristics of neighborhoods; and the effectiveness of strategies aimed at reducing the level and concentration of community risk factors. There is also interest in the area of youth violence to assess the economic efficiency of strategies, programs and policies designed to prevent youth violence. Effectiveness research to prevent serious and lethal violence among youth. Although there is a strong and growing evidence-base to prevent youth violence universal school-based programs, parentifamily focused interventions), there is less evidence addressing the more serious forms of violence among youth. Research is needed to determine ways to effectively prevent serious and lethal violence involving youth, particularly identifying and evaluating strategies addressing the leading mechanisms of youth homicide and assault-related injuries. 2. Research to prevent teen dating violence, intimate partner violence, and sexual violence." - Within the context of teen dating violence, intimate partner and sexual violence, there is interest in assessing the efficacyieffectiveness of primary prevention strategies aimed at preventing the initial perpetration of violence and promoting respectful, nonviolent relationships.6 lntervening in ways that prevent the initial perpetration of violence, that alter developmental trajectories leading to initial perpetration of violence, and that promote an environment of nonviolence and respect is key to eliminating sexual and intimate partner violence. - Effectiveness research to determine which community-level and societal-level strategies, programs, and policies effectively prevent teen dating violence, intimate partner and sexual violence. This includes studies to assess the effectiveness of economic schemes micro?nance, business improvement districts) and other efforts to improve the physical, social, and economic characteristics of neighborhoods and other settings; studies to assess the effectiveness of social and cultural norm change strategies at the community and societal level aimed at changing social contexts that condone or tolerate aggression and perpetration; and the effectiveness of strategies aimed at reducing the level and concentration of community risk factors. There is also interest in studies to assess the effectiveness of programs, policies, or strategies to prevent injuries and deaths in the context of teen dating violence and intimate partner violence. Women are much more likely than men to be injured or killed in incidents of violence between intimate partners. Research is needed to determine ways to effectively prevent serious and lethal violence against intimate partners, particularly identifying and evaluating strategies addressing the leading mechanisms of intimate partner homicide. 3. Research to prevent suicidal behavior.- - In the area of suicidal behavior, there is interest in ef?cacyfeffectiveness studies of social, economic, and environmental primary prevention strategies to prevent suicidal behavior, including strategies aimed at enhancing connectedness for groups at high-risk for suicidal behavior and community-level efforts to reduce social isolation and stigma associated with seeking help for personal crises. There is also interest in studies to determine whether evidence-based programs for other forms of violence can also prevent suicidal behavior. Suicidal behavior and interpersonal violence share a number of risk and protective factors. However, only a limited number of evaluations of strategies that have demonstrated reductions in interpersonal violence have examined the impact of these strategies on suicidal behavior. 0 There is also interest in studies assessing the effectiveness of programs, policies, and other intervention strategies to reduce access to lethal means. Research indicates that the means used in suicidal behavior jumping from a bridge, hanging or suffocation versus taking pills) has a substantial impact on whether the act results in significant injury or death. Strategies related to means restriction, however, have rarely been rigorously evaluated particularly for their impact and feasibility for broader implementation. Knowledge is also limited regarding the effects of means restriction on different age groups, and how means substitution switching from one suicide method to another) will limit the effectiveness of means-restriction strategies. Grants for Injury Control Research Centers (ICRCs) The purposes of this program are: 1) To support injury prevention and control research on priority issues as delineated in: Healthy People 2000; Injury Control in the 1990's: A National Plan for Action; Injury in America; Injury Prevention: Meeting the Challenge; and Cost of injury: A Report to the Congress; 2) To support ICRCs which represent CDC '5 largest national extramural investment in injury control research and training, intervention development, and evaluation; 3) To integrate collectively, in the context of a national program, the disciplines of engineering, epidemiology, medicine, biostatistics, public health, law and criminal justice. and behavioral and social sciences in order to prevent and control injuries more effectively; 4) To identify and evaluate current and new interventions for the prevention and control of injuries; 5) To bring the knowledge and expertise of ICRCs to bear on the development and improvement of effective public and private sector programs for injury prevention and control; and 6) To facilitate injury control efforts supported by various governmental agencies within a geographic region. Grants for Academic Centers of Excellence for Youth Violence Prevention The primary objectives of the Centers were to: 1) Build the scienti?c infrastructure necessary to support the development and widespread application of effective youth violence interventions, 2) promote interdisciplinary research strategies to address the problem of youth violence 3) foster collaboration between academic researchers and communities, and 4} empower communities to address the problem of youth violence. For the research component, centers could propose studies addressing the risk and protectives associated with youth violence as well as efficacy and effectiveness trials to prevent youth violence. From: Frieden, Thomas (Torn) Sent: Friday, April 15, 2016 4:37 PM To: Payne, Rebecca L. (CDCKUDIDCS) Cc: Solhtalab, Elizabeth Subject: RE: URGENT FOR APPROVAL: Support for Gun Violence Research Senator Thomas Carper - Folder 2353690 I?m ok it if Deb is From: Payne, Rebecca L. Sent: Friday, April 15, 2016 5:03 PM To: Frieden, Thomas {Tom} Cc: Villar, Carmen S. Hoffmann, Lauren (CDCIODIOCS) Subject: RE: URGENT FOR APPROVAL: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353690 Re funding we are being consistent with past statements and responses. The language you are asking about is consistent with responses we?ve sent to Congress via other inquiries. Our funded research in various violence related topic areas may touch on firearms even if it?s not the full scope of the research. For example, the evaluation of Safe Streets, a violence interrupter program in Baltimore, would touch on firearm access and use even though the program isn?t directly addressing firearms. +0eb in case this raises additional questions From: Payne, Rebecca L. Sent: Friday, April 15, 2016 4:47 PM To: Frieden, Thomas (Tom) Subject: RE: URGENT FOR APPROVAL: Support for Gun Violence Research - Senator Thomas Carper - Folder 2353690 The appendices are in the end of the word doc but pasted the full doc below as well we are checking on the funding The Honorable Thomas R. Carper Ranking Member, Committee on Homeland Security and Governmental Affairs United States Senate Washington, DC 20510 Dear Senator Carper: Thank you for your letter regarding the status of the Centers for Disease Control and Prevention?s (CDC) research into the causes and prevention of gun violence. CDC appreciates your concerns and those of the Committee on Homeland Security and Governmental Affairs, and is committed to protecting the health, safety, and security of the American people. Enclosed, please ?nd detailed responses to the speci?c questions outlined in your letter. We appreciate the Conunittee?s interest in this important public health issue. If you have additional questions or concerns, please contact Cristi Schwarcz in the CDC Washington Of?ce at or (202) 245-0600. Sincerely, Thomas R. Frieden, MD, MPH Director, CDC Enclosure Centers for Disease Control and Prevention (CDC) Response to the Senate Committee on Homeland Security and Governmental Affairs regarding Gun Violence Research 1. Please describe the CDC's policy toward scienti?c research into the causes and prevention of gun violence. Understanding the patterns, characteristics, and impact of firearm violence is an important step toward preventing firearm injuries and deaths in the United States. While National Center for Injury Prevention and Control (NCIPC) has no speci?c program dedicated to firearm violence research and prevention, ?rearms are a mechanism (cause) of injury. Therefore, CDC addresses firearm?related violence prevention in the context of addressing related areas, including youth violence, child maltreatment, domestic violence, and sexual violence. These areas coincide with topical line items that are supported through annual appropriation for research and non-research activities. The Fiscal Year (FY) 2017 President?s Budget includes $10 million to dedicate to gun violence prevention research. 2. Has the CDC or the Department of Health and Human Services' (HHS) Of?ce of the General Counsel conducted any analysis of the Dickey Amendment, including the types of gun violence research that are still permissible? If so, please provide this analysis. In 1997, after the Dickey Amendment was passed, CDC interpreted the amendment as prohibiting impermissible lobbying related to advocating or promoting gun control. CDC also interpreted the amendment to mean that activities that supported the collection of firearm injury-related data and engagement in scienti?c, public health research directed to preventing injuries from violence and ?rearms were still permissible. More recently, in January 2013, the President issued a Presidential Memorandum, ?Engaging in Public Health Research on the Causes and Prevention of Gun Violence? (Presidential Memorandum). This Presidential directive outlines the types of gun violence research that are permissible, including conducting or sponsoring research into the causes of gun violence and ways to prevent it, identifying the most pressing research questions with the greatest potential public health impact, and assessing existing public health interventions to prevent gun violence. The President?s plan to reduce gun violence, ?Now is the Time,? also states that the language in the Dickey Amendment, limiting the use of appropriated funds to ?advocate or promote gun control,? does not bar CDC from conducting research on the causes of gun violence, noting speci?cally that ?research on gun violence is not advocacy.? 3. In the aftermath of the shooting at Sandy Hook Elementary School in December 2012, President Obama issued a memorandum directing the Secretary of Health and Human Services (HHS), through the Director of the CDC and other agencies within HHS, to conduct or sponsor research into the causes of gun violence and the ways to prevent it. Please describe the efforts CDC has taken in response to this memorandum. In January 2013, in response to the President?s memorandum, CDC asked the Institute of Medicine (IOM), in collaboration with the National Research Council (NRC), to convene a committee to engage diverse stakeholders and identify the most pressing .research questions on gun violence, including those with the greatest potential public health impact. The released their report, which is available at chonszO BfPrio?tics- for-Rcsearch-to-Rcducc-thc- On June 5, 20l3. In addition, the CDC Foundation, in collaboration with CDC, commissioned the to develop and disseminate three supplemental discussion papers focusing on youth possession and acquisition of ?reamis, the relationship between alcohol and ?rearm violence, and ?rearm access by persons at risk of banning themselves or others. These papers, available at ediaf Fi less? Acti vitv?f?iZUFi lesx?Globalf 20 I 4-DEC- lSfYouth-Acouisition-Carrvin g-Fircarms-USpdf, iarF i U201 4- DEC - lilfAlcohoLF f, and vitv?MJEUFi obalf201 4-DEC- were released in late 2014. In February 2014, CDC met with a number of Executive Branch agencies, including representatives from HHS and the Department of Justice, to discuss approaches for strengthening data to understand patterns and characteristics of ?rearm violence, address research questions identi?ed in the report, ensure that research carried out by the different agencies is complementary and builds upon individual and collective and determine opportunities to collaborate on current or future efforts. For examples of CDC investigations, analyses of surveillance, and other data to document the public health burden of ?rearm injuries, see Appendix A. In FY 2015, with increased appropriations, CDC expanded the National Violent Death Reporting System from 18 to 32 participating states. In FY16, utilizing increased appropriation million), CDC plans to expand the to an additional four to seven states. is a state-based surveillance system that pools information about the ?who, when, where, and how? from data on violent deaths to provide insights on ?why? they occur. It gives states and communities a clearer understanding of violent deaths to guide local decisions about efforts to prevent violence and track progress over time. Findings from have resulted in tailored interventions, including increased veterans services to prevent suicide, ensuring child witnesses of domestic violence homicides are linked to social services, and screening older adults for depression. 4. In April 2013, the National Center for Injury Prevention and Control asked the Institute of Medicine to recommend a research agenda on the public health aspects of ?rearm-related violence. Please describe the actions the CDC plans to take in response to the ?ndings of the Institute of Medicine report issued in June 2013. The President?s FY 2017 Budget request includes $10 million in funding for gun violence prevention research. These funds would enable CDC to pursue research priorities identi?ed in the report. Should funding become available; CDC will pursue research activities that align with the priorities identi?ed in the IOMINRC report; Prioritiesfor Research to Reduce the Threat 0 Firearm-Related Violence (available at This includes understanding the characteristics of ?rearm violence patterns of access and use among children and youth, and among high?risk raciallethnic minority populations; ruralfurban differences in firearm-related violence); the risk and protective factors for homicide and suicide ?rearm violence alcohol. other situational or environmental factors; the factors in?uencing non-fatal firearm violence); and the effectiveness of interventions to prevent firearm violence (cg; safe storage practices; whether existing evidence?based approaches and policies for preventing interpersonal violence are effective in reducing ?rearm-related deaths and injuries). 5. From 1996 to the present; please describe notable examples of research conducted or funded by the including research by or through the National Center for Injury Prevention and Control, related to understanding gun violence. For a list of projects funded through the research grant programs; the Injury Control Research Centers (1C RC and the ?rst cycle ofthe Academic Centers of Excellence for Youth Violence Prevention (ACE). please see Appendix B. 5a. Please also provide all instances when the CDC included requests for gun violence research in its research proposal solicitation materials. Firearm-related research priorities were included in funding solicitations from 1996-2001 within the context of addressing assaultive behavior among youth, suicidal behavior. intimate partner violence and sexual violence. The funding solicitations for the and ACEs were broad and did not include specific priorities for fireann-related research. For a list ofthese funding announcements; please see Appendix C. 6. For each year from FY1996 to FY2015, what portion of the CDC's budget, including the budget of the National Center for Injury Prevention and Central. has been devoted to gun violence research? In FY 1997', Congress redirected $2.6 million from gun violence prevention activities to traumatic brain injury. CDC. addresses firearm?related violence prevention in the context of other violence-related areas. including youth violence. child maltreatment; domestic violence. and sexual violence. These areas coincide with topical line items that are supported through CDC is annual appropriation research and non-research activities. As previously noted; CDC has requested $10 million to dedicate to gun violence prevention research in the FY 2017 President?s Budget. Because firearms are a cause of injuries in these related areas; CDC has awarded research grants that address firearms as part of their scope; based on a competitive process. Proposals are evaluated for scientific and technical merit by an external peer review group, in accordance with CDC peer review policy and procedures. using stated review criteria. Since awards are competitive; the funding levels for firearm-related activities from 1997 thr0ugh 2015 have ranged from about $100,000 to just over $1 million. Comparisons to the total NCIPC budget or total CDC budget are not informative because the agency?s budget structure and scope have changed dramatic-ally in the past 20 years. Each year, CDC's Division of Violence Prevention solicits investigator-initiated research via an Grant Program Announcement. The language in these announcements signals to grant-seeking public health researchers the research priorities of the CDC and its Division of Violence Prevention. Please describe any Division of Violence Prevention's R01 Grant Program Announcements related to gun violence research put forward from 1996 to the present. Firearm-related research priorities were included in funding solicitations from 1996-2001 within the context of addressing assaultive behavior among youth, suicidal behavior, intimate partner violence, and sexual violence. All R?lapplications were evaluated for scienti?c and technical merit by an external peer review group, in accordance with CDC peer review policy and procedures, using stated review criteria. Following initial peer review, recommended applications received a second level of review. A variety of factors were considered in making funding decisions, such as scienti?c and technical merit of the proposed project as determined by scienti?c peer review, availability of funds, and relevance of the proposed projects to program priorities. The research solicitations during these years focused on enhancing the understanding of social, economic, and environmental factors that may impact the frequency and severity of these forms of violence. The research solicitations also focused on enhancing evaluations of policies, programs, or other interventions that may reduce morbidity, mortality, and disabilities associated with suicidal behavior, assaultive violence, firearm- related injuries, intimate partner violence, and sexual violence. Researchers proposed ?rearm?related research projects in the Injury Control Research Center (ICRC) grants and in the ?rst cycle of funding for the Academic Centers of Excellence for Youth Violence Prevention (ACES) during this period. The funding solicitations for the ICRCs and ACEs were broad and did not include specific priorities for ?rearm?related research. See Appendix C. The funding priorities for the R01 investigator-initiated research grants from 2002-2012 emphasized dissemination research and effectiveness research, particularly the effectiveness of primary prevention strategies to prevent child maltreatment, intimate partner violence, sexual violence, youth violence, and suicidal behavior. The research objectives outlined in Funding Opportunity Announcements are based on priorities in the NCIPC Research Agenda. 8. The National Violent Death Reporting System collects and combines data from multiple sources to provide states and communities with a more complete record of the circumstances surrounding violent deaths. Participation from all 50 states would signi?cantly increase the amount of data available to the National Violent Death Reporting System and, thereby, improve its effectiveness. In how many states has the National Violent Death Reporting System been implemented? has been implemented in 32 states, and with the FY2016 appropriations increase, the system will expand to include an additional four to seven states. The funding announcement was recently released, and states? applications are due to CDC on May 27. Final funding decisions will be made by September. CDC has requested an increase of $7.6 million in FY 2017 in order to support nationwide. 8a. How many states have applied to be included in this system? Over the years, 41 states have applied to the funding opportunity announcements. This year, 18 states and Washington, DC, are eligible to apply. The remaining 32 states are funded for multiple years. Therefore, they are not eligible to apply this year. 8b. What circumstances have prevented all state applicants from being added to the National Violent Death Reporting System? Currently, does not include all state applicants because levels of funding are not sufficient to support every state. Therefore, all prior funding opportunity announcements for have been competitive. Based on objective reviews, criteria for not funding prior applicants include lack of an injury prevention (or other suitable public health) infrastructure to provide adequate staf?ng and resources, inability to develop or demonstrate partnerships with data providers (vital registrars, coronersfmedical examiners, or law enforcement) required for problems with grantiapplieation writing, andz?or state legislation that restricts sharing of data required for The FY 2017" President?s Budget includes $23.5 million in funding for the National Violent Death Reporting System. With the total request of $23.5 million, CDC will be able to complete the expansion to all 50 states and Washington, DC. CDC expects that all states will apply for funding should full funding be provided to support a national system. In FY 2016 and FY 2017, to prepare for additional expansion, CDC and our partners will continue to work with unfunded states to determine barriers related to collecting violent death data and develop strategies to address identified barriers. CDC has and will continue to collaborate with partners to provide training to previously unfunded states to offer guidance for implementing the system and for facilitating collaboration between previously un?Jnded states and experienced states. 9. Has the CDC previously entered into any agreements with the National Ri?e Association offering to provide advanced notice of any publication on the subject of gun violence? If so, please provide a description of any such agreements as well as communications and documents memorializing the agreements. CDC routinely informs stakeholder organizations, including the National Ri?e Association, when articles of interest, such as articles on ?rearm?related violence, are released. 10. From 1996 to the present, has the CDC instructed any employee or researcher to not conduct scienti?c research on gun violence? Has the CDC instructed any employees or researchers to re-write reports submitted for publication to avoid using any variation of the word "gun"? CDC has not instructed employees or researchers to refrain from scienti?c research on gun violence. To ensure scientific integrity, technical accuracy, consistency with appropriations language, and usefulness to the intended audience, CDC has a standard agency review process for any manuscript or report produced by CDC scientists. Agency review is not speci?c to any topic area. In the course of reviewing manuscripts or reports on firearm violence, CDC has asked employees to use correct terminology?for example, to say ?died as a result of a ?rearm- related injury" vs. ?died from a ?rearm" in the same way as one would write ?died as a result of a motor-vehicle crash" vs. ?died from a car.? 11. What remedies are available to CDC researchers who believe their scienti?c research has been inappropriately suppressed or discouraged? Please describe any review or appeals processes and include a list of the of?ces or review boards who would address any such concerns. CDC is committed to a transparent research process and works to conduct scienti?c research in a manner that increases our knowledge of public health and ensures scientific quality and integrity. As diligent stewards of the public funds entrusted to us, CDC programs work to ensure that our scienti?c efforts meet established public health goals. Working with their leadership, scientists and subject matter experts ensure accuracy, validity, and appropriateness of results and findings and follow best practices to assure scienti?c quality and integrity. CDC scientists are required to complete scienti?c integrity and quality training. CDC has established an organizational framework that supports its scientists through the Associate Director for Science (ADS) structure. Through the ADS structure, CDC scientists can consult with their manager, leader, or ADS in their immediate program if they have concerns about research decisions. The ADS in the immediate program may escalate the matter to ADSs serving at higher organizational levels within the agency, as needed. Scientists may also escalate the matter to an ADS serving at higher organizational levels if they are in disagreement with the ADS in their immediate program or believe their research has been inappropriately discouraged. To enhance the agency?s strategic approach to scientific research, CDC also has established the Excellence in Science Committee (EISC). The EISC provides a forum for information exchange among ADSs. As an advocate for scienti?c quality and integrity, the EISC serves as a consulting body for science-related issues and makes recommendations when appropriate. Appendix A Examples of CDC ?rearm-related surveillance activities and analyses Fowler KA, Dahlberg LL, Haileyesus T, Annest JL. Firearm injuries in the United States. Preventive Medicine 2015; 79:5-14. Sullivan EM, Annest JL, Simon TR, Luo F, Dahlberg L. Suicide trends among persons aged 10? 24 years United States, 1994?2012. Morbidity and Mortality Weekly Report 2015; Kegler SR, Mercy JA. Firearm homicides and suicides in major metropolitan areas?United States, 2006-2007 and 2009-2010. Morbidity and Mortality Weekly Report 2013; 602. Sullivan, E., Annest, J. L., Luo, F., Simon, T. R., Dahlberg, L. L. Suicide among adults aged 35?64 years?United States, 1999?2010. Morbidity and Mortality Weekly Report, 2013, Ferdon CD, Dahlberg LL, Kegler S. Homicide rates among persons aged 10-24 years United States, 1981-2010. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, 2013, Egley A, Logan J, McDaniel D. Gang Homicides Five US. Cities, 2003?2008. Morbidity and Mortality Weekly Report, 2012; Appendix - CDC ?rearm-related research projects Projects listed below were funded through the research grant programs, the Injury Control Research Centers (ICRC) and the first cycle of the Academic Centers of Excellence for Youth Violence Prevention (ACE). Jeffrey Fagan Situational Contexts of Gun and Non-Gun Injuries R49HR01 1995-1997 Jeffrey Fagan Lethal Non-Lethal Adolescent Violence: Social, Economic, Neighborhood 1996-1998 David McDowall Injury Prevention Effects of Violence Interventions R49HR01 1996?1998 David Grossman Firearm Storage Device Evaluation R49HR01 1998?2000 David Hemenway Adult Firearms Survey ICRC 1998-2001 (Harvard) Daniel Webster Understanding risks for retaliatory shootings and opportunities for prevention ICRC 1999-2000 (Hopkins) Daniel Webster Estimating the effects of laws setting minimum legal age for handgun purchase and possession on youth suicide and homicide ACE 2000-2005 David Hemenvvay Evaluation of State-Level Firearms Policies ICRC 2001?2006 (Harvard) Appendix - Research solicitations A synopsis of ?rearm-related funding announcements, from 1996-2001, within the context of addressing assaultive behavior among youth, suicidal behavior, intimate partner violence and sexual violence, is provided below. 1996 CE96-011 Grants for Violence-Related Injury Prevention Research Grant applicants should concentrate on the need to reduce morbidity, mortality, and disabilities caused by suicidal behavior, assaultive behavior among youth, and family and intimate partner violence. 1.1niurv from Suicidal and Assaultive Behavior Enhancing our understanding ofsociai, economic, and environmental factors that may a?ect suicidalr behavior: 0 Study how choice of method (firearm, overdosing, etc.) in planning or attempting suicidal behavior is in?uenced by cultural, social, or environmental factors. I Conduct research to determine the nature of suicide risk among gay and lesbian persons in comparison to the general population. I Evaluate policies, programs, or interventions that may reduce suicidal behavior via the modification of social, economic, or environmental ciICumstances. . Assess the effectiveness of interventions that attempt to remove access to lethal means in reducing injury and severity of injury from suicidal behavior. Enhancing our understanding oftne importance ofsociai and economic factors that in?uence assaultive behavior among youth 0 Study why many socioeconomically disadvantaged youth do not engage in assaultive behavior despite their socioeconomic status. 1' Undertake research to increase our understanding of relationships between poverty and assaultive behavior among youth. I Study how unequal access to criminal justice, health care, and educational systems is related to assaultive behavior. I Evaluate policies, programs, or interventions that may reduce assaultive behavior among youth via the modi?cation of social or economic circumstances. 2. Family and Intimate Violence Prevention Address and define the needs ofmothers and children where intimate violence occurs. I Undertake research to determine effective interventions for mothers and children in families with ongoing violence - Conduct studies to determine which mothers and children are most likely to be helped by interventions designed for families with ongoing violence . Examine variables related to mothers, children, and families that may predict intervention effectiveness 0 Conduct studies related to the impact of children witnessing violence in their families. Define the incidence or prevalence ofjitnctionai limitations and among women as a resuit of intimate partner violence. - Quantify injuries sustained (nature and severity) and subsequent short and long-term (1-year) functional limitations and disability Ir Quantify the use of acute care, mental health, rehabilitation, and social services 0 Identify risk factors for adverse outcomes 1998 CE98-029 Grants for Violence-Related Injury Prevention Research Grant applicants should concentrate on the need to reduce morbidity, mortality, and disabilities caused by suicidal behavior, ?rearm-related injury, sexual violence, or intimate partner violence. I. Injury prevention research addressing emerging issues in suicidal behavior - Conduct research to develop and improve measurement instruments for the identi?cation and study of suicides and suicide attempts in surveys, research studies, and surveillance systems. 0 Conduct research designed to improve understanding of the nature of suicide risk among emerging high?risk populations such as young African American males. - Conduct research that further illuminates understanding of the contribution of potential risk factors for suicide Such as impulsivity, sexual orientation, and hopelessness. 2. Injury prevention research addressing injuries among children and adolescents - Conduct research to improve understanding of the motivations and deterrents for weapon carrying behavior among adolescents at high risk for ?rearm-related injuries. I Conduct research that estimates injury risk associated with ?rearm storage or carriage practices. 0 Conduct research that addresses the effects of ?rearm safety training and education programs on ?rearm storage and carriage practices. 3. Injury prevention research addressing sexual vioience or intimate partner violence 0 Conduct research to address the impact of welfare and welfare-to-work programs on women [and their children) who experience intimate partner violence. II Conduct research to determine the effectiveness of prevention programs for adolescent males at risk for perpetration of sexual violence or intimate partner violence or intervention programs for perpetrators of sexual violence or intimate partner violence. I Conduct research on risk factors for perpetration of sexual violence. 1999 CE99-055 Extramural Grants for Violence-Related Injury Evaluation Research The purposes of this program are to: evaluate the effectiveness andfor cost effectiveness of interventions and policies designed to reduce morbidity, mortality, and disabilities caused by suicidal behavior, ?rearm-related injury, sexual violence, or intimate partner violence. 1. In the area of suicide, there is particular interest in projects to evaluate suicide prevention interventions for general or high risk populations and projects to evaluate services provided in various settings such as a managed care setting. 2. In the area of firearm injuries, there is particular interest in projects evaluating prevention programs and policies that offer promise in preventing firearm injuries among children and adolescents safe storage of ?rearms in homes, safe gun technology, curricula to promote gun safety for children and adolescents). 3. In the areas of sexual violence and intimate partner violence, there is particular interest in evaluation research to determine the effectiveness of: I Prevention programs for adolescent males at risk for perpetration of sexual violence or intimate partner violence; or I Intervention programs for perpetrators of sexual violence or intimate partner violence. 2001 CEOl-{ll? Grants for Violence-Related Injury Prevention Research Research is sought to better understand the etiology of violence and its consequences, to determine how best to prevent violence-related injury among different segments of the population and in different settings, and how best to reduce the severity of the emotional and physical consequences of violence. 1. Improve understanding ofthe etiology of'violence interpersonal youth violence, child abuse, intimate partner violence, suicide, and sexual assault) and its consequences through research that addresses: I The independent, additive, interactive, and sequential effects of socioeconomic, and environmental risk and protective factors. I Factors that have differential effects on the onset, persistence, escalation, de-escalation, or desistance of violent offending at different ages. I Factors that increase the severity of the emotional and physical consequences of violence and suicidal behavior. I The effect of social and economic risk and protective factors such as poverty, social contagion, social norms, and social capital on interpersonal violence. I The effect of social, and environmental factors not directly related to mental health on suicide. I The risks and bene?ts of ?rearm access or carrying. Improve understanding of the relationships between different types of violence. of particular concern are: I The relationship between intimate partner violence victimization and perpetration to child abuse. I The effects of exposure to child abuse and intimate partner violence on suicidal behavior. I The effects of witnessing violence as a child in the home and community on violent behavior during adolescence and adulthood. Design and test preventive in terventionsjor intimate partner violence, sexual violence, suicidal behavior, and child abuse. Evaluate the ?-zasibilitv and impact of screening and intervention methods in the acute medical care settingforyouth interpensonal violence, child abuse, suicidal ideation. and intimate partner violence. Advance our unders tanding of the effectiveness of interventions to preventuvouth violence by evaluating: I The long-term impact of promising interventions. I Multifaceted interventions to prevent youth violence. I The effect youth-violence-prevention strategies in diverse cultural and social settings. The cost effectiveness of promising interventions 2015 CE15-001 Research Grants for Preventing Violence and Violence-Related Injury NCIPC is soliciting investigator-initiated research that will help expand and advance knowledge in three areas: (1) how best to disseminate, implement, and translate evidence-based primary prevention strategies, programs and policies designed to reduce youth violence; (2) what works to prevent violence by rigorously evaluating primary prevention strategies, programs, and policies; and (3) research to determine ways to effectively prevent serious and lethal interpersonal and self-directed violence. The following research objectives are the focus of this announcement: I. Research in prevent youth violence: - research to accelerate the adoption of evidence-based strategies, programs, and policies to prevent youth violence. There is particular interest in research that examines how models that have shown preventive effects on violence outcomes at the community level Communities That Care, Cardiff Violence Prevention Program) can be adopted for use in high risk communities. Prevention models that bring together different sectors within communities to make data driven decisions about the set of evidence?based prevention activities that are most appropriate for the local community and then en3ure implementation of those strategies have the potential to reduce risk for violence at the community level. Additional research is needed to help communities understand the capacity needed to implement these models, how the models can be appropriately adopted, and the effects of modifications on violence outcomes. a Effectiveness research to determine which community-level and societal-level strategies, programs, and policies effectively prevent youth violence. This includes studies to assess the effectiveness of economic development schemes business improvement districts) and other efforts to improve the physical, social, and economic characteristics of neighborhoods; and the effectiveness of strategies aimed at reducing the level and concentration of community risk factors. There is also interest in the area of youth violence to assess the economic efficiency of strategies, programs and policies designed to prevent youth violence. Effectiveness research to prevent serious and lethal violence among youth. Although there is a strong and growing evidence-base to prevent youth violence universal school-based programs, parentifamily focused interventions), there is less evidence addressing the more serious forms of violence among youth. Research is needed to determine ways to effectively prevent serious and lethal violence involving youth, particularly identifying and evaluating strategies addressing the leading mechanisms of youth homicide and assault-related injuries. 2. Research to prevent teen dating violence, intimate partner violence, and sexual violence." - Within the context of teen dating violence, intimate partner and sexual violence, there is interest in assessing the efficacyieffectiveness of primary prevention strategies aimed at preventing the initial perpetration of violence and promoting respectful, nonviolent relationships.6 lntervening in ways that prevent the initial perpetration of violence, that alter developmental trajectories leading to initial perpetration of violence, and that promote an environment of nonviolence and respect is key to eliminating sexual and intimate partner violence. - Effectiveness research to determine which community-level and societal-level strategies, programs, and policies effectively prevent teen dating violence, intimate partner and sexual violence. This includes studies to assess the effectiveness of economic schemes micro?nance, business improvement districts) and other efforts to improve the physical, social, and economic characteristics of neighborhoods and other settings; studies to assess the effectiveness of social and cultural norm change strategies at the community and societal level aimed at changing social contexts that condone or tolerate aggression and perpetration; and the effectiveness of strategies aimed at reducing the level and concentration of community risk factors. There is also interest in studies to assess the effectiveness of programs, policies, or strategies to prevent injuries and deaths in the context of teen dating violence and intimate partner violence. Women are much more likely than men to be injured or killed in incidents of violence between intimate partners. Research is needed to determine ways to effectively prevent serious and lethal violence against intimate partners, particularly identifying and evaluating strategies addressing the leading mechanisms of intimate partner homicide. 3. Research to prevent suicidal behavior.- - In the area of suicidal behavior, there is interest in ef?cacyfeffectiveness studies of social, economic, and environmental primary prevention strategies to prevent suicidal behavior, including strategies aimed at enhancing connectedness for groups at high-risk for suicidal behavior and community-level efforts to reduce social isolation and stigma associated with seeking help for personal crises. There is also interest in studies to determine whether evidence-based programs for other forms of violence can also prevent suicidal behavior. Suicidal behavior and interpersonal violence share a number of risk and protective factors. However, only a limited number of evaluations of strategies that have demonstrated reductions in interpersonal violence have examined the impact of these strategies on suicidal behavior. 0 There is also interest in studies assessing the effectiveness of programs, policies, and other intervention strategies to reduce access to lethal means. Research indicates that the means used in suicidal behavior jumping from a bridge, hanging or suffocation versus taking pills) has a substantial impact on whether the act results in significant injury or death. Strategies related to means restriction, however, have rarely been rigorously evaluated particularly for their impact and feasibility for broader implementation. Knowledge is also limited regarding the effects of means restriction on different age groups, and how means substitution switching from one suicide method to another) will limit the effectiveness of means-restriction strategies. Grants for Injury Control Research Centers (ICRCs) The purposes of this program are: 1) To support injury prevention and control research on priority issues as delineated in: Healthy People 2000; Injury Control in the 1990's: A National Plan for Action; Injury in America; Injury Prevention: Meeting the Challenge; and Cost of injury: A Report to the Congress; 2) To support ICRCs which represent CDC '5 largest national extramural investment in injury control research and training, intervention development, and evaluation; 3) To integrate collectively, in the context of a national program, the disciplines of engineering, epidemiology, medicine, biostatistics, public health, law and criminal justice. and behavioral and social sciences in order to prevent and control injuries more effectively; 4) To identify and evaluate current and new interventions for the prevention and control of injuries; 5) To bring the knowledge and expertise of ICRCs to bear on the development and improvement of effective public and private sector programs for injury prevention and control; and 6) To facilitate injury control efforts supported by various governmental agencies within a geographic region. Grants for Academic Centers of Excellence for Youth Violence Prevention The primary objectives of the Centers were to: 1) Build the scienti?c infrastructure necessary to support the development and widespread application of effective youth violence interventions, 2) promote interdisciplinary research strategies to address the problem of youth violence 3) foster collaboration between academic researchers and communities, and 4} empower communities to address the problem of youth violence. For the research component, centers could propose studies addressing the risk and protectives associated with youth violence as well as efficacy and effectiveness trials to prevent youth violence. From: Frieden, Thomas (Torn) Sent: Friday, April 15, 2016 4:37 PM To: Payne, Rebecca L. (CDCKUDIDCS) Cc: Newton, Donovan Subject: FW: What's new for ?schools violence prevention' in PubMed saw this abstract below and thought you might be interested in the article text can?t save the version for some reason]: California approves publicly funded gun research center Emily Underwood Science 24 Jun 2016: Vol. 352, Issue 6293, pp. 1505 For 2 decades, firearm advocates in Congress have blocked taxpayer-funded research into the causes and consequences of gun violence, which kills more people in the United States than in any other developed nation. Last week, California's state legislature bucked that trend, voting to establish the nation's first publicly funded center for studying gun violence. The new California Firearm Violence Research Center will be run by the University of California (UC) system. Its lean budget?$1 million per year over the next 5 years?will likely preclude large-scale studies, but backers hope it will demonstrate the value of publicly funded gun research and perhaps help build support in Congress for a similar federal effort. The 16 June vote to create the center poses ?a very stark" contrast to the continuing gridlock in Congress, says epidemiologist Garen Wintemute, who studies firearm violence at UC Davis. Last fall, he worked with state Senator Lois Wolk (D) to develop plans for the center. Coincidentally, the California vote came just 4 days after a gunman killed 49 people and injured 53 at a gay in Orlando, Florida, sparking renewed debate in Congress over proposals to impose new federal rules on gun purchases. Events like the Orlando massacre?one of the country's worst mass shootings?"leave us searching for answers," Wolk said in a statement. ?We know that using real data and scientific methods, our best researchers can help policy makers get past the politics and find real answers to this public health crisis.? ?This shows the kind ofthing states can do? in the absence of federal action, says David Hemenway, a health policy researcher at Harvard University. In 1996, the National Rifle Association and other groups successfully lobbied Congress to stifle federally funded gun research. Led by then-Representative Jay Dickey lawmakers barred the 0.5. Centers for Disease Control and Prevention from funding any activity that would ?advocate or promote gun control" and eliminated at $2.5 million pot of money for gun-related studies. Dickey, now retired, has since reversed his position and advocates for more gun research. But the lack of public funding means that few young scientists are drawn to the field, says Wintemute, who has spent more than $1 million of his own funds to sustain his research. The new center will focus on interdisciplinary research ?to provide the scientific evidence upon which to base sound firearm violence prevention policies and programs,? according to Wolk. "You name it, we need to know about it,? says Hemenway, citing the need for more information on everything from firearm training and gun thefts to their role in suicide and homicide. Wintemute adds that the center could enable a small team of researchers to examine California's unique data set on statewide gun transfers and other firearm~re ated activities. One pressing question, he says, is why California's annual fatalities from gun violence have dropped by roughly 20% since 2000, even as the nationwide rate has not changed. ?We don't know why that is,? Wintemute says. ?Are we doing something right? Or are we not doing something wrong that other [states] are?" The location of the new center is not yet "locked in,? but Wintemute believes UC Davis is the most likely candidate. And he hopes the state funding will help researchers attract additional money from private donors. From: My NCBI Sent: Friday, July 22, 2015 6:19 AM To: Hertz, Marci F. 10% from 2005 to 2015 for 99% of counties in the U.S., with 87% of counties showing increases of I Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S., with the exception of southern California and parts of Washington. I Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the U5. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement (written in collaboration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please find below some tailorable social media posts to help further promote the data: I Data released by @CDCInjury featured in @AmJPrevMed shows county-level trends in suicide rates in the US I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts I Trends about suicide, like geographic patterns, helps us develop more targeted community-based #suicideprevention strategies so we can reduce annual suicide rate 20% by 2025 I Rural counties in the US had the highest estimated suicide rates from 2005-2015 according to just-released @AmJPrevMed I Tracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts I Together we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: I @Action Alliance I @AASuicidology I [ofafsgnational I I MtofDefense I @Dept?v?etaffairs I I I - I @SAVEvoicesofedu I I @TrevorProiect Some resources that you may also find helpful as you promote the data include: I Action Alliance?s Transforming Communities: Key Eiements for the impiementation of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. I CDC's Preventing Suicide: A Technical Package of Paiicv, Programs, and Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this larger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Piease join us for a pianning caii on Thursday, 31 M330 am. ET to gian ahead [or caiiective statement about CDC data. We will send you a calendar invite (containing cal ~in information) to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC for giving us the heads up about the data. Thank you. #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 From: Doyle, Nadine Sent: 27 Jun 2016 08:17:34 -0400 To: Robert Gebbia;Christine Moutier,?McMillen, John Cc: Stone, Deborah Elizabeth Nadine Subject: Head?s Up: New CDC Report on Suicide by Occupation Good morning Bob, Christine, and John, I hope you guys are well! it's been wonderful to collaborate more closely over the past several months- Beth and Jim tell me that you all had a productive visit up in NYC a few months ago, and we truly appreciated the Opportunity to have Beth speak at your Advocacy Day a few weeks ago. I'm not sure if Beth has told you, but she will be going on temporary detail to Office on Smoking and Health for the next four months; in the meantime, I will remain your primary point of contact and look forward to continuing the discussions we?ve begun! in the spirit of continued coordination and information sharing, I wanted to let you know in advance about an upcoming article in MMWR which will be titled Suicide by Occupation 17 States, 2012. This article will be released on Thursday, June 30, 2016 at 1 pm ET. The data have been pulled from the National Violent Death Reporting System, and the report analyzes suicide deaths for those over the age of 16 by sex and occupation. The key findings from the report (which I unfortunately can?t share outside the agency yet) will include the highest rates of suicide by occupational categories. These findings can help employers and suicide prevention professionals know who may need to be reached by suicide prevention activities. i appreciate you keeping this information about this article within your organization until the report is officially released (Thursday, June 30, 2016 at 1 pm but hope you will consider joining the conversation after the release date by: I Sharing a message on social media: 0 New CDC repon analyzes highest suicide rate by occupation and sex. #VetoVioleoce 0 Results from new CDC report can help target suicide prevention work to certain occupations. #VetoViolence Forwarding the upcoming partner announcement through email I Sending questions about the report to dvpinquiries@cdc.gov Thank you for all of your work to prevent suicides and help people live their lives to theirfullest potential! Nadine Doyle, MPA Policy and Partnerships Team Division of Violence Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention Office 770413841316 Mobile ti: 404-394-4307 Telewark Tuesdays 8c Wednesdays; Out of Office Fridays To: Torguson, Kimberly;Belyeu, Erin Miranda Alexander Sally C. Valerie M. Jesse;Hausman, Bridgette;Hedegaard, Holly Kristin Mollyr Regina James (NIHKNIMH) [E];Mc5hane, Kristen rg;D'Keefe, Lindsey Jane [E];Reed, Malia Linda;5tone, Deborah Margaret James Subject: Media Messaging Work Group Call Attachments: Media Messaging Work Group Call .msg itair?ol uhject: Media Messaging Work Group Call ocation: Phone Number: soa-sm-zsos (access code tart: Thu li:00 AM nd: Thu 6.512018 [21.10 PM ecurrence: (none} eeting Status: Accepted rganizer: Torguson. Kimberly Phone Number: [access code Email Context [From Hello Media Messaging Work Group (MMWG). Following the email below. we wanted to let you know that the CDC data expected to be released on .lune 5 will now be released on June Additionally, we received word that we will not be receiving an embargoed copy so we?ll be rescheduling our MMWG group call (originally scheduled for Thursday. May 31] to Thursday1 June 7 at 11:00 a.m. The goal ofthis call is to convene our partners to: discuss the data. and 2] develop consensus on our messaging that will be used to craft a statement. if you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you canjoin us on Thursday, .lunc 7 at I :00 am. Lastly. we want to thank CDC for giving us the heads up about the data. Best. Hello Media Messaging Work Group, We wanted to call to your attention to ajust?released article published in the American Journal of Preventive Medicine that looks at county-speci?c estimates of suicide rates. The paper titled ?Conny-level Trends in Suicide Rates in the U.S.. 2005-2015" was written by our Partner, CDC (authors include: Lauren M. Rossen, Holly Hedegaard. Diba Khan and Margaret Warner from NCHS). Key ?ndings include: Posterior predicted mean county-level suicide rates increased by from 2005 to 2015 for 99% of counties in the U.S.. with 87% ofceunties showing increases of}20%. Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S.. with the exception of southern California and parts of Washington. Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015. and also the largest increases overtime. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the U.S. While the Action Alliance does notplan to put out a formal statement about the data at this time. we encourage you to reference our past collective statemen?written in collabOration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county?level trends data. Please ?nd below some tailorable social media posts to help further promote the data: Data released by DC Injury featured in @AmJPrevMed shows trends in suicide rates in the US New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts Trends about suicide. like geographic patterns. helps us develop more targeted community- based #suicideprcvention strategies so we can reduce annual suicide rate 20% by 2025 Rural counties in the LLS. had the highest estimated suicide rates from 2005-2015 according to just-released @AmJPrevMed Tracking county-level suicide rates helps our ?eld to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts Together we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-levei risk and protective factors as shown in recent data by @CDCinj ury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: {direction Alliance @AASuicidology {r'ilafspnational {ciJC DC MWR ff airs galEDCTweets gd?NIMHgov @samhsa gov @SAVEvoicesofedu PRC tweets {EiJTrevorProject Some resources that you may also find helpful as you promote the data include: Action Alliance?s Communities: Eel) Eiemenrs for the imniemenrgn'on of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. Preventing Suicide: A Technical Package efi?eiicv. Programs, and Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June St". The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this larger data release. we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Pleasejefn usfar a planning cell on Tn?readilyi Ma]; 31 at 2:00 n1. ET toplan aheadfor collective statement gbeur CDC date, We will send you a calendar invite [containing call?in information) to you shortly. It" you are unable to participate on this call. you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC For giving us the heads up about the data. Thank you. From: Torguson, Kimberly Sent: 14 May 2018 22:58:33 +0000 To: Torguson, Kimberly;Belyeu, Erin Miranda Alexander Sally C. Valerie M. Jesse;Hausman, Bridgette;Hedegaard, Ho y Kristin Molly Regina James [E];Mc5hane, Kristen fe, Lindsey Jane lNleNlMH] [E1;Fieed, Malia Linda;Stone, Deborah Margaret James Subject: Media Messaging Work Group Cell Phone Number: 366-370-2803 (access code Email Content [From 5/14}: Hello Media Messaging Work Group (MMWG), Following the email below, we wanted to let you know that the CDC data expected to be released on June 5 will now be released on June 7. Additionally, we received word that we will not be receiving an embargoed copy so we?ll be rescheduling our MMWG group call (originally scheduled for Thursday, May 31) to Thursday, June Ii at 11:00 am. The goal of this call is to convene our partners to: 1) discuss the data, and 2) develop consensus on our messaging that will be used to craft a statement. if you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you can join us on Thursday, June 2 at 11:00 am. Lastly, we want to thank CDC for giving us the heads up about the data. Best, Hello Media Messaging Work Group, We wanted to call to your attention to a justareleased article published in the American Journal of leygl Trendg in Sylgigg?gtgs in the was written by our Partner, CDC {authors include: Lauren M. Hossen, Holly Hedegaard, Diba Khan and Margaret Warner from Key findings include: - Posterior predicted mean county-level suicide rates increased by >10% from 2005 to 2015 for 99% of counties in the U.S., with 87% of counties showing increases of - Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S., with the exception of southern California and parts of Washington. . Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the U5. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement (written in collaboration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please find below some tailorable social media posts to help further promote the data: I Data released by featured in @AmJPrevMed shows county-level trends in suicide rates in the US I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts I Trends about suicide, like geographic patterns, helps us develop more targeted community?based #suicideprevention strategies http://bitJy/2iHo6hk so we can reduce annual suicide rate 20% by 2025 I Rural counties in the 11.5. had the highest estimated suicide rates from 20052015 according to just?released @AmJPrevMed I Tracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts I Together we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: IQAgjgn Alliance I @AASuicidology I @afspnational I @CDCIniugy I @DeptofDefense I @DeptVetAffairs I @EDCTweets I I @Ef??s?ggt I @SAVEvoicesofedu I I @Trevorproiect - Some resources that you may also find helpful as you promote the data include: I Action Alliance's Transforminggommunities: KeLEiemen ts fo_rti1e imgiementotion of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. I (2005 Preventing Suicide: A Technical Package of Poiicy, Programs! and Practices - A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this larger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Please jaln as for a planning call on Thursday, May 31 at 2:00 pan. to plan ahead for collective statement about CDC data. We will send you a calendar invite (containing call-in information) to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC for giving us the heads up about the data. Thank you. To: Torguson, Kimberly;Belyeu, Erin Miranda Alexander Sally C. Valerie M. Jesse;Hausman, Bridgette;Hedegaard, Holly Kristin Mollyr Regina James (NIHKNIMH) [E];Mc5hane, Kristen rg;D'Keefe, Lindsey (NIHINIMH) Jane [E];Reed, Malia Linda;5tone, Deborah Margaret James Subject: Media Messaging Work Group Call Attachments: Media Messaging Work Group Call .msg object: Media Messaging Work Group Call ocation: Phone Number: sea?3m-2sos (access code tart: Thu ?r?Ti?Z?lS ?:00 AM nd: Thu 6.51201812110 PM how Time As: Tentative ecurrence: {none} eeting Status: Not yet responded rganizer: Torguson. Kimberly Phone Number: {access code Email Contest [From Hello Media Messaging Work lGroup (MMWG). Following the email below. we wanted to let you know that the CDC data expected to be released on June 5 will now be released on June 7. Additionally, we received word that we will not be receiving an embargoed copy so we'll be rescheduling our MMWG group call (originally scheduled for Thursday, May 3 l] to Thursday, June at ?:00 a.m. The goal ofthis call is to convene our partners to: discuss the data. and 2] develop consensus on our messaging that will be used to craft a statement. If you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you canjoin us on Thursday, .lune 7 at I :00 em. Lastly, we want to thank CDC for giving us the heads up about the data. Best, Hello Media Messaging Work Group, We wanted to call to your attention to ajust?released article published in theAmericrm Jam-mil of Preventive Medicine that looks at county-speci?c estimates of suicide rates. The paper titled ?Conny-level Trends in Suicide Rates in the U.S., 2005-2015" was written by our Partner, CDC (authors include: Lauren M. Rossen, Holly Hedegaard, Diba Khan and Margaret Warner from NCHS). Key ?ndings include: Posterior predicted mean suicide rates increased by 0% from 2005 to 2015 for 99% of counties in the U.S., with 87% of counties showing increases of 320%. Counties with the highest model-based suicide rates were consistently located across the western and northwestem U.S., with the exception of southern California and parts of Washington. Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015. and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community?based suicide prevention efforts in the US. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statemendwritten in collaboration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please ?nd below some tailorable social media posts to help further promote the data: Data released by @CDCInjury featured in shows county-level trends in suicide rates in the US New article featured in @AmJPrevMed underscores need for coordinated and comprehensive suicide prevention efforts Trends about suicide, like geographic patterns, helps us develop more targeted community- based #suicideprevention strategies so we can reduce annual suicide rate 20% by 2025 Rural counties in the US. had the highest estimated suicide rates from 2005-2015 according to justsreleased @AmJPrevMed Tracking county-level suicide rates helps our ?eld to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts httpo?i?bitJyIZIHo?hk Together we can reduce the annual suicide rate 21:} percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury http:iibit.lyi2lHofihk When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: {iiJAction Alliance {E?AASuicidology {r?afspnational {tiJDeptotDefense @DeptVemffairs {nJEDCTweets gov (riisamhsagov {LiJSAVEvoiccsofedu {citTrevorProject Some resources that you may also ?nd helpful as you promote the data include: Action Alliance?s Transforming Communities: Kev Eiemenrs for the Implementation of Comprehensive (Immunity-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. Preventing Suicide: A Technical Package (It Poiicyi Programs: and Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June St?. The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this larger data release, he convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Pleasejnr'n usfar a planning cell on Marv 31 at 2:00 n. m. to plan ahead [or collective statement ghoul CDC data. We will send you a calendar invite [containing call-in information) to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC For giving us the heads up about the data. Thank you. From: Torguson, Kimberly Sent: 29 May 2018 15:18:15 +0000 To: Torguson, Kimberly;Belyeu, Erin Miranda Alexander Sally C. Valerie M. Jesse;Hausman, Bridgette;Hedegaard, Holly Kristin Molly Regina James [E];Mc5hane, Kristen fe, Lindsey Jane lNleNlMH] [E1;Fieed, Malia Linda;Stone, Deborah Margaret James Subject: Media Messaging Work Group Cell Phone Number: 366-370-2803 (access code Email Content [From 5/14}: Hello Media Messaging Work Group (MMWG), Following the email below, we wanted to let you know that the CDC data expected to be released on June 5 will now be released on June 7. Additionally, we received word that we will not be receiving an embargoed copy so we?ll be rescheduling our MMWG group call (originally scheduled for Thursday, May 31) to Thursday, June Ii at 11:00 am. The goal of this call is to convene our partners to: 1) discuss the data, and 2) develop consensus on our messaging that will be used to craft a statement. if you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you can join us on Thursday, June at 11:00 am. Lastly, we want to thank CDC for giving us the heads up about the data. Best, Hello Media Messaging Work Group, We wanted to call to your attention to a justereleased article published in the American Journal of leygl Trendg in Syigigg?gtgs in the was written by our Partner, CDC {authors include: Lauren M. Hossen, Holly Hedegaard, Diba Khan and Margaret Warner from Key findings include: - Posterior predicted mean county-level suicide rates increased by >10% from 2005 to 2015 for 99% of counties in the U.S., with 87% of counties showing increases of - Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S., with the exception of southern California and parts of Washington. . Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the U5. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement (written in collaboration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please find below some tailorable social media posts to help further promote the data: I Data released by featured in @AmJPrevMed shows county-level trends in suicide rates in the US I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts I Trends about suicide, like geographic patterns, helps us develop more targeted community?based #suicideprevention strategies http://bitJy/2iHo6hk so we can reduce annual suicide rate 20% by 2025 I Rural counties in the 11.5. had the highest estimated suicide rates from 20052015 according to just?released @AmJPrevMed I Tracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts I Together we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: IQAgjgn Alliance I @AASuicidology I @afspnational I @CDCIniugy I @DeptofDefense I @DeptVetAffairs I @EDCTweets I I @Ef??s?ggt I @SAVEvoicesofedu I I @Trevorproiect - Some resources that you may also find helpful as you promote the data include: I Action Alliance's Transforminggommunities: KeLEiemen ts fo_rti1e imgiementotion of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. I (2005 Preventing Suicide: A Technical Package of Poiicy, Programs! and Practices - A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this larger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Please jaln as for a planning call on Thursday, May 31 at 2:00 pan. to plan ahead for collective statement about CDC data. We will send you a calendar invite (containing call-in information) to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC for giving us the heads up about the data. Thank you. From: Belyeu, Avery Sent: 6 Apr 2017 14:58:19 +0000 To: Caraballo, Rachel;Reed, Jerry;Bird, Doreen;Carr, James Gebbia;Magda a Labre;Stone, Deborah Eileen John Helm;Johnson, Brandon J. Kimberly Subject: National Action Alliance: Transforming Communities Paper Release Attachments: Action Alliance Press Release_Transforming Communities_Final.docx Dear Community-Based Suicide Prevention Working Group, We are pleased to share with you the final Transforming Communities paper and corresponding promotional materials. We thank you for all of your ideas and contributions to the materials and look forward to working with you to jointly promote. The Action Alliance will be distributing the press release and email announcement today (416] at 11:00 am. ET. We encourage you to also share the press release with media contacts as well as promote via your various channels. Please use the following link when promoting: http:/fbitJyJ Communities. (Additionally, we?ve attached a Word version in the case you need pieces of content for various communication channels.) Below, please find an email announcement {which mentions the April 12th webinar) to share widely across your various listservs and contact lists. Lastly, please find a few tailorable social media posts below for your convenience. Feel free to tweak as needed as well as retweet/like the Action Alliance?s social media posts. Twitter: I Today national groups collectively release resources to help communities prioritize #suicideprevention Communities @action_a liance @afspnational @cdcgov I New resources to guide community-based suicide prevention Communities @action_a liance @afspnational @cdcgov - lust-released TWO new tools to help communities comprehensively address suicide Communities @action_a liance @afspnational @cdcgov Facebook: I Today, the Action Alliance and its partners including the American Foundation for Suicide Prevention, Centers for Disease Control and Prevention (CDC), and the Substance Abuse and Mental Health Services Administration?s Suicide Prevention Resource Center (SPRC) collectively released two new resources that current knowledge about community~based suicide prevention and emphasize the need for comprehensive efforts that combine multiple strategies that work together to prevent suicide. Take a look at these justvreleased tools and please share widely with your networks: Communities Again, we appreciate everyone?s assistance and collaboration. Thank you. Kim Email Announcement Subject Line - Just-Released: New Suicide Prevention Tools to Help Guide Communities Good afternoon, We are pleased to share two new resources aimed at improving commu nity-based suicide prevention efforts nationwide. The National Action Alliance for Suicide Prevention (Action Alliance] and its partners including the American Foundation for Suicide Prevention, Centers for Disease Control and Prevention (CDC), and the Substance Abuse and Mental Health Services Administration?s Suicide Prevention Resource Center released the following resources: ii'r Transforming Communities: Kev Elements for Couml?EMlVE community-Based Suicide Prevention Developed by the Action Alliance, this resource presents seven key elements for comprehensive community-based suicide prevention, identified via a review of relevant programs, guidance, and models. The elements are key considerations that should guide community?based suicide prevention efforts?aimed at helping communities create policies, programs, and services that reduce suicide and improve individual, family, and community health. They are meant as broad guidance for the field, and can help inform the development of suicide prevention programs and future resources. ii" Preventing Suicide: A Technical Package of Policy, Programs, and Practices Developed by CDC, this resource helps states and communities take advantage of the best available evidence for suicide prevention interventions. The package highlights seven strategies for suicide prevention and the evidence of their impact on suicidal behaviors and related risk and protective factors. The two resources current knowledge about community?based suicide prevention and emphasize the need for comprehensive efforts that combine multiple strategies that work together to prevent suicide. The first resource, released by the Action Alliance, identifies seven key elements that should guide program planning and implementation. The second resource, released by CDC, outlines specific, evidence-based suicide prevention strategies for communities to consider as a part of their comprehensive approach. Together, these two resources address how communities can carry out suicide prevention efforts and what they can do. Community leaders, suicide prevention program planners, and others can use these new resources to guide the planning, implementation, and evaluation of comprehensive community-based suicide prevention efforts. The resources can also inform the development of future resources, such as step?bye step implementation guides, tools, and websites tailored to the needs of specific communities and settings schools, workplaces, justice system}. The strategies and elements outlined in the two resources support the goals and objectives of the reduce the annual rate of suicide 20 percent by 2025. To learn more about these resources and how they can be used, the Action Alliance will be hosting a 90- minute webinar on April 12. To register for the webinar, go to: Communities and please share widely with your networks. Additionally, please take a look at the Action Alliance?s press release: htth/bitiy/ Communities. Lastly, we encourage you to please promote the resources by sharing them via your social media channels. Below are a few tailorable posts, for your convenience. Twitter: I- Today national groups collectively release resources to help communities prioritize #suicideprevention Communities @action_a liance @afspnational @cdcgov - New resources to guide community-based suicide prevention htth/bitiy/ Communities @action_a liance @afspnational @cdcgov - Just?released TWO new tools to help communities comprehensively address suicide http://bitJyl Communities @actiongalliance @afspnational @cdcgov Face-book: Today, the Action Alliance and its partners including the American Foundation for Suicide Prevention, Centers for Disease Control and Prevention (CDC), and the Substance Abuse and Mental Health Services Administration?s Suicide Prevention Resource Center (SPEC) collectively released two new resources that current knowledge about community-based suicide prevention and emphasize the need for comprehensive efforts that combine multiple strategies that work together to prevent suicide. Take a look at these justvreleased tools and please share widely with your networks: http:/fbitJy/ Communities Thank you for your collaboration and commitment. it it My Best, Avery Avery Belyeu National Partnerships Associate National Action Alliance for Suicide Prevention The Education Development Center 1025 Thomas Jefferson St, Washington, DC 2000? {823) 40641029 (Direct) early, Learning Km" EDC transforms -. SPRC lives. Action A/Hance FOR SUICFUE PREVENTIUN FOR IMMEDIATE RELEASE MEDIA CONTACT: April 6, 2017'r Kim Torguson - (202) 572-3337 Suicide Prevention Tools Launched to Guide Communities Nationwide Notionoi groups reieose comprehensive guidance aimed at reducing onnuoi suicide rote in the US. Washington, tools to improve community-based suicide prevention efforts were released today by the National Action Alliance for Suicide Prevention (Action Alliance}, the nation?s public-private partnership championing suicide prevention as a national priority, and its partners from the Centers for Disease Control and Prevention American Foundation for Suicide Prevention and the Substance Abuse and Mental Health Services Administration?s Suicide Prevention Resource Center Suicide remains one of the 10 leading causes of death in the U.S., causing tremendous pain and loss to communities across the country?especially rural communities recent CDC data show. The Action Alliance aims to advance the Qig?gg??gtegg?ar Suicide ?re?m?w roadmap that when implemented, will lead to the vision of a nation free from the tragic experience of suicide. According to the NSSP, community-based programs, policies, and services can play an important role in suicide prevention. To ensure that communities know where to start and what they can do to implement comprehensive suicide prevention efforts, the Action Alliance and several of its national and community partners jointly reieased two resources that current knowledge about community-based suicide prevention and emphasize the need for comprehensive efforts that combine multiple strategies that work together to prevent suicide. The strategies and elements outlined in the two resources support the goals and objectives of the NSSP. The first resource, released by the Action Alliance, identifies seven key eiements that should guide program planning and implementation. The second released by CDC, outlines speci?c, evidence?based suicide prevention strategies for communities to consider as a part of their comprehensive approach. Together, these two resources address how communities can carry out suicide prevention efforts and what they can do. "These resources are a result of tremendous collaboration among various partners from the public and private sectors coming together to help prevent suicide at the community level,? said Dr. Jerry Reed, director of SPRC and executive committee member of the Action Alliance. "The collective efforts by dedicated people and groups within the field of suicide prevention create a robust knowledge base that can help move our work forward while preventing duplication." These new resources include: Transforming Communities: Key Elements for Comprehensive Community-Based Suicide Prevention Developed by the Action Alliance, this resource presents seven key elements for comprehensive community?based suicide prevention, identified via a review of relevant programs, guidance, and models. The elements are key considerations that should guide community-based suicide prevention efforts?aimed at helping communities create policies, programs, and services that reduce suicide and improve individual, family, and community health. They are meant as broad guidance for the field, and can help inform the development of suicide prevention programs and future resources. i'r Preventing Suicide: A Technical Package of Policy, Programs, and Practices Developed by CDC, this resource helps states and communities take advantage of the best available evidence for suicide prevention interventions. The package highlights seven strategies for suicide prevention and the evidence of their impact on suicidal behaviors and related risk and protective factors. "We know that suicide is preventable. These resources will help communities to start now, act on the best available evidence, and work together." said James Mercy, director, Division of Violence Prevention, National Center for Injury Prevention and Control. "The strategies laid out in the technicai package, as well as the key elements outlined in the paper, are intended to work in combination and reinforce each other.? Community leaders, suicide prevention program planners, and others can use these new resources to guide the planning, implementation, and evaluation of comprehensive community?based suicide prevention efforts. The resources can also inform the development of future resources, such as step-by?step implementation guides, tools, and websites tailored to the needs of specific communities and settings schools, workplaces, jUStice system}. ?We are pleased that AFSP and the Action Alliance have set a common goal to reduce the annual suicide rate 20 percent by 2025," said Bob Gebbia, chief executive officer. "Working together to develop and implement comprehensive community-based suicide prevention strategies will help us to achieve this goal? saving and improving the most lives possible.? ii if ADDITIONAL INFORMATION ABOUT RESOURCES: On April 12, the Action Alliance will host a QULminute webinar to provide a detailed overview about the two resources. To register for the webinar, go to: Communities. FOR MEDIA PARTNERS: Research shows that the media may influence suicide rates by the way they report on suicide. Evidence suggests that when the media teil stories of people positively coping in suicidal moments, more suicides can be prevented. We urge all members of the media working on these stories to refer to the Recommendations for Reporting on Suicide for best practices for safely and accurately reporting on suicide. For stories of persons with lived experience of suicidaiity and finding hope, refer to NATIONAL ACTION ALLIANCE FDR SUICIDE PREVENTION: The National Action Alliance for Suicide Prevention is the public-private partnership working to advance the Notionoi Strategyfor Suicide Prevention and make suicide prevention a national priority. The Substance Abuse and Mental Health Services Administration provides funding to to operate and manage the Secretariat for the Action Alliance which was launched in 2010. Learn more at and join the conversation on suicide prevention by following the Action Alliance on ?ebggk, DEED and [gulutle From: Warner, Margaret Sent: 2 Nov 2016 17:02:56 -0400 To: Alexis O'Brien;Belyeu, Reidenberg';'lohn Draper';5tout, Elly;'Jacl< Benson?;5tephanie Deborah Gonzalez';'Michae Rosen';'Ashley Kristin Liliya;Crosby, Alexander Holly Linda;Gass, Jesse;Scanlon, Michaelle [C];Reed, Jerry;Padgett, Jason;Zeller, Eileen Rebecca [C];Steve Mendelsohn Cc: Curtin, Sally C. Subject: RE: Action Alliance Media Messaging Work Group Call- Potential Data Release Planning Call. Thanks for sending. It would be interesting to see a comparison of federal funding to reduce MVTC deaths. Because the comparison is to MV deaths, I did want to point you to an MMWR highlighting the success in reducing MV deaths which is considered one of the great public health achievements of the 20th century. . And Here is some language about how the MV deaths were reduced using a multi?faceted approach I think the key here is that it is not one thing, but many different Government agencies and other organizations joined together to achieve great reductions in the number of deaths from motor vehicle crashes A comprehensive approach, including improvements in the safety of vehicles; improvements in roadways; increased use of restraint systems, such as seat belts and child safety seats; reductions in speed: and also efforts to reduce driving under the in?uence of alcohol and drugs. contributed to the decline in motor vehicle related deaths. Using a comprehensive, multifaceted approach. it may be possible to reverse the trend in [suicide] mortality. Let me know if you have further questions. Thanks, Margaret NCHS From: Alexis O'Brien Sent: Wednesday, November 02, 2016 4:26 PM To: Belyeu, Avery; 'Dan Reidenberg' 'John Draper' Stout, Elly; 'Jack Benson' Stephanie Coggin eneely@reingold.com; Stone, Deborah Carr, Colleen 'Amy Kulp' 'Frances Gonzalez' 'Michael Rosen' 'Ashley Vactor' Holland, Kristin (CDCIONDIEHINCIPQ Melnyk, Liliya; Crosby, Alexander (CDCIONDIEHINCIPC) Hedegaard, Holly (CDCIOPHSSINCHS) 'Paul Lauricella' Sobottka, Linda Gass, Jesse ;Scan on, Michaelle Reed, Jerry Padgett, Jason Warner, Margaret Zeller, Eileen Kurikeshu, Rebecca ;Steve Mendelsohn Subject: RE: Action Alliance Media Messaging Work Group Call? Potential Data Release Planning Call. Please see attached re: research funding. From: Belyeu, Avery Sent: Wednesday, November 02, 2016 4:15 PM To: Belyeu, Avery; 'Dan Reidenberg'; 'John Draper'; Stout, Elly; 'Jack Benson'; Stephanie Coggin; eneelv@reinoold.com; Stone, Deborah Carr, Colleen; ?Amy Kulp'; 'Frances Gonzalez'; 'Michael Rosen'; 'Ashley Vactor?; Holland, Kristin Melnyk, Liliya; Crosby, Alexander Hedegaard, Holly 'Paul Lauricella'; Sobottka, Linda; Gass, Jesse; Scanlon, Michaelle (NIHXNIMH) Reed, Jerry; Padgett, Jason; Warner, Margaret Cc: Zeller, Eileen Alexis O?Brien; Kurikeshu, Rebecca Steve Mendelsohn Subject: FW: Action Alliance Media Messaging Work Group Call- Potential Data Release Planning Call. Importance: High Please see attached. From: Pearson, Jane Sent: Wednesday, November 02, 2016 11:59 AM To: Belyeu, Avery ; 'Paul Sobottka, Linda ; 6355, Jesse Scanlon, Michaelle Reed, Jerry Date: Friday, November 4, 2016 at 9:02 AM To: "Carr, Colleen" , "Crosby, Alexander , 'Paul Lauricella' "Sobottka, Linda" "Gass, Jesse" Cc: Eileen Zeller Alexis O'Brien "Kurikeshu, Rebecca Steve Mendelsohn Subject: RE: Action Alliance Statement in response to 4 Nov. MMWR release In response to a great question i just received- For organizations that will use this content to inform an organization?specific press release, please be sure to include a reference to the Action Alliance to spread the message of the importance of public and private sector collaboration to reduce the burden of suicide. For example: w(enter organization name)__ is a partner of the National Action Alliance for Suicide Prevention, the public?private partnership advancing the National Strategy for Suicide Prevention and championing suicide prevention as a national priority. Original Message-?? From: Carr, Colleen Sent: Friday, November 04, 2016 8:42 AM To: Belyeu, Avery 'Jane Pearson' earson nih. ov>; 'Dan Reidenberg 'John Draper' Stout, Elly ; 'Paul Lauricellar Sobottka, Linda Gass, Jesse Cc: 'Zeller, Eileen 'Alexis O'Brien' wrote: Hello All, This statement has also been posted on the Action Alliance website and may be accessed at the link below: lliance 04%201?4 i ckStats . Please feel free to use this link or the shorter link below when posting to Facebook and twitter. My Best, Avery Original Message?w From: Carr, Colleen Sent: Friday, November 04, 2016 7:42 AM To: Belyeu, Avery ?Jane Pearson? Cc: Zeller. Eileen Alexis O'Brien Kurikeshu, Rebecca (NIHJNIMH) irebecca.kurikesliuf?lnihgove: Steve Mendelsohn Subject: RE: Action Alliance Statement in response to 4 Nov. MMWR release Action Alliance Media Messaging Workgroup, Please see the attached Action Alliance statement in response to the Nov 4 MMWR From CDC. Thank you for all ofyour ideas and contributions to this document over the last 24 hours. Our sincere appreciation to Margy and Sally at NCHS for giving us advance notice this was coming out as well as walking us through the data on Wednesday's call. This was a great example of public and private sector collaboration to advance national suicide prevention efforts. Please use the PDF version for sharing with your networks (cg, listservs, social 1nedia)? the word version is attached in case you need pieces ofcontent for various communication channels. Amy will take the lead on posting to AAS listserv. Let's collectively use this statement to ensure our prevention messages are aligned and focused on hope, resiliency, and recovery. Future efforts: As Margy mentioned on Wednesday?s call, 2015 mortality data is expected to be released in December and we will plan to re-convene at that time as well as begin to think about proactive messaging as John proposed on the call. With sincere appreciation, Colleen Colleen Carr. MPH Manager of Policy and Strategic Partnerships National Action Alliance for Suicide Prevention BBC 1025 Thomas Jefferson St, Washington, DC 20007 ccarr@edc.org From: Carr, Colleen Sent: Thursday, November 03, 2016 10:21 PM Subject: Action Alliance Statement in response to 4 Nov. MM WR release All, The MMWR QuickStat is live on website if you would like to see it. We are putting the ?nishing touches on the Action Alliance statement and will send that out to the full group by 9am tomorrow so folks can distribute via their communication channels. eel free to contact me with any questions. Colleen Original Appointment-nu From: Belyeu, Avery Sent: Monday, October 3 20l 6 PM To: Belyeu, Avery; 'Jane Pearson'; ?Dan Reidenberg'; 'John Draper'; Stout, Elly; 'Jack Benson?, 'Stephanie Coggin'; enecly@reingold.com; ?chorah Stone?; Carr, Colleen; 'Amy Kulp'; ?Frances Gonzalez'; 'Michael Rosen?; 'Ashley Vactor'; Jane ?l?lolland, Kristin Melnyk, Liliya; 1Crosby, Alexander 'l?ledegaard, Holly ?Paul Lauricella'; Sobottka, Linda; Gass. Jesse; ?Scanlon. Michaelle (NIHWIMH) Reed, Jerry; Padgett, Jason; Warner, Margaret (CDCJOPHSSINCHS) Cc: Zeller, Eileen Alexis O'Brien; Kurikcshu, Steve Mendelsolin Subject: Action Alliance Media Messaging Work Group Call- Potential Data Release Planning Call. When: Wednesda November 02., 2016 3:00 Phil-4:00 PM Central Time 85 Canada). Where: . No passeode needed Dear Media Messaging Workgroup, Please join a call on Wednesday, November 2nd at 4pm 1pm PT to discuss an upcoming CDC Quiekstat data release. <31 Fiie: Agenda. Media Messaging Workgroup Call. 1.2.16.pdf>> As in previous calls we will use this time to discuss the information we currently have about the data release and outline next steps For a coordinated and collaborative response. Please access the call by calling {No passeode needed]. My Best. Avery From: Belyeu, Avery Sent: 20 Mar 2017 14:55:33 +0000 To: Stone, Deborah Demello;Caraballo, Rachel;Mercy, James Gebbia;Reed, Jerry;Magdala Elly;Bird, c.rochester.edu;Zeller, Eileen (SAM John bini.com;Carr, Colleen;Ken Helm;Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Hello All, It looks like there will be a lot of great conversations on this topic at AAS. Please note there will also be a full day prenconference on this topic for state suicide prevention coordinators titled: Store Suicide Prevention Coordinator Preconference Creating and Supporting Comprehensive Community-based Suicide Prevention Programs. Presenters include: Adam Swanson ,Patricia Smith, Alan Holmlund, Richard McKeon, Eileen Zeller, Elly Stout, and Avery Belyeu. We will use the key elements outlined in the Transforming Communities paper as a foundation for this conversation. My Best, Avery From: Stone, Deborah Sent: Monday, March 20, 2017 9:38 AM To: Elaine Demello; Belyeu, Avery; Cara ballo, Rachel Mercy, James Robert Gebbia; Reed, Jerry; Magdala Labre CMoutier@afsp.org; Stout, Elly; Bird, Doreen heidi@heidibryan.com; jarrod.hindman@state.co.us; Zeller, Eileen Dr. John Harrison; gigi@gcolombini.com; Carr, Colleen Ken Norton bprice@cadca.org; Melissa Helm Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Hi Elaine, Thanks for letting the group know of your AAS presentation. On a related note, I will be presenting on our CDC technical package on Friday 4128 at 1:30 [Suite 318]. Deb From: Elaine Demello Sent: Monday, March 20, 2017 10:15 AM To: Belyeu, Avery Caraballo, Rachel Subject: RE: Action Alliance Update: Transforming Communities Paper Congratuiations on this work, everyone! I think it has been a timely and comprehensive of national and international efforts around community implementation. last year I submitted to do a workshop at AAS on Comprehensive Community Based Suicide Prevention Programs. The proposal was accepted and the workshop will be on Saturday afternoon, April 29. If any of you are attending AAS and interested in being part of that workshop, please let me know. At very minimum I would like to reference our work on this paper, if that is ok with the group. Regards, Elaine Elaine de Mello, LCSW Connect Supervisor of Training and Prevention Services NAMI NH 85 N. State Street Concord NH 03301 603-225-5359, ext 315 (office) 6503-3401062 [cell] From: Belyeu, Avery Sent: Tuesday, March 14, 2017 5:35 PM To: Caraballo, Rachel; iam2@cdc.gov; Robert Gebbia; Reed, Jerry; Magdala Labre; CMoutier@afsp.org: Stout, Elly; Bird, Doreen; heidi@heidibryan.com; Elaine Demello; ?red.hindman@state.co.us; mruhe@naccho.org; Annmarie white@urmc.rochester.edu; Eiteen.Zeller@samhsa.hhs.gov; Dr. John Harrison; gigi@gcolombini.com; Carr, Colleen; Ken Norton; law; Melissa Helm; Torguson, Kimberly Subject: Action Alliance Update: Transforming Communities Paper Dear Working Group, Thank you all for your feed back to the most recent version of the Transforming Communities paper. Your contributions were all very helpful and will result in an even stronger product. 7th Please note that the meeting this Friday, March 1 like to provide you with a few key updates: -The paper is currently being finalized which includes copy editing and graphic design work. We are on track for a late March release. II Communication leads from SPRC, the Action Alliance, AFSP, SAMHSA and CDC are working together to align our messages regarding this paper and the CDC Technical Package. As part of this process the Action Alliance is creating a communications guide that may be used by partner organizations when the Transforming Communities paper is released. We will share that with you prior to the release date so that you can participate in this unified message. I- We will convene a full group meeting in late April or early May to discuss how to maximize our collective impact on this topic. Thank you for your ongoing collaboration. If you have any questions regarding the updates listed above please don?t hesitate to reach out. My Best, Avery Avery Belyeu National Partnerships Associate National Action Alliance for Suicide Prevention will be cancelled. In lieu of a meeting we would The Education Development Center 1025 Thomas Jefferson St, Washington, DC 2000? (828) 406-4029 (Direct) - tearnfing ?335? ms From: Stone, Deborah Sent: 20 Mar 2017 15:06:02 +0000 To: Stout, Elly;E aine Demello;Belyeu, Avery;Caraballo, Rachel;Mercy, James Gebbia;Reed, Jerry;Magdala c.rochester.edu;Zeller, Eileen John bini.com;Carr, Colleen;Ken Helm;Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Sounds great and I?m not too proud to get the added 'plug? Thanks, Elly and Avery! Deb From: Stout, Elly Sent: Monday, March 20, 2017 10:58 AM To: Elaine Demello; Stone, Deborah Belyeu, Avery; Caraballo, Rachel; Mercy, James (CDCIONDIEHINCIPC) Robert Gebbia Reed, Jerry Magdala Labre CMoutier@afsp.org; Bird, Doreen heidi@heidibryan.com; jarrod.hindman@state.co.us; mruhe@naccho.org; Zeller, Eileen (SAMHSAICMHS) Dr. John Harrison; Carr, Colleen Ken Norton bprice@cadca.org; Melissa Helm; Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Hi all, As you may have heard on one of our previous group calls, SPRC is doing a ful ~day preconference for state suicide prevention coordinators on community?based suicide prevention at AAS this year Avery and Eileen will be presenting on the paper, and we will be using the 7 elements to frame the rest of the day. We're happy to plug Elaine and Deb?s sessions at the end of the preconference for folks let us know if there are other related sessions that we should mention to the state coordinators! Thanks ?E ly Ellyson Stout Director of Grantee and State Initiatives Suicide Prevention Resource Center at EDC 43 Foundry Avenue, Waltham, Ma 02453 Direct Phone: 61161842206 From: Elaine Demello Sent: Monday, March 20, 2017 10:44 AM To: Stone, Deborah Belyeu, Avery Caraballo, Rachel Mercy, James (CDCIDNDIEHINCIPC) Robert Gebbia Reed, Jerry Magdala Labrel {him} I CMoutierQafsgorg; Stout, Elly Bird, Doreen heidi@heidibryan.com; jarrod.hindman@state.co.us; Annmarie white@urmc.rochester.edu; Zeller, Eileen Dr. John Harrison Carr, Colleen ?:?trQedcorgx Ken Norton bprice@cadca.org; Melissa Helm Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Thanks, Deb-that is good to know. I will try and attend if I can. Looking forward to it! Elaine Elaine de Mello, LCSW Connect Supervisor of Training and Prevention Services NAMI NH 85 N. State Street Concord NH 03301 603-225-5359, ext 315 (office) 603-340-1062 (cell) From: Stone, Deborah Sent: Monday, March 20, 2017 10:38 AM To: Elaine Demello; Belyeu, Avery; Caraballo, Rachel; Mercy, James Robert Gebbia; Reed, Jerry; Magdala Labre; Wm; Stout, Elly; Bird, Doreen; heidi@heidibryan.com: mod.hindman@state.co.us: mruhe@naccho.orq; Annmarie white@urmc.rochester.edu; Zeller, Eileen Dr. John Harrison; Heather.Stokes@livinqworksnet; qiqi@ocolombini.com; Carr, Colleen; Ken Norton; bprice@cadca.org; Melissa Helm; Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Hi Elaine, Thanks for letting the group know of your AAS presentation. On a related note, I will be presenting on our CDC technical package on Friday 4/28 at 1:30 (Suite 318}. Deb From: Elaine Demello [mailtozedemelIo@naminh.orgl Sent: Monday, March 20, 2017 10:16 AM To: Belyeu, Avery Caraballo, Rachel Mercy, James Robert Gebbia Reed, Jerry Magdala Labrel (b?libi I Stone, Deborah CMoutier@afsp.org; Stout, Elly Bird, Doreen ; Robert Gebbia Reed, Jerry sireed@edc.orga; Magdala Labrel (bif?i I CMoutier@afsp.org; Bird, Doreen heidi@heidibryan.com; iarrod.hindman@state.co.us; mruhe@naccho.org; Annmarie white@urmc.rochester.edu; Zeller, Eileen Dr. John Harrison Heather.5tokes@livingworksnet; gigi@gcolombini.com; Carr, Colleen Ken Norton bprice@cadca.org; Melissa Helm Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Hi all, As you may have heard on one of our previous group calls, SPRC is doing a full-day preconference for state suicide prevention coordinators on community-based suicide prevention at AAS this year Avery and Eileen will be presenting on the paper, and we will be using the 7 elements to frame the rest of the day. We?re happy to plug Elaine and Deb?s sessions at the end of the preconference for folks let us know if there are other related sessions that we should mention to the state coordinators! Thanks Ellyson Stout Director of Grantee and State Initiatives Suicide Prevention Resource Center at EDC 43 Foundry Avenue, Waltham, Ma 02453 Direct Phone: 611618-2206 From: Elaine Demello Sent: Monday, March 20, 2017 10:44 AM To: Stone, Deborah Belyeu, Avery eu edc.or Caraballo, Rachel Mercy, James (CDCIONDIEHINCIPC) Robert Gebbia Reed, Jerry Magdala Labrel fbii6i I CMoutierQafsgorg: Stout, Elly Bird, Doreen Subject: RE: Action Alliance Update: Transforming Communities Paper Thanks, Deb?that is good to know. I will try and attend if I can. Looking forward to it! Elaine Elaine de Mello, LCSW Connect Supervisor of Training and Prevention Services NAMI NH 85 N. State Street Concord NH 03301 603-225?5359, ext 315 (office) 603-340-1062 [cell] From: Stone, Deborah [mailtozzaf9@cdc.gov] Sent: Monday, March 20, 201ir 10:38 AM To: Elaine Demello; Belyeu, Avery; Caraballo, Rachel; Mercy, James Robert Gebbia; Reed, Jerry; Magdala Labre; CMoutier afs .or Stout, Elly; Bird, Doreen; heidi@heidibryan.com; jarrod.hindman@state.co.us; mruhe@naccho.org; Annmarie white@urmc.rochester.edu; Zeller, Eileen Dr. John Harrison; gigi@gcolombini.com; Carr, Colleen; Ken Norton; bpricchadm; Melissa Helm; Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Hi Elaine, Thanks for letting the group know of your AAS presentation. On a related note, I will be presenting on our CDC technical package on Friday 4/28 at 1:30 [Suite 318}. Deb From: Elaine Demello Sent: Monday, March 20, 2017 10:16 AM To: Belyeu, Avery Caraballo, Rachel Subject: RE: Action Alliance Update: Transforming Communities Paper Congratulations on this work, everyone! I think it has been a timely and comprehensive of national and international efforts around community implementation. FYI, last year I submitted to do a workshop at AAS on Comprehensive Community Based Suicide Prevention Programs. The proposal was accepted and the workshop will be on Saturday afternoon, April 29. If any of you are attending AAS and interested in being part of that workshop, please let me know. At very minimum I would like to reference our work on this paper, ifthat is ok with the group. Regards, Elaine Elaine de Mello, LCSW Connect Supervisor of Training and Prevention Services NAMI NH 85 N. State Street Concord NH 03301 603~225?5359, ext 315 (office) ens?3404062 (cell From: Belyeu, Avery Sent: Tuesday, March 14, 201? 5:36 PM To: Caraballo, Rachel; law; Robert Gebbia; Reed,Jerry; Magdala Labre; Stout, Elly; Bird; Doreen; heidi@heidibryan.com; Elaine Demello; iarrod.hindman@state.co.us; mruhe@naccho.org; Annmarie white@urmc.rochester.edu; Eileen.Zeller@samhsa.hhs.gov; Dr. John Harrison; gigi@gcolombini.com; Carr, Colleen; Ken Norton; bpricchadcaorg; Melissa Helm; Torguson, Kimberly Subject: Action Alliance Update: Transforming Communities Paper Dear Working Group, Thank you all for your feed back to the most recent version of the Transforming Communities paper. Your contributions were all very helpful and will result in an even stronger product. Please note that the meeting this Friday, March 17th will be cancelled. In lieu of a meeting we would like to provide you with a few key updates: IThe paper is currently being finalized which includes copy editing and graphic design work. We are on track for a late March release. 0 Communication leads from SPRC, the Action Alliance, AFSP, 5AMHSA and CDC are working together to align our messages regarding this paper and the CDC Technical Package. As part of this process the Action Alliance is creating a communications guide that may be used by partner organizations when the Transforming Communities paper is released. We will share that with you prior to the release date so that you can participate in this unified message. I We will convene a full group meeting in late April or early May to discuss how to maximize our collective impact on this topic. Thank you for your ongoing collaboration. If you have any questions regarding the updates listed above please don?t hesitate to reach out. My Best, Avery Avery Belyeu National Partnerships Associate National Action Alliance for Suicide Prevention The Education Development Center 1025 Thomas Jefferson St, Washington, DC 20007 {828) 406-4029 (Direct) Learning SW transforms SPRC lives. From: Zeller, Eileen Sent: 21 Mar 2017 12:17:52 +0000 To: Elaine Demello;Stone, Deborah Avery;Caraballo, Rachel;Mercy, James Gebbia;Reed, Jerry;Magdala Elly;Bird, c.rochester.edu;Dr. John Ha Colleen;Ken Helm;Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper I?ll try to attend both presentations. From: Elaine Demello Sent: Monday, March 20, 2017 10:44 AM To: Stone, Deborah Belyeu, Avery; Caraballo, Rachel; Mercy, James Robert Gebbia; Reed, Jerry; Magdala Labre; CMoutier@afsp.org; Stout, Elly; Bird, Doreen; heidi@heidibryan.com; jarrod.hindrnan@state.co.us; mruhe@naccho.org; Zeller, Eileen Dr. John Harrison; gigi@gcolombini.com; Carr, Colleen; Ken Norton; bprice@cadca.org; Melissa Helm; Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Thanks, Deb?that is good to know. I will try and attend if I can. Looking forward to it! Elaine Elaine de Mello, LCSW Connect Supervisor of Training and Prevention Services NAMI NH 85 N. State Street Concord NH 03301 603-225-5359, ext 315 (office) 603?340-1062 [cell] From: Stone, Deborah (CDCJONDIEHINCIPC) Sent: Monday, March 20, 201? 10:38 AM To: Elaine Demello; Belyeu, Avery; Caraballo, Rachel; Mercy, James Robert heidi@heidibryan.com; iarrod.hindman@state.co.us; mruhe@naccho.orq; Annmarie white@urmcrochesteredu; Zeller, Eileen Dr. John Harrison; qioi@ocolombini.com; Carr, Colleen; Ken Norton; bprice@cadca.org; Melissa Helm; Torguson, Kimberly Subject: RE: Action Alliance Update: Transforming Communities Paper Hi Elaine, Thanks for letting the group know of your AAS presentation. On a related note, I will be presenting on our CDC technical package on Friday 4,08 at 1:30 (Suite 318]. Deb From: Elaine Demello Sent: Monday, March 20, 2017 10:16 AM To: Belyeu, Avery Caraballo, Rachel Mercy, James Robert Gebbia Reed, Jerry Magdala Labrel (131(6) IStone, Deborah Civioutier@ afsp.org; Stout, Elly Bird, Doreen Subject: RE: Action Alliance: Community-based Suicide Prevention Priority Group Meeting {2pm Centralfllam Pacific) Hello all, We look forward to Friday's gathering of the CBSP Priority Group at {2pm Eastern/1pm Central/11am Pacific). Based on overall response, we?ll continue to use the Weber: platform with the understanding that sometimes some members will only be available via phone. Per preferences of some members, this information is being sent both an Outlook invitation and as an email. I would highly recommend being on the platform this week as Deb Stone?s presentation will be shared on screen, but there is not a handout or attachment related to it. Attached are three items: 1. Agenda for Friday?s full priority group call 2. Assignments document 3. Last message with notes/materials from June's call The two key goals for Friday?s call are to: 1. Better understand the CDC Technical package and how it impacts this work [how is it com plementarylaligned; how is it duplicativei 2. Ensure members understand their assignments and reach a decision about how to gather in smaller groups to identify core elements/key lessons from the As always, if you have questions, concerns, or comments, please let me know. Kindly, Jason Jason H. Padgett, MPA, MSM Deputy Secretary, National Action Alliance for Suicide Prevention Manager of National Partner initiatives, Suicide Prevention Resource Center Associate Project Director, EDC Inc. Phone: 202-599-0532 Skype: jason?sprc ?Envisioning A Nation Free From the Tragic Experience of Suicide -- Do not delete or change any of the following text. Join me now in my Personal Room. JOIN WEBEX MEETING El JOIN BY PHONE 1. Call one of the following numbers: 1-617-618-2000 Audio and Web Conferencing 2. Follow the instructions that you hear on the phone: Cisco Unified MeetingPlace meeting ID: Access code: Can'tjoin the meeting? Contact support here: IMPORTANT NOTICE: Please note that this WebEx service allows audio and other information sent during the session to be recorded, which may be discoverable in a legal matter. Byjoining this session, you automatically consent to such recordings. if you do not consent to being recorded, discuss your concerns with the host or do not join the session. From: Robert Gebbia Sent: 1 Nov 2016 23:31:03 +0000 To: Padgett, Jason;Mercy, James Jerry;l Ll?ilt?l IStone, Deborah Moutier;5tout, Elly;Carr, Colleen;Belyeu, Avery Cc: Rachel Caraballo Subject: RE: Action Alliance: Community-based Suicide Prevention Priority Leadership Team {2pm Centralfllam Pacific] Thanks Jason, the agenda looks good to me. Bob Sent from my Verizon. Sumsung Galaxy sniortpiirane Original message From: "Padgett, Jason" Date: 5:40 PM To: ?Mercy, James Robert Gebbia ?Reed, erry" (bile: IDeborah Stone Christine Moutier ?Stout, Elly" ?Carr, Colleen? "Belyeu, Avery" Cc: Rachel Caraballo Subject: RE: Action Alliance: Suicide Prevention Priority Leadership Team (2pm Eastern/?113m Central! 1 1am Paci?c) Good evening all, Below is a suggested agenda for the call for this Friday at 2pm ETfl pm CT. I Staff liaison transition -Joson I Summary of EXCOM Meeting - Bob, Jim, 8.: Jerry I Option of potential next steps: I Alignment with Zero Suicide- Jerry I Alignment with CDC Technical Package? Jim I Awareness of CARFNAJDSPO lnitiative? Jerry I Getting input on elements from community stakeholders Jerry/Elly I Planning Call for November Avery Are there any other items that you would like to add to this agenda? if so, please send those agenda items to Avery Belyeu [abeiyeutf?edcorg] by COB on Thursday, November lam looking forward to connecting with you on Friday. Kindly, Jason Jason H. Padgett, MPA, MSM Center Operations Director Center for the Study and Prevention of Iniury, Violence and Suicide Phone: 202-599-0532 I Skype: jason-sprc Learning tra nsforms Cl lives. Original From: Padgett, Jason Sent: Thursday, April 28, 2016 3:26 PM To: Padgett, Jason; Mercy, James Robert Gebbia; Reed, Jerry; I (11 1(6) I Deborah Stone; cmoutier@afsp.org; Stout, Elly; Carr, Colleen; Belyeu, Avery Cc: Rachel Caraballo Subject: Action Alliance: Community-based Suicide Prevention Priority Leadership Team (2pm Eastern/1pm Pacific) when: Friday, November 4, 2016 1:00 Film-2:00 PM Central Time 3: Canada). where: Web?based video conference call (see details far below) Importance: High Got several to move, talk to all available on Friday. -- Do not delete or change any of the following text. -- Join me now in my Personal Room. Join WebEx meeting l iitvm I Join by phone 1. Call one of the following numbers: 1?517-618-2000 Audio and Web Conferencing 2. Follow the instructions that you hear on the hone: Cisco Unified Meetin Place meeting ID: Access code: Eb From: Pearson, Jane Sent: 21 Feb 201?' 20:?t6:11 +0000 To: Reed, Jerrv;Stone, Deborah Gebbia;McKeon, Richard (SAM Cc: McGowan, Angela Subject: RE: Hi Deb, This is a great idea, but I think I am calendar challenged, and will likely be in Nevada. The JAMA report today is a clear illustration of how policy can affect adolescent suicide risk: Could do the same with NSDUH APHA is in Atlanta Nov 4-8 is in Henderson Belinda Sims or Eve Reider are interested in the upstream youth suicide prevention efforts for this. Jane From: Reed, Jerry Sent: Tuesday, February 21, 2017 12:29 PM To: Stone, Deborah Robert Gebbia Pearson, Jane McKeon, Richard Cc: McGowan, Angela (OSXOASW Subject: RE: I would be interested if others are. Jerry Jerry Reed, MSW Senior Iv?ice President for Practice Leadership :5 Director, Center for the Study and Preyention of injury, Vioience and Suicide EDC 1025 Thomas Jefferson Street, Suite 700W Washington, DC 20007 (202) 5723771 (direct) (202) 223?4059 (202) 294?8132 {ceii} Learning ED transforms lives. From: Stone, Deborah Sent: Tuesday, February 21, 2017 11:32 AM To: Robert Gebbia ; Robert Gebbia ; cmoutiergtiiafsporg; Stout, Elly Chervin, Doryn Melnyk, Lili?ya Subject: Suicide Technical Package and the White Paper on a Comprehensive, Community~based Approach to Suicide Prevention Hi all, I?ve been meaning to send you this message since our phone meeting several weeks back. Attached is an example of a technical package. This one addresses child abuse neglect, but it gives you a sense of the kind of document that we are in the process of developing for suicide. As we?ve shared Deb is leading this process for us along with several other staff. I wanted all of us to be clear on what we are in the process of developing because it sounds like what we are talking about in terms of a white paper could be similar. Our timeline for this is longer than that for the white paper, but I think, and Deb please correct me if I?m wrong, the bulk ofthe writing for the suicide technical package will be undertaken this summer. We released the attached technical package on child abuse neglect about a month or so ago as well as one addressing sexual violence. So far they have been received very well. If you have am}l questions please let me know. Best, Jim From: Crosby, Alexander (CDCJONDIEHINCIPCJ Sent: 15 Dec 2017 10:05:44 -0500 To: Brummett - CDPHE, Sarah Cc: Hindman - CDPHE, Jarrod;Betz, Marian;cc: Runyan, CarotAllen, Michael;cc: Kyle Brown - GovOffice;5tone, Deborah Natalie J. Peter M. wrote: Greetings: You are quite welcome. it was a very 8: important set of visits. One consideration that I had was the involvement of the faith-based organizations. I think that group was mentioned at all three locations but I only recall 1 representative which was at the El Paso site. I was wondering about making sure that others such as Ms Warren Mr Bretz are still involved. Alex From: I-Iindman - CDPHE, Jarrod Sent: Monday, December I l, 2017 5:44 PM To: Sarah Brtunmett - CDPHE Gutierrez, Peter M. gov> {PetenGutierrezt??vagov? Brian Turner ; Quinlan, Kristen {Kt luinlangwedcorg}; Caine, Eric Subject: Thank you! Hello everyone Thank you for spending so much of your valuable time with us last week to visit Colorado Springs, Pueblo and Fort Collins. It was a big commitment and I hope you found the meetings to be informative and valuable. I feel like we achieved our goals of learning about each community, starting the process of building partnerships, and informing each community about the CNC. There is a great deal of work in front of us, but this was a great ?rst step. I have followed-up with the community leaders that helped me organize last week and have shared a link to the data dashboard, the technical package, the transforming communities document, Alex and erry's slides, info on the May 2018 RTI, and Kristen's inventory document with each community. I also promised that we'd share meeting notes and next steps and schedule a follow?up call with each community in the next couple of weeks. We will share notes with everyone once they are all complete. Larimer County partners already developed and sent out a survey to all attendees (you may have received that already), and Emily is helping craft a survey for El Paso and Pueblo. We will share those results as well. next steps for the CNC steering team: - Follow-up with local partners - CDC Foundation Proposal - ID local leadership groups and key partners in each community - ID priorities and common vision across counties - Develop implementation strategies andx?or menu of strategies Formulate evaluation processes Develop plan for ?delity, data collection, reporting - Develop sustainability plan Some of these are long-term of course, but it's what Ijotted down during our debrief on Wed afternoon. Let me know what follow?up questionsfconcerns you have and thank you again to everyone that traveled to each community. Thank you also to everyone that drove. Finally, thanks for getting up so early on Tuesday and Wednesday, and thanks for putting in a 12?hour day on Tuesday! Jarrod Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch El 303.692.2539 303.691.7901 4300 Chery Creek Drive South. Denver CO 80246 iarrod.hindman@state.eo.us From: Mercy, James (CDCIONDIEHJNCIPC) Sent: 24 May 2018 08:41:09 -0400 To: Robert Gebbia;Belyeu, Avery;Reed, Jerry;5tone, Deborah Elly;Carr, I{Zolleen;Christine Moutier;Me issa Helm Subject: Re: Transforming Communities Priority 5.23 Leadership Call: Next Steps 18 from 3-4 works best for me as well. 6f15 won?t work for me. From: Robert Gebbia Date: May 24, 2018 at 7:34:34 AM EDT To: Belyeu, Avery Reed, Jerry Mercy, James (CDCIONDIEHKNCIPC) Stone, Deborah (CDCIONDIEHINCIPC) Stout, Elly Carr, Colleen Christine Moutier Melissa Helm Subject: Re: Transfonning Communities Priority 5.23 Leadership Call: Next Steps Avery, Good call yesterday, thanks. Best date and time for me is an 8 from 3 to 4 pm. I?m traveling on 6/15, but should be able to join the call from 2 to 3 pm. The other times won't work for me. Best regards, Bob Sent From my Verizon. Samsung Galaxy sma-irlphone Original message From: ?Belyeu, Avery? Date: 5:?23f18 5:41 PM To: "Reed, Jerry" Robert Gebbia ?Mercy, James "Stone, Deborah "Stout, Elly" "Carr, Colleen" Christine Moutier, Melissa Helm Subject: Transforming Communities Priority 5.23 Leadership Call: Next Steps Hello All, It was a pleasure connecting with you all today. Thank you for a generative call. Below is an outline of next steps: 0 Bob, Deb, and Jerry will present the idea of a day- long "academy? to the Colorado National Collaborative and report back to this group regarding the outcome of that conversation. This event would focus on presenting currentlv existing resources including the CDC Technical Package, the Transforming Communities Paper, implementation tools from partner organizations SPRC) and as well as relevant data. I Ongoing work with these partners could provide feedback regarding current tools and help to answer the questions: Are additional tools or resources needed? Do existing tools need to be adapted to better meet the needs of the field? I Any future ?stage 2? efforts in other locations could build on what is learned through this work in Colorado. 0 If the decision is to move forward with an "academy" the Secretariat will create an outline of possible structure and assess the potential cost. As discussed we want to meet again in a few weeks to keep these conversations moving forward. Please review the days and times listed below and reSpond with your availability: - Friday, June 15: 9?10am ET 0 2?3pm ET - Monday, June 18: llam-12pm ET 0 3pm 4pm ET Thank you all for your participation in this call and for helping to identify immediate next steps. i look forward to speaking again in a few weeks. Kindly, Averv Averv Belveu National Partnerships Associate National Action Alliance for Suicide Prevention The Education Development Center (EDC) 1025 Thomas Jefferson St, Washington, DC 2000? (828} 4064029 {Direct} Learning GI) ED transforms SPRC lives. From: Stone, Deborah Sent: 24 May 2018 12:59:0? +0000 To: Robert Gebbia;Belyeu, Avery;Reed, Jerry;Mercy, James Elly;Carr, Colleen;Christine Moutier;Melissa Helm Subject: RE: Transforming Communities Priority 5.23 Leadership Call: Next Steps Monday times work best for me. Thanks! Deb From: Robert Gebbia Sent: Thursday, May 2d, 2018 7:33 AM To: Belyeu, Avery Reed, Jerry; Mercy, James Stone, Deborah (CDCXONDIEHXNCIPC) Stout, Elly Carr, Colleen; Christine Moutier Melissa Helm Subject: Re: Transforming Communities Priority 5.23 Leadership Call: Next Steps Avery, Good call yesterday, thanks. Best date and time for me is or 18 from 3 to 4 pm. I'm traveling on or 15., but should be able to join the call from 2 to 3 pm. The other times won't work for me. Best regards, Bob Sent from my Verizon. Samson; Lii-Iltmy srnuriphone Original message From: "Belyeu, Avery" Date: 5f23f18 5:41 PM To: "Reed, Jerry" Robert Gebbia "Mercy, James {jm?cdoeov}, ?Stone, Deborah ?amrfr'zcdogove, "Stout, Elly" siestoutgriiedcergir. "Carr, Colleen? Christine Moutier Melissa Helm {MHelmit?afsp.org> Subject: Transforming Communities Priority 5.23 Leadership Call: Next Steps Hello All, It was a pleasure connecting with you all today. Thank you for a generative call. Below is an outline of next steps: - Bob, Deb, and Jerry will present the idea ofa day long ?academy? to the Colorado National Collaborative and report back to this group regarding the outcome of that conversation. - This event would focus on presenting currently existing resources including the CDC Technical Package, the Transforming Communities Paper, implementation tools from partner organizations SPRC) and as well as relevant data. I Ongoing work with these partners could provide feedback regarding current tools and help to answer the questions: Are additional tools or resources needed? Do existing tools need to be adapted to better meet the needs of the field? II Any future "stage 2" efforts in other locations could build on what is learned through this work in Colorado. I if the decision is to move forward with an "academy" the Secretariat will create an outline of possible structure and assess the potential cost. As discussed we want to meet again in a few weeks to keep these conversations moving forward. Please review the days and times listed below and respond with your availability: - Friday, June 15: 9-10am ET 2-3pm ET - Monday, June 18: Ham-12pm ET 0 3pm~ 4pm ET Thank you all for your participation in this call and for helping to identify immediate next steps. I look forward to speaking again in a few weeks. Kindly, Avery Avery Belyeu National Partnerships Associate National Action Alliance for Suicide Prevention The Education Development Center 1025 Thomas Jefferson St, Washington, DC 20007 (828) 406-4029 (Direct) Learning $54 transforms SPRC lives. From: Reed, Jerry Sent: 25 May 2018 01:46:28 +0000 To: Stone, Deborah Gebbia;Belyeu, Averijercy, James Elly;Carr, Colleen;Christine Moutier;Melissa Helm Subject: RE: Transforming Communities Priority 5.23 Leadership Call: Next Steps All proposed times work for me. Thanks. Jerry Jerry Reed, MSW Senior Vite President for Practice Leadership Suicide, Violence 8: Injury Prevention Portfolio Lead National Action Alliance for Suicide Prevention Executive Committee Member 202-572-3771l0l I 202494-8132 (M) I 2022234059 Education Develo ment Center Inc. Education Development Center From: Stone, Deborah Sent: Thursday, May 24, 2018 8:59 AM To: Robert Gebbia Belyeu, Avery; Reed, Jerry Mercy, James Stout, Elly,- Carr, Colleen Christine Moutier; Melissa Helm Subject: RE: Transforming Communities Priority 5.23 Leadership Call: Next Steps Monday times work best for me. Thanks! Deb From: Robert Gebbia Sent: Thursday, May 24, 2013 7:33 AM To: Belyeu, Avery Reed, Jerry Mercy, James Stone, Deborah Stout, Elly Carr, Colleen Christine Moutier Subject: Re: Transforming Communities Priority 5.23 Leadership Call: Next Steps Avery, Good call yesterday, thanks. Best date and time for me is 5/18 from 3 to 4 pm. I'm traveling on 6/15, but should be able to join the call from 2 to 3 pm. The other times won't work for me. Best regards, Bob Sent from my lv'erizon, Samsung Galaxy smartphone Original message From: "Belyeu, Avery" Date: 5f23f18 5:41 PM To: "Reed, Jerry" Robert Gebbia "Mercy, James <'am2 cdc. ova, "Stone, Deborah "Stout, Elly" , "Carr, Colleen" Christine Moutier Melissa Helm Date: 5/23/18 5:41 PM To: "Reed, Jerry" Robert Gebbia "Mercy, James , "Stone, Deborah "Stout, Elly" "Carr, Colleen" Christine Moutier Melissa Helm Subject: Re: Transforming Communities Priority 5.23 Leadership Call: Next Steps Avery, Good call yesterday, thanks. Best date and time for me is 6/18 from 3 to 4 pm. I'm traveling on 6/15, but should be able to join the call from 2 to 3 pm. The other times won't work for me. Best regards, Bob Sent from my Verizon, Samsung Galaxy smartphone Original message From: "Belyeu, Avery" Date: 5/23/18 5:41 PM To: "Reed, Jerry" Robert Gebbia "Mercy, James "Stone, Deborah "Stout, Elly" "Carr, Colleen? Christine Moutier Melissa Helm Subject: RE: Update Regarding New CDC Report on Suicide by Occupation Thanks Brad, I appreciate it. Thanks, Stephanie Stephanie Coggin VP, Communications Marketing American Foundation for Suicide Prevention 120 Wall Street floor New York, NY 10005 T: 212.363.3500 ext. 2027 C: 9113183132 you're TALK concerned about and let them 5 know y0u ca re. SA LIVES 7' mp my?l?al?mn From: Bartholow, Brad Sent: Tuesday, June 28, 2016 10:22 AM To: Stephanie Coggin Subject: RE: Update Regarding New CDC Report on Suicide by Occupation Good morning Stephanie, I'll check with our Communications and Policy Teams. I?ll let you know. Thankg Brad From: Stephanie Coggin Sent: Tuesday, June 23, 2016 9:49 AM To: Bartholow, Brad Subject: RE: Update Regarding New CDC Report on Suicide by Occupation Thank you so much! I think it would be helpful so you have others able to support you right when the report is released. Thanks, Stephanie Stephanie Coggin VP, Communications 8; Marketing American Foundation for Suicide Prevention 120 Wall Street I29th floor New York, NV 10005 T: 212.363.3500 ext. 202? C: 917.318.3132 youte concerned about and let them know you care. mambo-roll Emorxfialt?nan-n From: Bartholow, Brad (CDCIONDIEHINCIPQ Sent: Tuesday, June 23, 2016 11:4? AM To: Stephanie Coggin Subject: RE: Update Regarding New CDC Report on Suicide by Occupation Hi again Stephanie, Our communications team lead is attempting to get clearance to release the em ba rgoed report to you. Unfortunately, our key POCs are off site today, so we are hoping that they will check their e-mail sometime soon and grant permission. Thanks, Brad From: Stephanie Coggin [mailto:SCoggin@afsporg] Sent: Tuesday, June 28, 2015 10:31 AM To: Bartholow, Brad Subject: FW: Update Regarding New CDC Report on Suicide by Occupation Hi Brad With Deb out through Thursday, is this something that you could help us with? Thanks, Stephanie Stephanie Coggin VP, Communications 81 Marketing American Foundation for Suicide Prevention 120 Wall Street floor New York, NY 10005 T: 212.363.3500 Ext. 2027 C: 9113183132 youre concerned about and let them know you care. magnum-mm lspoeg?AISnanv-n From: Stephanie Coggin Sent: Tuesday, June 23, 2016 9:43 AM To: Deborah Stone Cc: Alexis O'Brien Subject: RE: Update Regarding New CDC Report on Suicide by Occupation Hi Deb ?Thank y0u for the heads up. This is important news. Would this be a report that you could share under embargo by tomorrow? I'd like to give our AFSP team an opportunity to be supportive with a statement or media inquiries. Copying our PR Director Alexis O'Brien too. Thanks, Stephanie Stephanie Coggin VP, Communications 3: Marketing American Foundation for Suicide Prev-ention 120 Wall Street 29th floor New York, NV 10005 T: 212.363.3500 ext. 2027 C: 9113133132 you're concerned about and let them know you care. mum "qu'L IIJIZ 7' ?r""'ill'lr l?lbOrKJTAIf-m Lk? From: Zeller, Eileen Sent: Tuesday, June 28, 2016 8:53 AM To: Belyeu, Avery; Pearson, lane Dan Reidenberg; John Draper; Stout, Elly; Jack Benson; Stephanie Coggin; eneely@reingold.com; Stone, Deborah Carr, Colleen; Weber, Mark Amy Kulp; Cheryin, Doryn; Frances Gonzalez; Michael Rosen; Ashley Vactor; Pearson, Jane Holland, Kristin Melnyk, Liliya Subject: RE: Update Regarding New CDC Report on Suicide by Occupation Thank you! CDC Colleagues: We look forward to reading this. From: Belyeu, Avery Sent: Monday, June 27, 2016 5:49 PM To: Pearson, Jane (NIHINIMHI Zeller, Eileen Dan Reidenberg; John Draper; Stout, Elly; Jack Benson; Stephanie Coggin; eneel Stone, Deborah Carr, Colleen; Weber, Mark Amy Kulp; Chewin, Doryn; Frances Gonzalez; Michael Rosen; Ashley Vector; Pearson, Jane Holland, Kristin Melnyk, Liliya Subject: Update Regarding New CDC Report on Suicide by Occupation Dear Media Messaging Workgroup, On the Media Messaging Workgroup call on Monday, June 20th, Deb Stone shared information about an upcoming article in MMWR. Please see the information below regarding the upcoming release of the article on June, 30th, including how to join the conversation after the release date and who to contact for more information. My Best, Avery In the spirit of continued coordination and information sharing, I wanted to let you know in advance about an upcoming article in MMWR which will be titled Suicide by Occupation 17 States, 2012. This article will be released on Thursday, June 30, 2015 at 1 pm ET. The data have been pulled from the National Violent Death Reporting System, and the report analyzes suicide deaths for those over the age of 16 by sex and occupation. The key findings from the report {which I unfortunately can?t share outside the agency yet] will include the highest rates of suicide by occupational categories. These findings can help employers and suicide prevention professionals know who may need to be reached by suicide prevention activities. I appreciate you keeping this information about this article within your organization until the report is officially released (Thursday, June 30, 2016 at 1 pm ET), but hope you will consider joining the conversation after the release date by: I Sharing a message on social media: 0 New CDC report analyzes highest suicide rate by occupation and sex. #VetoVioIence 0 Results from new CDC report can help target suicide prevention work to certain occupations. #Veto?v'iolence II Forwarding the upcoming partner announcement through email I Sending questions about the report to dvpinquiries@cdc.gov Thank you for all of your work to prevent suicides and help people live their lives to their fullest potential! Avery Belyeu National Partnerships Associate National Action Alliance for Suicide Prevention The Education Development Center 1025 Thomas Jefferson St, Washington, DC 2000? {823) 406-4029 (Direct) Learning ttansforms lives. e57 From: Gutierrez, Peter M. Sent: 30 Nov 2017 00:19:37 +0000 To: Hindman - CDPHE, Jarrod;Sarah Brummett - Turner;Ethan Jamison Kirk;Emily Fine - Becker;Gebbia, Robert;5choenbaum, Michael [C];McKeon, Richard Alexander KristemCaine, Eric D. MD;Reed, Jerry;White, AnnMarie;Conwell, Yeates;Smith, Lakeesha {Shakiylal Cc: Kyle Brown - GovOffice;Betz, MariamAllen, Michael;Runyan, Carol Subject: RE: Detailed agendas Thanks, Jarrod, the agendas look fine to me. Hope the larger group in Larimer ounty doesn't complicate things too much for us, but it"s great there is so much interest! Cheers, Pete Peter M. Gutierrez, Clinicalr?Research -, ROCKY MOUNTAIN MIRECC Of?ce: 303?329-4408 ext 30] Professor University of Colorado School of Medicine, Department of lcomeasgx From: Hindman - Jarrod Sent: Wednesday, November 29, 2017 4:32 PM To: Sarah Brummett - CDPHE Gutierrez, Peter M. Brian Turner Ethan Jamison - CDPHE Bol, Kirk Emily Fine - CDPHE Barb Becker Gebbia, Robert Schocnba'am, Michael (NIHXNIMH) McKeon, Richard Crosby, Alexander Quinlan, Kristen Caine, Eric D. MD Reed, Jerry White, AnnMarie Conwell, Yeates Smith, Lakeesha {Shakiyla} (CDCIONDIEI Cc: Kyle Brown - GovOftice Betz, Marian Allen, Michael Runyan, Carol Subject: Detailed agendas Attached. Let me know what I've missed andror what needs to be amended. Alex I Shakiyla Can one of you present on the Technical Package? Jerry} Bob Can one of you present on the Transforming Communities doc?.l Ethan Kirk - note the data presentation section and let me know if anything needs to be tweaked. FYI. . . I just sent these to local partner leaders as well, so there may be some adjustments. I'll keep you posted if so. Thank you. Jarrod Jarrod Hindman, MS Deputy Chief Violence and In] my Prevention-Mental Health Promotion Branch 303.692.2539 303.69l.790] 4300 Cherry Creek Drive South. Denver CO 80246 ierred.hindman?lstateeous Issue Keywords Terms from Original request to cull NUIX output Date Range (Vital Signs AND Suicide) OR (MMWR AND Suicide) Or (Suicide AND Dickey} Dickey or MMWR (note it seems pointless to use "suicide for Or ?Technical Package? NA (Vital Signs AND Suicide] DR (M MWR AND Suicide) OR (Suicide and Technical Package) OR Dickey To:!Frorn: Mail Boxes Searched From: Sent: To: Subject: Dear National Rifle Association 2 Apr 2018 15:15:02 -0600 Duncan, James Brad Exclusively ForJames - NRA Member vv ll-i NATIONAL RIFLE ASSOCIATION MEMBERSHIP . 'l Every time NRA has a fight, you dedicate your membership dues and donations to our cause. YOU are the reason why NRA wins and why we have our guns today. That?s why I want to thank you by giving you membership bene?ts that are worti far more than you pay in dues. To tap the fantastic value of your NRA membership benefits, visit our website, today. Thanks again for your friendship and support of NRA. Yours In Freedom, Wayne LaPierre Executive Vice President National Rifle Association Waples Miil Rd Fairfax, VA. 22030 Please do not reply to this e?mail. Unsuhscribe Contact Us Thank you. From: National Rifle Association Sent: 11 Mai; 2018 10:29:51 0600 To: Duncan, James Brad Subject: Lt. Colonel Oliver North Poised to Become NRA President VIEW IN BROWSER NATIONAL RIFLE ASSOCIATION Lt. Colonel Oliver North Poised To Become NRA President exciting .rrevais: for MR4 member-"s since Charlton Bea-zine of (For tri?zssooiatfon; E?Vewe LaPierre said. (DALLAS, TX) Lt. Colonel Oliver North, USMC (Ret) will become President of the National Rifle Association of America within a few weeks, a process the NRA Board of Directors initiated this morning. ?This is the most exciting news for our members since Charlton Heston became President of our Association," said NRA Executive Vice President and CEO Wayne LaPierre. ?Oliver North is a legendary warrior for American freedom, a gifted communicator and skilled leader. In these times, I can think of no one better suited to serve as our President.? North said he was eager to take on this new role as soon as his business affairs were put in order. North is retiring from Fox News, effective immediately. am honored to have been selected by the NRA Board to soon serve as this great organization?s President," North said. appreciate the board initiating a process that affords me a few weeks to set my affairs in order, and I am eager to hit the ground running as the new NRA President." The NRA Board acted quickly to begin the process for North to become President, after former NRA President Pete Brownell announced this morning that, in order to devote his full time and energy to his family business, he had decided not to seek election to a second term. In his letter to the Board, Brownell wholeheartedly endorsed North for President. ?Discussing this with Wayne LaPierre," Brownell said in the letter, ?he suggested we reach out to a warrior amongst our board members, Lieutenant Colonel Oliver North, to succeed me. Wayne and feel that in these extraordinary times, a leader with his history as a communicator and resolute defender of the Second Amendment is precisely what the NRA needs. After consulting with NRA-ILA Executive Director Chris Cox, First Vice President Childress and Second Vice President Meadows, I can report there is extraordinary support for Col. North." ?Pete has served the NRA with great courage and distinction,? LaPierre said. am grateful that he joined me in enthusiastically recommending Oliver North to the Board of Directors." After the announcement, NRA First Vice President Richard Childress informed the board that he had multiple commitments in the next several weeks and was unable to be immediately available to serve as interim President. The Board then selected Second Vice President Carolyn Meadows to serve as its interim President. Meadows will step aside in a few weeks, when Lt. Colonel North is prepared to take on his new role as NRA President. LaPierre congratulated the NRA Board for its action. ?The board acted quickly and with great vision," LaPierre said. ?Oliver North is, hands down, the absolute best choice to lead our NRA Board, to fully engage with our members, and to unflinchingiy stand and fight for the great freedoms he has defended his entire life.? ?Oliver North is a true hero and warrior for freedom,? LaPierre said, ?and NRA members are proud to stand with him.? National Ri?e Association of America - 11250 Wapies Mill Rd Fairfax, VA. 22030 Please do not reply to this email. Thank you From: National Rifle Association Sent: 23 Apr 2018 11:31:27 -0600 To: Dunca n, James Brad Subject: NRA Board of Directors Loses Beloved Member VIEW lN BROWSER {In} "m NATIONAL RIFLE ASSOCIATION ?hj? . R. Lee Ermey Passes Away at 74 By Philip Schreier, Senior Curator, NRA Museums - Monday, April 16, 2018 The NRA Board of Directors lost one of its beloved members on Sunday, April 15, 2018 when R. Lee Ermey of Palmdale, Calif, passed away from complications of pneumonia at the age of Known to millions of fans as "Gunny," Ermey was a native of Emporia, Kansas. He enlisted in the United States Marine Corps at the age of 17 and served for 1 1 years, 14 months of which were spent in Vietnam. It was Stanley Kubrick?s 1987 film, Full Metal Jacket, that earned him lasting fame and the sobriquet "Gunny" for his stunning performance as Marine Corps Drill Instructor Gunnery Sergeant Hartman. Although he was medically discharged from the Marine Corps as a Staff Sergeant, he was recalled from retirement and of?cially promoted to Gunnery Sergeant and then immediately retired at the rank for which everyone came to know and love him. Ciick Here To Continue National Rifle Association of America - 11250 Waples Mill Rd - Fairfax. VA. 22030 Pleaee do not reply to this a-mail. Manage Your Email Lists Contact Us Thank you From: National Rifle Association Member Support Sent: 4 Apr 2016 08:35:55 To: Holcomb, Daniel (Dan) Subject: The gift you selected with your "m NATIONAL RIFLE Dan Holcomb, From all of us at NRA. I want to send my most sincere thanks for your decision to join our NRA family and our ?ght for freedom. Over the past few weeks, we've heard from patriots and leaders like you from across the nation. all committed to one single goal to protect our Second Amendment rights and all our freedoms in the most important election our nation has ever faced. In fact. so many new members have joined our ranks in the past few days that we've run short of the bag that we promised when you joined. Don?t worry more are on the way! And I know you'll enjoy this symbol of your leadership and commitment for years to come. But in the meantime. it may take a few weeks to get your bag to you. and ask for your patience. Your decision to join NRA has given me new hope and encouragement that we will win this election and that we will keep our guns and all the precious freedoms that our Constitution guarantees. It's a tremendous honor to have you on our team. I look forward to sending your bag just as soon as our new shipment arrives. and I look forward to working closely with you this year. Yours in Freedom. Wayne LaPierre Executive Vice President National Rifle Association of America National Ri?e Association of America 11250 Waples Mill Road. Fairfax. VA 22030. United States Contact ll;- Click Here To Unsuoscrihc- From: Sent: To: Subject: Attachments: Importance: 10 Apr 2017 11:03:08 -0400 Sarge, Ionathan (CTR) Your Certificate Id Card - Electronic copy' JONATHAN E. Safety Officer.pdf High THE NATIONAL RIFLE ASSOCIATION OF AMERICA CERTIFIES THAT IO NATHAN E. SARGE Hers me! {he requirements by the Nun'rmu! Ri?e QfAmel-?iea and here/{1* desigmned cm NRA RANGE SAFETY OFFICER qu ?m 10h}: c. FRAZER. SECRETARY NATIONAL RIFLE ASSOCIATION Valid through: 5I31I201B From: Sent: To: Subject: Attachments: Importance: 10 Apr 2017 11:02:14 -O400 Sarge, jonathan (CTR) Your Certificate Id Card - Electronic com:l JONATHAN E. High THE NATIONAL RIFLE ASSOCIATION OF AMERICA CERTIFIES THAT IO NATHAN E. SARGE Has success?t/ly me! {he requirements esmb/isl?zed by the Nun'rmuf Ri?e Associcm'nn and is here/7y desigmned cm NRA INSTRUCTOR and is emf/rocked to leach basic courses: Certi?ed Pistol Personal Protection In The Home Personal Protection Outside The Home RIFLE ASSOCIATION 333: Wic?? If?. Joi?u c. FRAZER. SECRETARY Valid through: 5.8112013 From: Sent: To: Subject: Attachments: Importance: 12 Sep 2016 19:08:59 0400 Wallace, Joshua Your Certificate Id Card - Electronic copy' JOSHUA ANDREW WALLACE-Instructorpdf High THE NATIONAL RIFLE ASSOCIATION OF AMERICA CERTIFIES THAT JOSHUA ANDREW WALLACE Has success?II/y {he} established by the Natiom? Ri?e Associcm'nn (#14 mcricu and is here/{1' cm NRA INSTRUCTOR and is cmf/rorizcd to leach thefOHm-ving basic courses: Certi?ed Pistol Certi?ed Ri?e Certi?ed Shotgun ha? 1 I 10161 C. FRAZER SECRETARY NATIONAL RIFLE ASSOCIATION Valid through: 913012013 From: Sent: To: Subject: Attachments: Importance: 12 Sep 2016 19:08:15!r 43400 Wallace, Joshua Your Certificate Id Card - Electronic com:l JOSHUA ANDREW High National Rifle Association Credentials JOSHUA ANDREW WALLACE instructor Certi?ed Pistol? Certi?ed Rillu Certilied Shotgun 2' n3 Expires: 09:30:20" rSecr ct ire-?Irl ior LBN Enforcement LJI NRA Securliy Officer Courses. mam poog. 'noii uo spuedap slatoous pue ?sun? 1o 311nm aidoed Io mow 'anum se rinunururoo out or so new se leap nori Vi 141er esoui 01 ritruieleri eroum aul ?ulluasaJda: IOJ. Iililqisuodsai sameo preo sun to uorssassod :ueuig com-Lemon .3 Joetuoo 1 ENDORSED MEMBER BENEFITS insurance created just for certified firearms instructors As a NRA Certified Firearms Instructor you have access to benefits specifically designed for you. The NRA knows firearms trainers have special insurance needs. That's why they endorse Firearms instructor Pius Liability Insurance to protect certified instructors, training counselors and coaches who provide firearms training. Protect yourself and your assets before you conduct your first training. From: Sent: To: Subject: Attachments: Importance: 12 Sep 2016 19:08:41 43400 Wallace, Joshua Your Certificate Id Card - Electronic copy' JOSHUA ANDREW High National Rifle Association Credentials JOSHUA ANDREW WALLACE instructor Certi?ed Pistol? Certi?ed Rillu Certilied Shotgun 2' n3 Expires: 09:30:20" rSecr ct ire-?Irl ior LBN Enforcement LJI NRA Securliy Officer Courses. mam poog. 'noii uo spuedap slatoous pue ?sun? 1o 311nm aidoed Io mow 'anum se rinunururoo out or so new se leap nori Vi 141er esoui 01 ritruieleri eroum aul ?ulluasaJda: IOJ. Iililqisuodsai sameo preo sun to uorssassod :ueuig com-Lemon .3 Joetuoo 1 ENDORSED MEMBER BENEFITS insurance created just for certified firearms instructors As a NRA Certified Firearms Instructor you have access to benefits specifically designed for you. The NRA knows firearms trainers have special insurance needs. That's why they endorse Firearms instructor Pius Liability Insurance to protect certified instructors, training counselors and coaches who provide firearms training. Protect yourself and your assets before you conduct your first training. From: Sent: To: Subject: Attachments: Importance: 10 Apr 2017 11:03:40 -O400 Sarge, jonathan (CTR) Your Certificate Id Card - Electronic com:l JONATHAN E. SARGE-ldCard.pdf High National Rifle Association Credentials JONATHAN E. SARGE Range Safety Officer instructor Certi?ed Pistol Personal Protection In The Home Personal Protection Outside The Home 3' 5? NRA 193?5714? 4 RE Page. Expires: 0531:2013 am at U?ilfl for LBN Enforcement ur NRA Secunty Training Courses. mam coca. 'noai 11o spuedap slatoous pue ?sun? 1o ?Alull? amood IEHM go irony-.1 'anum se filiLmiLiLuO?.) out 01 so new era leap noi esoLn 01 iitrujaleu ?unoous Broom aul ?ulluasaJda: not lililqrsuodser sameo pJeo sun to uorssessod 510'bumu?1mesunoo?uruien :ueuig ocer-tezisnt) ?urugei 1; uoneonpa Joetuoo or i ENDORSED MEMBER BENEFITS Insurance created just for certified firearms instructors As a NRA Certified Firearms Instructor you have access to benefits specifically designed for you. The NRA knows firearms trainers have special insurance needs. That's why they endorse Firearms instructor Pius Liability Insurance to protect certified instructors, training counselors and coaches who provide firearms training. Protect yourself and your assets before you conduct your first training. 0 From: Dahlberg, Linda L. Sent: 15 Jul 2018 09:16:29 -0400 To: Stone, Deborah Kristin (CDCKUNDIEHKNCIPQ Subject: A few more to approach summaries to review Attachments: 5U _Postvention - for SME review.docx, SU _Safe Reporting and Messaging About Suicide - for SME review.dock Hello Here are two more summaries to review over the next few days. For all of these, no need to do a thorough review ?just a quick scan to make sure there are no glaring mistakes or things missing that should definitely be included. Let me know if you have any questions. Thanks for your helpl Linda From: Dahlberg, Linda L. Sent: Friday, July 13, 2018 3:07 PM To: Stone, Deborah (CDCIONDIEHXNCIPCJ Holland, Kristin Subject: For Review by COB 8/17: suicide approach summaries for the implementation guidance Hello, We are in the home stretch of completing the implementation guidance for the One component of the guidance pertains to the specific approaches in the technical packages. We are down to the last 8 summaries 7 of them are specific to the suicide TP. We put these on hold until after the Vital Signs for obvious reasons! Attached are 3 short ones for your review. Lindsey is hoping to get this last batch into clearance ASAP we are up against a contract deadline with Banyan. if you could review and send any on the three attached by Tuesday COB, I?ll incorporate your changes and get them ready for clearance. The other ones that we need to finalize include: I Postvention I Safer suicide care through system change II Treatment for people at risk of suicide I Treatment for victims/survivors (which includes content across the technical packages} Please let me know if you have any questions. Thanks in advance for your help! Unda Postvention Postvention approaches are implemented after a suicide has taken place and are intended to provide bereavement support for surviving family members, friends, and other close contacts. Postvention includes debrie?ng sessions, counseling, support groups, and other activities to facilitate healing. People who have lost a friendfpeer, family member, co-worker or someone else close to them to suicide are at increased risk for suicide. Care and attention to the bereaved is important for helping reduce this risk. Strategy 1- Lassen Harms and Prevent Future Risk (Suicide) Key Objectives implementation Consmerations Sector Engagement Example Quitomes Additional Rescm rces Facilitate healing and promote healthy recovery of individuals, families, and communities bereaved by suicide Prevent suicide among surviving friends. family, andfor community members Postvention may be delivered in a variety of settings leg, schools, workplaces, community} Procedures for responding effectively to suicide and connecting survivors to community services and resources should be developed and in place prior to a death by suicide A multidisciplinary team comprised of mental health professionals, people who have previous experience surviving a suicide loss, and others involved in crisis response activities can help ensure resources are appropriately identified and in place to support survivors Postvention plans should be flexible to address a variety of circumstances and take into account both shorter- and longer?term needs Public health Education Business and Labor Healthcare Government Community organizations RedUctions in survivors? guilt, feelings of depression, and distress contagion effects related to suicide 0 suicide attempts suicidal ideation Postvention (Suicide Prevention Resource Center} approachjpostvention Postvention for College Campuses {Higher Education Mental Health Alliance] guidepdf Postvention Guide Alaska Suicide Prevention Plan Example Programs/PracticesfPolicies: - StandBy Response Service {Suicide} Example Programs StandBv Response Service {Suicide} Description: StandBv Response Service is a suicide bereavement support service. The service provides clients with face-to-face outreach and telephone support provided bv a professional crisis response team. A site coordinator then develops a customized case management plan, referring clients to other existing community services matched to their needs. The program also includes communitv education and activities with local community groups, businesses, and other organizations. Specific PopulationsISettings Kev Partners Considerations I Populationlsl: Persons I Health care I Services are available 24!? and may bereaved by a recent or past - Mental health providers be delivered in?person or by phone suicide - Community organizations Consultation and SUPPUHZ l5 0 Public health agencies available to coordinators at Standbv I Communitv RESPONSE sites 0 Program cost information is not available Additional Information I StandBv Support After Suicide Program Site Safe Reporting and Messaging About Suicide The manner in which information on a recent suicide is communicated to the public can heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion. This approach promotes prevention messaging and reporting on suicide in a way that reduces the possibilityI of suicide contagion, encourages help-seeking, and promotes evidence-based actions that can help prevent suicide. Strategy I Lessen Harms and Prevent Future Risk (Suicide) Key Obienlves implementation Considerations Sector Engagement Example Outcomes Additional Resources Increase awareness and adherence to guidelines for reporting on suicide Reduce the likelihood of suicide contagion Promote positive prevention messages Present accurate information about suicide rates and trends Use suicide prevention experts to provide accurate information on suicide risk factors, warning signs, and prevention Avoid sensationalizing suicide or referring to suicide as ?successfu "failed attempt? AVoid conveying details around the method used in the suicide Provide information in a way that avoids attributing suicide to a single cause Incorporate prevention messages and actions that can help prevent suicide Promote evidence-based solutions and prevention success stories Use stories of hope and resilience Encourage help?seekingbv Incorporating information on local resources and support Public health Media Education Government Community organizations or ?unsuccessful" or a Reductions in 0 rates of suicide 0 contagion effects related to suicide Increases in protective factors Improvements in reporting following suicide Recommendations for Reporting on Suicide - Suicide Prevention Resource Center - reporting From: Stone, Deborah Sent: 26 Mar 2018 13:06:12 +0000 To: Simon, Thomas Katherine A. Scott R. Keming Kristin Asha Z. Alexander Subject: Attachments for 10 am Attachments: MMWR WG meeting 3.26.13.docx, Suicide Vital Signs MMWR Test 3.23.18 v3.2 SK TS ds.docx, Suicide Vital Signs MMWR Text 3.19.18 v3 MRCdocx Hi Evervone, Attaching the most recent version of the MMWR with Scott and Tom?s edits incorporated. I've left in tracked changes the final things needing discussion. Also including the ore-clearance version with reviewer suggestions and a handout. Thanks, Deb Deb Stone, MSW, MPH Centers for Disease Control EMU li'i'evention National Center l'or Inning F'iovenilori and Division or vioience Prevention SUIciile, "i?ouil1 Violence Se Elrler lVlalLrearniern' Team 270,333. 39d}. ds_ton?di_cdcgov CDC's Injury Center Preventing Injuries and Violence Through Science and Action 3/26/18 Vital Signs Suicide MMWR WG Meeting Purpose: to discuss revisions based on ore-clearance draft feedback prior to clearance submission Items to discuss in article text 0 Reactions to edits generally 0 Title of MMWR efor authorship statements - Deletion of p<.01 everywhere 0 *Revision to the definition of MHP - *Reporting on treatment {mental health and substance abuse) 0 Reporting of results, vs I Discussion, first paragraph and clarification on substance abuse disorders - Other suggested changes Table comments: Table 1: Wonder if in a revised title or footnote if it needs to be revised to reflect this also includes District of not changing Suggest being clear on what these period, similar to how done in another footnote. Changing to 1999 2001 and 2014?2016 to represent first and last reporting periods, respectively. Table 2 I is an additional footnote needed on total or on the categories below to reflect why some don't add up to the overall total age, incident type) 0 1?single Suicide" made me wonder about simultaneous or related suicides by more than one person, especially given this is available in Wonder if need another category for multiple, related suicides or if the suicide category should be renamed Table 3 Typo in "release?. Is it possible to also describe what recent means? Past two week or is this quite variable? Given the broad audience of MMWR, can this be put into more simple terms? lad H-IGHUI Rev 3.25.18 v3.2 Short title: ncreasing Trends in State Suicide Rates and Contributing Circumstances among people all) years] Comment Need to edit this. Deborah M. Stone, Thomas R. Simon Ph0;? Katherine A. Fowler, Ph0;' Scott R. kegler, Keming Yuan, l'v'lii;JL Kristin M. Holland, Asha Z. Ivey-Stephenson, Ale): E. Crosby, M01 Structured abstract [2451250 words?this word count is not included in the 1800 max for the remainder] Background: Suicide rates have risen nearly 30% since 1999. Mental health problems are just one factor contributing to suicide. Examining state?level trends in suicide and other contributing circumstances can inform comprehensive state suicide prevention planning. fl Methods: Trends in age?adjusted suicide rates among people aged 210 years, by state and sex, across six consecutive three?year periods (1999?2016], were assessed using data from the National Vital Statistics System for 50 states and Washington, DC Data from the National Violent Death Reporting System, hoverindgEr'mJl states in 1015, were used to examine contributing circumstances among decedents with and without known MHP. Results: From 1999?2016, suicide rates increased significantly in 44 states, with 25 states experiencing increases of 30% or more. Rates increased signi?cantly among males and females, in 34 and 43 states, respectively. Over half of decedents did not have a known MHP. Among decedents with circumstance information, those without known MHP were more likely {all p501] than those with a MHP to have relationship problemsi?loss (45.1% vs life stressorsfloss {54.2% vs 49.7%] and recent/impending crises {32.9% vs but these circumstances were common across groups. Conclusions: Suicide rates increased significantly across most states from 1999-2015. 1various circumstances contributed to suicides among people with and without known MHP. Implications for Public Health Practice: States can use a comprehensive evidence?based public health approach to prevent suicide risk before it occurs, identify and support people at risk, prevent reattempts, and help friends/family after a suicide occurs. INTRODUCTION BACKGROUND AND PURPOSE {255,4'250 words] In 2016, nearly 45,000 suicides [agaradjustedjl occurred in the United States among people 210 years old Between 1999 and 2016, suicide rates increased across sexes, racial/ethnic groups, and urbanization levels Suicide is the 10?? leading cause of death and is one of just three leading causes that are increasing Additionally, rates of Emergency Department visits for nonfatal self-harm,a key risk factor for suicide, increased nearly 45% betWeen 2001 and 2015 Together, suicides and self-harm injuries cost the nation more than SEE-9 billion in direct medical and work loss costs The National Strategiffor Suicide PreventioniNSSP} calls for a public health approach to suicide prevention with efforts spanning across multiple levels individual, family/relationship, community, and societal]. Such an approach underscores that suicide is rarely caused by any single factor, but rather, is multi-determined. Despite the NSSP guidance, suicide prevention efforts largely focus on identifying and treating individuals with mental health problems Other contributing circumstances include social and economic problems, access to lethal means leg, substances, firearms, bridges] among people at risk, poor coping and problem- solving skills, and prior suicide attempts Expanded awareness of the additional circumstances that contribute to suicide risk apart from MHP, and action to address them, can help reach the nation?s goal of Could be interpreted that contributing circumstances are increasing as well. {[Comment [1319]: Is this still accurate? Rev 3.25.18 v3.2 40 reducing suicide rates 20% by 2025 To assist states in achieving this goal, this study analyzes state-specific trends in suicide rates, assesses the multiple contributing factors, and provides recommendations for multi?level 4 42 comprehensive suicide prevention. 43 METHODS (256,050 words} 44 Suicide rates were analyzed for people aged 210 years only, as attributions of suicidal intent in yoUnger children 45 are variable Age?specific suicide counts were tabulated based on National Vital Statistics System coded death 4s certi?cate records (international Ciassr?cotion of Diseases 10?? Revision, underlying-cause?of death codes X60- 4? X34, TRIO, Age-specific population estimates were obtained from 0.5. Census Bureauill-lational Center for 48 Health Statistics bridged?race population data releases. 49 50 National and state-level suicide rate estimates were calculated for six consecutive three-year aggregate periods 5] spanning 1999-2015. Rate estimates were age-adjusted to the 0.5. year 2000 standard population and expressed 52 per 100,000 persons per year. Age-adjusted suicide rate trends were modeled using the same three-year data 53 aggregates, employing weighted least squares regression with inverse-variance weighting. Modeled rate trends 54 are reported in terms of average annual percentage changes 55 56 Characteristics {Table 2) and circumstances (Table 3) of suicide decedents 210 years, with and without known 57 MHP, were compared in the 2? states with complete data participating in National Violent Death 58 Reporting System in 2015. defines MHP as disorders listed in the Diagnostic and Statistical 59 Manual of Mental Disorders, Fifth Edition For this study, alcohol and other substance use disorders were not 6 death certificates, coronerfmedical examiner reports (including toxicology), and law enforcement 62 reports. Decedents with and without known MHP were compared using Chi?square tests. Logistic regression to analyses estimated adjusted odds ratios with 95% confidence intervals (CI), controlling for age group, sex, and 64 raceiethnicity. as assurrs (seafood words] as The most recent overall suicide rates (representing 2014?2016] varied four?fold, from 5.9 to 29.2 6? (Montana) per 100,000 persons per year (Table 1). Across the study period, rates increased in all states, except 68 Nevada (with the 9?1 highest current suicide rate], with absolute increases ranging from +0.8 (Delaware) to +3.1 69 (Wyoming) per 100,000. Percentage increases in rates ranged from +99% (Delaware) to 67.6% (North Dakota), it) with increases more than 30% observed in 25 states. 'il ?2 Modeled suicide rate trends indicated significant increases for 44 states, as well as for the U5. overall (Table i3 By sex, modeled rate trends indicated significant increases in 34 states for males and in 43 states for females. T4 Nationally, the model-estimated AAPC for the overall suicide rate was By sex, the national AAPC was 75 +11% for males and +2.59; for females. 76 Suicide decedents without known MHP were compared to those with MHP While all is decedents were predominately male (Table 2; 75.8%} and non?Hispanic white those without known i9 MHP, relative to those with MHP, were more likeiy male (33.6% vs. 68.8%; adjusted odds ratio 95% CI 80 2.2?2.5] and racial/ethnic minorities (odds ratio range: Cl range Suicide 8 decedents without known MHP also had significantly greater odds of perpetrating homicide-suicide 2.9, 82 95% CI of firearm suicide 1.6, 95% CI and oftesting positive for alcohol 1.2, 33 95% CI Among adult decedents, 20.1% and 15.3% of people without and with MHP, respectively, [ever 34 served, or were serving,}n the 0.5. military. 2 Comment Inf"): The comment made was that it wasn't clear how we defined MHP since substance use disorders are a diagnosis in Changed this to be more strai htforward. [Comment ham]: Correct definition for military services? Rev 3.25.18 v3.2 85 Although firearms were used most often, overall decedents with known MHP were more likely to die by as suffocation (31.3 vs. 26.9%] and poisoning {19.8% vs. 10.4%] than those without knowo MHP . 3? All suicide decedents with known MHP iN=9,407} and approximately 35% without MHP had available 88 circumstances information {Table People without known MHP were less likely to have any substance abuse 89 problems 95% While two-thirds of those with known MHP had a history of mental health 90 or substance abuse treatment just over half were in current treatment. 9 [Decedents without known MHP, versus those with known lv'lHP had a significantly greater likelihood of any 92 relationship problemfloss [45.1% vs. specifically intimate partner problems {30.2% vs. 93 [115% vs. and recently perpetrating interpersonal violence vs. They 94 were also significantly more likely to have experienced other life streSSors, such as criminal-legal problems 95 vs. or eviction/loss of home vs. and they were more likely to have had a crisis within as the preceding or upcoming two Weeks [32.9% vs. Among both grDUps, the most common crises were 98 Deco-dents without known MHP had signi?cantly lower odds of recent release from any institution, but among 99 those who were recently released those without a known l?v?lHP were signi?cantly more likely to be released from a correctional facility [25.7% vs. or hospital (433% vs. 33.0%] than those with a known MHP. Among decedents with known MHP who were recently released from an institution 42.3% were IUI l02 released from facilities. [Decedents without known MHP, compared to those with were less likely to have a history of suicidal [04 ideation 95% 0:04-05) and prior suicide attempt 95% Both groups disclosed l05 suicide intent frequently, {22.4% vs. respectively] lilo Conclusions and Comments [6801?00 words] It)? From 1999?2015, 44 states saw significant suicide rate increases. Half of the states experienced increases of 30% or more. Rates increased significantly in 34 states among males and 43 states among females. Commant lzal?J]: I kept this paragraph con?ned to percentages but did add some additional aDR's in other places. Comment [15:19]: We were asked to include disclosure of suicide intent. something here like, This latter finding may indicate that the historical protective [Comment Izaf9]: Thinking to add effect of being female may be changinginto the causes of these trends is necessary 10 1' JL 1 JL ll? Researchers and practitioners regularly state that suicide is not caused by a single factor, however, the focus of II II suicide research and prevention practices, almost solely, focus on identify and treating MHP. The current study ?2 found that more than half of suicide decedents in did not have a known MHP. This group suffered more I I3 relationship problems and life stressors such as criminal-legal matters, evictionfloss of home, and recent or I I4 impending crises. This is particularly noteworthy in light of findings that suggest many suicides and attempts I IS occur with minimal deliberation I I6 Among people with MHP, two?thirds had a history of mental health andfor substance abuse treatment and over ll? half were in current treatment. This suggests that additional supports for this population are needed to keep HE them safe. This includes broader implementation of affordable and effective treatment modalities such as ?9 doctor-patient collaborative care models and cognitive-behavioral therapy. Additionally, greater access to [20 behavioral health providers, especially in underserved areas is needed, as is expansion of healthcare systems needed that integrate physical and behavioral health and that better support suicide prevention and patient Ill [22 safety, especially through care transitions 123 Study findings indicate that people with known MHP also experienced other life stressors such as joblfinancial, IE4 relationship, and/or physical health problems. These findings point to the need to both prevent the conditions Rev 315,18 v3.2 I25 associated with mental health problems in the first place and the need to support people with known MHP to decrease their risk of poor social, health, and economic outcomes These results, together, underscore the importance of comprehensive statewide suicide prevention activities I28 that address multiple factors associated with suicide. Prevention strategies may include: strengthening I29 economic supports le.g., housing stabilization policies, household financial support}; teaching coping and 130 problem-solving skills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social connectedness to increase a sense of belongingness and access to informational, tangible, 132 emotional, and social Support, and identifying and better Supporting people at risk. Other strategies include I33 creating protective environments leg, reducing access to lethal means among people at risk, creating I34 organizational and workplace policies to promote help-seeking, easing transitions into and out of Work for I35 people with MHP and other life challenges], supporting family and friends after a suicide, and assuring safe 136 reporting by the media in order to prevent suicide contagion Some states, such as Colorado, are planning l3? and implementing such a comprehensive approach to suicide prevention I38 These findings have at least three limitations. In the state-level analysis, rankings for four states (MD, MA, RI, I39 might have been impacted by large proportions of injury deaths of undetermined intent lie. decreasing I40 suicide rates), or decreased percentages of such deaths over time lie. increasing suicide rates}. Second, is not yet nationally representative, the 2? states included in the current study of the U5. I42 hopulation. Third, abstractors of data are limited to information contained in investigative reports. anon-Ha I43 Therefore, the extent of informant knowledge can impact data completeness and accuracy. Studies including in? I44 depth interviews with next~ofal50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Media Advisory Embargocd Until 1 pm. EDT Thursday, June 7, 2018 Contact: CDC Media Relations (404) 639-3286 CDC Telebrie?ng: New Vital Signs Report Nearly 45 .000 deaths by suicide in 2016: What can be done to prevent suicides? What According to the latest Vital Signs report. suicide increased in nearly every US. state from 1999 through 2016. In addition, suicide rates increased more than 30%] in half of states. Mental health conditions are often seen as the cause of suicide, but suicide is rarely caused by any single factor. In fact. many people who die by suicide are not known to have a diagnosed mental health condition at the time of death. Who CDC Principal Deputy Director Anne Schuchat. MD. RADM, USPHS When Thursday, June 7. at 12:00 p.111. ET Dial-In Media: Non-Media: 800-369-1605 INTERNATIONAL: 1-630-395-0331 PASSCODE: CDC Media Important Instructions If you would like to ask a question during the call, press *1 on your touchtone phone. Press *2 to withdraw your question. You may queue up at any time. You will hear a tone to indicate your question is pending. TRANSCRIPT A transcript of this media availability will be available following the brie?ng at web site: that US. Department of Health and Human Sewices CDC 1-1 -o t'lx'Jf 24/? protecting America is health, safety, and security. Wiether diseases start at home or abroad, are curable or preventable, chronic or acute, or from human activity or deliberate attack. CDC responds to America ?s most pressing health threats. CDC is headquartered in Atlanta and has experts located throughout the United States and the world. Press Release Embargoed until 1:00 pm ET Thursday. June 7, 2018 Contact: CDC Media Relations 404-639-3286 Suicide rates rising across the U.S. Comprehensive prevention goes beyond n?acns on mental' health concerns Suicide rates have been rising in nearly every state, according to the latest Vito! Sign report by the Centers for Disease Control and Prevention (CDC). In 2016, nearly 45,000 Americans age 10 or older died by suicide. Suicide is the 10th leading cause of death and is one ofjust three leading causes that are on the rise. Suicide is rarely caused by a single factor. Although suicide prevention efforts largely focus on identifying and providing treatment for people with mental health conditions, there are many additional opportunities for prevention. ?Suicide is a leading cause ofdeath for Americans and it?s a tragedy for families and communities across the country." said CDC Principal Deputy Director Anne Schuchat, MD. ?From individuals and communities to employers and healthcare professionals. everyone can play a role in efforts to help save lives and reverse this troubling rise in suicide." Many factors contribute to suicide For this Vital Signs report, CDC researchers examined state-level trends in suicide rates from 1999- 2016. In addition, they used 2015 data from National Violent Death Repolting System, which covered 27 states, to look at the circumstances of suicide among people with and without known mental health conditions. Researchers found that more than half of people who died by suicide did not have a known diagnosed mental health condition at the time of death. Relationship problems or loss, substance misuse; physical health problems; and job, money. legal or housing stress often contributed to risk for suicide. Firearms were the most common method of suicide used by those with and without a known diagnosed mental health condition. State suicide rates vary widely The most recent overall suicide rates (2014-2016) varied four-fold; from 6.9 per 100.000 residents per year in Washington. DC. to 29.2 per 100.000 residents in Montana. Across the study period. rates increased in nearly all states. Percentage increases in suicide rates ranged from just under 6 percent in Delaware to over 57 percent in North Dakota. Twenty-five states had suicide rate increases of more than 30 percent. Wide range of prevention activities needed The report recommends that states take a comprehensive public health approach to suicide prevention and address the range of factors contn'buting to suicide. This requires coordination and cooperation from every sector of society: government, public health, healthcare, employers, education, media and community organizations. To help states with this important work, in 2017 CDC released a technical package on suicide prevention that describes strategies and approaches based on the best available evidence. This can help inform states and communities as they make decisions about prevention activities and priorities. Everyone can help prevent suicide: I Learn the waming signs of suicide to identify and appropriately respond to people at risk. Find out how this can save a life by visiting: wwaeThel to.com I Reduce access to lethal means such as medications and firearms among people at risk of suicide. I Contact the National Suicide Prevention Lifeline for help: (8255). The media can avoid increasing risk when reporting on suicide by: I Following and sharing recommendations available at for example, avoiding dramatic headlines or explicit details on suicide methods); I Providing information on suicide warning signs and suicide prevention resources; and I Sharing stories of hope and healing. Vita! Si gig is a CDC report that typically appears on the ?rst Tuesday of the month as part of the CDC journal Morhidin' and Mortaiin' l?Veekiv Report. The report provides the latest data and information on key health indicators, and what can be done to drive down these health threats. LLS. Department of Health and Human Services CDC works protecting America ?s heaith, safem and security. Whether diseases start at home or abroad, are curable or pre veritabie, chronic or acute, or from human activity or deliberate attack, CDC responds to America 's most pressing heaith threats. CDC is headquartered in. Atlanta and has experts located throughout the United States and the worid. Suicide rates ruse across the US from 1999 to 2016. SOURCE: Nationa! Vita! Statistics SystemFrom: Holland, Kristin Sent: 25 May 2018 19:26:53 +0000 To: Holland, Kristin Deborah Subject: Conversation with Holland, Kristin Holland, Kristin 9:22 AM: now i'm about to get in big trouble! Stone. Deborah (CDCIDNDIEHINCIPC) 9:22 AM: oh no, why?! Holland, Kristin (CDCIONDIEHINCIPQ 9:23 AM: so, i mentioned the media recs for reporting on mass shootings to marie bellman, and she looked them up and has now emailed me twice [bf'c i didn't respond to the first emailwere involved in developing them and when they were cleared! (facepalm) Stone, Deborah (CDCIONDIEHINCIPC) 9:24 AM: Holland, Kristin (CDC/onolewucwcl 9:24 AM: exactly Stone. Deborah (CDCIONDIEHINCIPC) 9:25 AM: so is listed on them specifically Holland, Kristin 9:25 AM: yeah Stone, Deborah (CDCIONDIEHINCIPC) 9:25 AM: i'm totally getting fired! It's been a good 3 our names aren't on them are they?! Holland, Kristin (CDCIDNDIEHINCIPC) 9:25 AM: ha whatever, this one is totally on me Stone. Deborah 9:26 AM: why? Holland, Kristin 9:26 AM: i'm the one who said i would submit them for clearance and i completely forgot to and then next thing we knew, they were published! This consensus project was led by SAVE and included national and international experts from AFSP, the CDC, Columbia University, IASP Media Task Force, JED, SPRC, and multiple media industry experts. Stone, Deborah 9:27 AM: Oh. I didn't remember that. Holland, Kristin 9:23!r AM: f*ck Stone. Deborah (CDCIONDIEHINCIPC) 9:2? AM: Holland, Kristin 9:27 AM: i even sent her the link. is wrong with me?? Stone, Deborah (CDCIDNDIEHINCIPC) 9:27r AM: lol. you are bold! Holland, Kristin 9:28 AM: i should have just 'forgotten' to send it to her Stone, Deborah 9:28 AM: well if she asked i'm pretty sure she'd keep reminding you Holland, Kristin 9:28 AM: yeah, she had already reminded me once Iol Stone, Deborah 9:28 AM: so what are we going to do? Holland, Kristin 9:29 AM: sh*t. i don't know Stone, Deborah (CDCIDNDIEHINCIPC) 9:29 AM: Can we tell Dan to just take offl? Holland, Kristin (CDCIONDIEHINCIPQ AM: ok, so her question says 'what capacity did we contribute? - which i can say we attended phone calls and provided links to empirical research on suicide contagion and we suggested revisions as necessary to the docs {not sure whether i should say that] but the 2nd question was 'what was the review/clearance process? was it similar/different from DVP involvement with the suicide reporting recs?? i wasn't around for that, so i don't know what that process was, but they probably actually followed the rules and got that cleared Stone, Deborah 9:31 AM: ?ght Holland, Kristin 9:31 AM: you're right - it has been a nice 8 years maybe i can get a job as the receptionist at the twins' daycare. they're hiring. Stone, Deborah 9:32 AM: smh. well, maybe tell her we'll get them to take off. ha! You wouldn't last long there. Holland, Kristin (CDCIDNDIEHINCIPC) 9:32 AM: you're right about that Stone, Deborah 9:32 AM: i'm thinking about going to work for the action alliance or or afsp or wherever Holland, Kristin 9:33 AM: well that would be a logical step Stone. Deborah 9:33 AM: heck, maybe dan will hire us! Holland, Kristin (CDCIONDIEHINCIPC) 9:33 AM: you could take michelle cornette's place from wherever she's moving from Stone, Deborah 9:33 AM: that's hilarious. oh btw, remind me to tell you something. about her Holland, Kristin (CDCIDNDIEHINCIPCJI 9:33 AM: ha! i'm sure dan is like 'um, kristin never responds to emails. i'm not hiring her' Stone, Deborah 9:33 AM: i know, i don't either. he probably hates us. ok but seriously, how can i help? Holland, Kristin 9:34 AM: i don't know. marie is on the list of people who hate me right now Stone. Deborah (CDCIONDIEHINCIPC) 9:35 AM: maybe go buy her a present and tell her you're really sorry and to please have mercy. oh and get a card so i can sign it too. ugh Holland, Kristin 9:35 AM: well she obvs wants an answer now Stone, Deborah 9:36 AM: Holland, Kristin 9:36 AM: think i should call her and be like, so i just realized there was an issue with in that we never got it cleared. Iol Stone. Deborah 923? AM: yeah, maybe tell her the reason you sent her the link is as a confession, there was a clearance issue, there wasn't any. Holland. Kristin (CDCIONDIEHINCIPQ 9:37 AM: it says all the same things as the suicide recs basically hahaha Stone. Deborah 9:38 AM: do you want to set up a meeting or does that make it too obvious we're afraid?! Holland, Kristin 9:33 AM: so, what ifi call her and be like 'i didn't miss your first email, but i was looking into it to see what process we had gone through for clearance lb/c it has been a really long time since we worked on it} and i realized that it must have fallen through the cracks and not gotten cleared and then i can say that i can contact dan and have CDC taken off of it, or could we clear it after the fact and keep CDC on it? (although that introduces a whole slew of issues we obvs can't ask dan to change anything now). i don't even know how easy it would be to ask him to take our name off Stone, Deborah (CDCIONDIEHINCIPC) 9:43 AM: Yeah, i was thinking about post-hoc clearance. Do you think Dan would be amenable to changes at all? Maybe he could call them revised guidelines and they'd get more media how long have they been out? Holland, Kristin 9:43 AM: i don't know it says copyright 2017 i think they came out in likejan 2017 Stone, Deborah 9:43 AM: ok. Holland, Kristin 9:44 AM: so i could contact marie and say all that stuff and say i can contact den and ask if he would be amenable to revisions, if not, just take CDC name off? but we can still point people to the recommendations, right? even if they're not 'ours' ok, i'm going to call her now wish me luck? phew no answer. i'll try again in a bit Stone, Deborah 9:49 AM: oh sorry i missed my chance for good luck. Good luck for next time!! Holland, Kristin 9:49 AM: haha how do i get myself into these messes?? i suppose it has something to do with my laissez faire attitude about clearance Stone, Deborah (CDCIDNDIEHINCIPC) 9:49 AM: you have an insatiable desire to be of service to the public! Holland, Kristin AM: ah, yes, that's it! Stone, Deborah AM: better than your explanation! same goes for me. Holland, Kristin 9:50 AM: at least you follow the rules most of the itme you err on the side of the caution and i usually throw caution to the wind! lol i reread the recommendations, and there's nothing bad in there Stone, Deborah 9:55 AM: ok that's good and i'm not sure about your assessment. i mean i guess i try to follow the rules! Holland, Kristin 9:51lr AM: at least you always think about what others will think in a caring, thoughtful way, i mean not like you're caught up in other people's opinions Stone. Deborah 9:5? AM: yes but only in certain on who the others are and whether they scare me. Holland, Kristin 9:5?r AM: exactly Iol Stone, Deborah 9:58 AM: ok, getting on a call in a min. let me know if you want me to join a call or anything. i'm sure i will be involved before too long. Holland, Kristin 9:59 AM: i'm going to try to keep your name out of it Stone. Deborah (CDCIDNDIEHINCIPC) 10:00 AM: well at this point it doesn't really matter! bf: i'm in hot water already Holland, Kristin (CDCIONDIEHINCIPQ 10:02 AM: well, i'm trying to keep you out of more. i don't even think yours is as bad as this, actually. you had that paper cleared by a million different people! Stone. Deborah 10:06 AM: Stone. Deborah 11:28 AM: Anything new? 11:23 AM The following can't receive right now: Holland. Kristin (CDCIONDIEHINCIPC) Anything new? Holland. Kristin 12:31 PM: the convo with marie went well the plan now is that she's going to check with leslie dorigo to see how to move forward, but she doesn't want me to contact dan until we decide exactly what to do. she wants us to go ahead and get it cleared though, so that we can reference it when the SAVD paper comes out and i put it all on me, btw, i was like 'i totally remember that there was so much going on at the time i recall it was when you were in NY with your mom, we were making ?nal revisions to the TP, we were working on this and a million other things, so it just slipped through the cracks and i told her i was the one who was supposed to get it cleared and then i was like 'it's been nice working here for 9 years, so at least i'll have that when they fire me' and she was like, 'no please this is the least of my worries right now' she seemed to think it wasn't a HUGE deal Stone. Deborah 12:42 PM: Oh thank Dodged that bullet i feel bad for Tom. I think this thing isn't good. Holland. Kristin 12:43 PM: which thing? oh shit i just see your email now that's the one i emailed tom about and said 'i would have been more concerned about this it seems quite similar to our study except they go into a more granular level of detail' ugh Stone, Deborah 12:45 PM: i know, i remember that was the onell can you help me with a quA possibly? Holland, Kristin (CDCIDNDIEHINCIPC) 12:47 PM: sure about that study in particular, or something else? Stone, Deborah (CDCIDNDIEHINCIPC) 12:48 PM: yeah about that study. i will try and read it today but just don't know i'm going to get to it. if you don't have time, i can just do it over the weekend. Holland, Kristin (CDCIONDIEHINCIPC) 12:48 PM: i actually put something about it in the CIA already but i put it under ?recent research' if you want me to come up with a question like 'how is this study different from i can do that Stone, Deborah 12:52 PM: I thought we probably had something in there from our mmwr. Ok, that question is good. Thanks. Holland, Kristin (CDCIDNDIEHINCIPC) 12:53 PM: ok Holland, Kristin 1:42 PM: ok, so she talked to leslie, and leslie agrees that it would be good to have our name on the document so we can disseminate it, but we obys need to get it cleared so i'm going to reach out call with him to discuss this. do you want to be on the call? do you want me to cc you on the email? or do you want to be completely left out of this {i don't blame you if you do} Stone. Deborah 3:26 PM: i'm happy to be on the call. that sounds good From: Stone, Deborah Sent: 22 May 2018 14:20:02 +0000 To: Bruce, Cc: Black, Erin Marie R. Subject: DC Letter Attachments: MRC TS DS_rev ds.docx Importance: High Hi The DC letter needs to be updated further. The title of the MMWR was incorrect, yikes! I hope it's not too late. May be good for us to touch based about all the products and their status. It would be good to get the whole list of all the products and where they are and where they need to go and by when. Deb Deb Stone, MSW, MPH Centers for Disease Corm'ol anti F?reversuon National Center lor Injury and Control of Violence Prevention Suicide. Youth Violenco 8: Elder Team 30/12 CDC's Injury Center Preventing Injuries and Violence Through Science and Action Comment leat?ll: Title has changed. i Trends in State Suicide Rates?United l: States, 1999-2016 and Circumstances i Contributing to Suicide?2? States, 2015 Comment NOTE TO REVIWERS: DVP will add more speci?c activities to this paragraph off-line and insert it before Friday. Review Tracker II DC Leslie Dorigo: DVP ADS Tom Simon: 4f24f18 DVP Policy Malia Richmond-(2mm; 4/23/18 SME Dela Stone; 4l24j'13 DVP HCET Marie Bellman: Dear Colleague: I The CDC Vital Signs series, launched in 2000, addresses a single, important public health topic i each month. This month's edition presents trends in suicide rates across all states and D.C., i examines contributing factors to suicide in 27 states, and highlights strategies For comprehensive suicide prevention. We also highlight strategies for state public health departments and atlaees I partners working to help reduce suicides. This e-mail contains advance copies of several Vitoi Signs materials, including the Morbidicv and Mortoiity Weekiv Report article, ?[Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Roast?. edition of CDC Vital Signs will be released today, Tuesday, one 7, 2018, at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vita! Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older From 1999?2016. suicide rates increased in nearly every state, with 25 states experiencing 0 Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition I A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use. physical health.job, ?nancial, and legal problems. [After the embargo is lifted today at 1 pm (EDT), please share the CDC Vita! Signs information broadly with your colleagues and partners. Visit the Vital Signs Web page to ?nd the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vital Signs buttons and email updates. lv?isit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June12, 2016, at 2:00 pm (EST). Virai Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communitiesincreases of more titan 30% each Thank you for your support. Debra Houry, MD, MPH James A. Mercy, Director Director National Center for Injury Prevention and Control Division of Violence Prevention National Center for Injury Prevention and Control From: Stone, Deborah Sent: 26 Feb 2018 22:31:16 +0000 To: Caine, Eric Jerry Subject: AJPH Opinion Editorial Attachments: FINAL OD Planning Document - Suicide 91-29-201? rev.docx Hi Guys, As you may have heard from me? others? CDC is releasing a Vitoi Signs on Suicide on June 5th. This is a really high profiiefhigh impact publication. It includes a website, MMWR, Fact Sheet, Social Media messages, press release, telebriefing by Acting CDC Director and a Town Hall Meeting (We already have on record that the Surgeon General may participate in the telebriefing}. Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? i know you are probably tired of being singled out for all of your great work and but would the three of you or some combination of you do us the honor of writing an opinion editorial (1200 words, 7 references, lfor us in AJPH about comprehensive suicide prevention and CD efforts [we can refine later but for purposes here, this is the topic]? I?m happy to set up a call to discuss but in the meantime, please see attached Vital Signs description with preliminary results [Please do not distribute or otherwise use or l?ll probably be fired]. Also see recent Vital Signs {on opioidsl and the companion commenjtam Also, editorial is due to AJPH April 5thl! So it?s coming right up. By. Look forward to hearing of your interest and thoughts. Deb Duh Stone. Sci). MSW: MPH Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research 8: Evaluation Branch 4770 Buford Highway. MS F-E4 Atlanta. GA 30341 ??0.488.3942 d_stnee_3@cecggv September 29, 201? Vital Signs DD Planning Document-Approved Suicide Prevention CDC Signs {Proposed release: June 5, 2018) The Problem: More than 44,000 lives are lost every year in the U.S. to suicide. More than half of these occur among adults in the prime of their lives, ages 35-64. Between 2000 and 2015, suicide rates in the U.S. increased by about 28%, while most other leading causes of death declined. Suicide and non-fatal attempts cost more than $59 billion annually in direct medical and work loss costs. Decades of research have shown that suicide is a preventable public health problem. To help states make greater use of the best available evidence for suicide prevention, the CDC recently released Preventing Suicide: A Technical Package of Policy, Programs, and Practices. This Vital Signs is an important step toward raising awareness about the need and the opportunity for suicide prevention. Proposed Vital Signs Approach to Data: The proposed Vital Signs will use data from the National Vital Statistics System (NVSS, 1999-2016) and National Violent Death Reporting System 2015). The trends in rates in the 0.5. overall and by state and sex, will be reported. Changes in state rankings over time will also be reported. Preliminary results indicate that rates have increased in 29 states by 25% or more over these 18 years. To help the reader fully understand the factors influencing suicide risk, the report will also summarize suicide circumstances using the 2015 We will compare suicide risk factors among people with and without mental health problems to describe the social and environmental factors contributing to suicide. Recommendations to be made: The gold standard of suicide prevention is a population-based public health approach rather than solely a mental health approach that seeks to identify and treat people with mental health problems. The need for a public health approach was announced in the 1999 Surgeon General?s Call to Action to Prevent Suicide, but barriers to this approach continue today. CDC recently released a technical package for suicide prevention that includes the best available evidence for suicide prevention. The technical package describes seven strategies: strengthening economic supports, strengthening access and delivery of suicide care, creating protective environments, promoting connectedness, teaching coping and problem-solving skills, identifying and supporting people at risk, and lessening harms and preventing future risk. These strategies are designed to work synergistically at the population level. Examples ofspecific programs, practices, and policies for each strategy are described in the technical package. Each approach was rigorously evaluated and found to have beneficial effects on suicide or suicide risk and protective factors. Fit with current program: The NCIPC Director has made suicide prevention a top priority because of the fast-growing mortality and the existence of evidence-based prevention strategies. The NCIPC technical package on suicide prevention describes evidence-based policies, programs, and practices for comprehensive action. In addition, NCIPC has developed a strategic plan to focus our suicide prevention efforts, and the proposed VitalSigns is an important early part of this plan. Newsworthiness: This is the first state-based analysis of increasing suicide rates across all 50 states and Washington, D.C, over 18 years, and results will be mapped. The reader will be informed about the most important factors associated with suicide, including situational factors such as job, financial, substance abuse, relationship, and legal problems, that are contributing to risk for suicide among those with and without mental health problems. Preventive solutions will be provided using a comprehensive population?based approach to prevention based on policy, programs, and practices described in the Suicide Prevention Technical Package. From: Stone, Deborah Sent: 7 Jun 2018 13:36:54 +0000 To: McKeon, Richard Jane (NIHINIMH) [EL'John Draper Subject: Embargoed until 1pm June 2: Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Attachments: Signs_ Suicide_6.7.2018_article.pdf, MMWR Supplemental tab e_VS Suicide_ 6.7.2018_final.pdf, FACT Dear Richard, Jane, and John, Circling back to you after many months. Our Vital Signs report is being released today at 1:00. I want to thank you for your input early on and I look forward to discussing on Tuesday?s Federal Partner call. I hope this report will bring greater attention to the problem of suicide, the multiple factors associated with suicide, and how we can prevent suicide. This vital signs took a lot of CDC resources and it is heartening to know that the issue, our issue, was taken up. This is a good sign and I hope it will have a very positive impact for the field. We sure need it. Best wishes, Deb The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e?mail contains advance copies of several Vita! Signs materials, including the Morbidin? and Mortality Week?v Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a fourrpage consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June T, 2018, at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999?2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than halt'ot? people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, ?nancial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Sions Webpage to ?nd the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vital Signs buttons and email updates. Visit CDC ?s Public Health Media Library at and search on the term Vital Signs. We also invite you tojoin us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vim! Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Weekly/Vol. 67 i No. 22 June 8, 2018 Vital Signs: Trends in State Suicide Rates United States, 1999?201 6 and Circumstances Contributing to Suicide 27 States, 2015 Deborah M. Stone. 5:th 'l?homas R. Simon l?hDi; Katherine A. Fowler, l?th; Scott R. Kegler, Pth; Keniing Yuan, Kristin M. Holland, Asha Z. hey-Stephenson, I?th; Alex E. Crosby, Abstract Introduction: Suicide rates in the United States have risen nearly 30% since 1999., and mental health conditions are one of several factors contributing to suicide. Examining stateelevel trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. Methods: Trends in age-adjusted suicide rates among persons aged :10 years, by state and sex, across six consecutive 3-year periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data From the National Violent Death Reporting System, covering 27 states in 20! 5, were used to examine contributing circumstances among decedents with and without known mental health conditions. Results: During 1999?20 16, suicide rates moreased signi?cantly in 44 states, with 25 states experiencing mcreases Rates increased significantly among males and females in 34 and 43 states, rmpectively. Fifty-four percent ofdecedents in 27 states in 201 5 did not have a known mental health condition. Among decedents with available information, several circumstances were signi?cantly more likely among those without known mental health conditions than INSIDE among those with mental health conditions, including 625 Invasive Methicillin-Resistant Staphylococcus oureus relationship problemsi'loss (45.1% versus life Infections Among Persons Who Inject Drugs Six Sites, 2005?201 6 629 Tobacco Product Use Among Middle and High School Students United States, 2011?2017 634 Update: Influenza Activity in the United States During stressors (50.5% versus and recent! impending crises (32.9% versus but these circumstances were common across groups. Conclusions: Suicide rates increased significantly the 201??18 Season and Composition ofthe 2018?19 across most states during 1999?2016. Various Influenza Vaccine circumstances contributed to suicides among persons 643 Update: ACIP Recommendations for the Use of With and without known mental health conditions. Quadrivalent Live Attenuated Influenza Vaccine Implications for Public Health Practice: States United Sis??95: 2018?19 Influenza 59350" can use a comprehensivg evidence?based public 646 Notes from the Hemorrhagic health approach to prevent suicide risk before it Fever Outbreak?Central Uganda, August?September occurs, identify and support persons at risk, prevent 201? reattempts, and help friends and family members in 6?48 QuickStats the aftermath of a suicide. Continuing Education examination available at infolitmliiweekly. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Introduction in 2016. nearly 45,000 suicides population [age-adjusted? occurred in the United States among persons aged :10 years From 1999 to 2015. suicide rates increased among both sexes, ail racial/ ethnic groups, and all urbanization levels (2.3). Suicide rates have also increased among persons in all age groups <75 years, with adults aged 45?64 having the largest absolute rate increase (from 13.2 per 100,000 persons [1999] to 19.2 per 100,000 [2016]) and the greatesr number ofsuicides (232,108) during the same period (1.3). Suicide is the tenth leading cause ofdeath and is one ofjust three leading causes that are increasing in addition, rates ofemergency department visits for nonfatal self-harm, a main risk factor for suicide, increased 42% from 2001 to 2016 (1). Together, suicides and self-harm injuries cost the nation approximately $730 billion per year in direct medical and work loss costs if}. The National Strategy for Suicide Prevention calls for a public health approach to suicide prevention with efforts span? ning multiple levels (individual, famiiyfrelationship, community, and societal]. Such a comprehensive approach underscores that suicide is rarely caused by any single factor. but rather, is deter? mined by multiple factors. Despite this call to action, suicide prevention largely focuses on identifying and tefEtring suicidal persons to mental health treatment and preventing reattempts (6). in addition to mental health conditions and prior suicide attempts, other contributing circumstances include social and economic problems, access to lethal means (eg, substances, firearms) among persons at risk, and poor coping and problem- solving skills Expanded awareness of these additional circum- stances contributing to suicide risk and action to address them can be] reach the national goal, established by the National Action Alliance of Suicide Prevention and the American Foundation for Suicide Prevention, of reducing the annual suicide rate 20% by 2025 To assist states in achieving this goal, CDC analyzed state?specific trends in suicide rates and assessed the multiple contributing factors to suicide; this report presents options for strategies to include in comprehensive suicide prevention efi'orts that are based on the best available evidence. Methods Suicide rates were analyzed for persons aged :10 years because determining suicidal intent in younger children can be difficult (8). Ageaspecific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (International Class?imrion ofDireiases, Fitme- Revision, underlying?cause?ofdeath codes ?37.0. Age? specific population estimates were obtained from U.S. Census Bureau/National Center for Health Statistics bridged?race population data releases. National and staterlevel suicide rate estimates were calculated for six consecutive 3?year aggregate periods spanning i999? 2016 (1999?2001; 2002?2004; 2005?2007; 2003?2010; 2011?2013; and 2014-2016). Rate estimates were age- adjusted to the U.S. 2000 standard population and expressed The of publications is published by the Center for Surveillance. Epidemiology, and Laboratory Services. Centers For Disease Control and Prevention US. Department DE Health and Human Services, Atlanta, GA 30329-4027. Suggc?ed citation: [nudist tomes; first three. then ct .1L. if more than steel [Report title]. MMWR Morb Mortal Wkly Rep 2018;67:linc1usive page numbers]. Centers for Disease Control and Prevention Robert R. Redfield, MD, Dir-retal- Annc Schucllat. MD. Principe! Depend Dirmor Leslie Dauphin. Acting Arterial? Diremar?r .S'rz?mcr Joanne Conn. MD. 542M, Dir-emu [wire 43am.- Quality Chesiey L. Richards, MD. MPH. Deputy Public Health Erin-tri?e 5mm: Michael F. ladetnaico. MD. MPH. Din-am: Center?rr Epidemiology mm'LdiEremmq Service: MMWR Editorial and Produetion Staff [Weaklyl Charlotte K. Kent. MPH. Acting Edimn'n Chief: Executive Editor- Jacqueline Gladier. MD. Editor Mary Dotr, MD. MPH, (Julius Editor Temsa F. Rutledge. Managing fairer Douglas W. Weathuwax. Lead Tat?nimi? Wtr??f?ar Glenn Damon. Soumya Dunworth, Teresa M. Hood. MS. manual Writer-a?oat: Martha F. Boyd. Lew} Visual Specialise Maureen A. Lei-ally. Julie C. Mnrtinroe. SmphenR. Spriggs. Tong Yang. Vitae! In?rmetfm Sammie: 'Quang M. Dean. MBA. H. King. Terraye M. Starr, Mona Yang, In?ramim spa-area MMWR Editorial Boon! Timothy F. Jones. MD. Matthew L. Buuitoo. MD. MPH Virginia A. Cains. MD Katherine Daniel. PM) Jonathan E. Fielding, IulD. MPH, NIBA David Fleming. MD eta MMWR Jun88,2018 r' Vol.6? No.22 William E. Helper-in. MD. DIPH. MPH King K. Holmes. MD. Robin Ikrda. MD. MPH Rim-.1 F. Khabbaz. MD Meadows. MSN. RN Jewel Mullen. MD. MPH. MFA Patricia Quinlislt. MD. MPH Patrick L. Remington. MD. MPH Carlos R'oig. M5. MA Wait-.1.? L. Roper. MD. MPH William Seha?iter. MD US Department of Health and Human ServicesiCemers for Disease Control and Prevention Morbidity and Mortality Weekly Report per 100,000 persons per?year. Age-adjusted suicide rate trends were modeled using the same 3-year data aggregates, employ- ing weighted least-squares regression with inverse-variance weighting. Modeled rate trends are reported in terms oF average annual percentage changes. Characteristics oF persons aged 1:10 years who died by suicide, with and without known mental health conditions, and the circumstances surrounding the suicides were compared in the 27 states? with complete data participating in CDC's National Violent Death Reporting System in 2015. defines mental health conditions as disorders and listed in the Diagnostic and Statistical Manual Disorders, Farr; Edition (9), with the exception oF problematic alcohol use and other subsranee use that are captured separately in VDRS aggregates data From three primary data sources: death certi?cates, coroneri'medical examiner reports (including toxi? cologyl, and law en Forcement reports. A range oF circumstances (relationship problems, life stressors, and recent or impending crises)I have been identi?ed as potential risk Factors For suicide in Circumstances captured are those identi?ed as con? tributing to suicide in coronerfmeclical examiner or law en Force? ment reports, which re?ect inForntation provided by Family and Friends at the time oF death. Decedents could have experienced multiple circumstances. Decedents with and without known mental health conditions were compared using chi-square tests. Logistic regression analyses were used to estimate adjusted odds ratios (aORsl with 95% confidence intervals (Cls), controlling For sex, age group, and tacoll ethnicity. Results The most recent overall suicide rates (representing 2014? 2016} varied FourFold, From 6.9 (District oF Columbia]I to 29.2 (Montana) per [00,000 persons per year (Supplementary Table; Across the study period, rates increased in all states except Nevada (where the rate was consistently high throughout the study period}, with absolute increases ranging From 0.8 per 100,000 (Delaware) to (Wyoming). Percentage increases in rates ranged From 5.9% (Delaware) to 57.6% (North Dakota), with increases >50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2013 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:31:? State Flate Change 2:33"; 1999 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Flank (State Rank} 1l (State Rink} 35111 12.3 We) 12.7 1+ 0.4) 12.3 1+ 0.2) 13.3 1+ 0.3) 14.5 1+ 0.3) 15.4 1+ 0.3) 1.5 31. 1p<.01) Na 3.1 0172.) 25.4 31.1mm 0.8. Male 20.311173) 2121+ 0.4) 21.3 1+ 0.0) 22.5 1+1.3) 23.5 1+ 1.0) 2451+ 1.0) 1.1 31. 1154.01) Female 4.7111711) 5.0 1+ 0.3) 5.3 1+ 0.2) 5.7 1+ 0.4) 3.2 1+ 0.5) 3.3 1+ 0.7) 2.3 31. 111.401) Both 14.31013) 13.4[ 0.91 14.1 0.31 153{+1. 31 13.4 0.71 11 25 +3.1 (311 ?1?0 [331 AL Male 25.1 {?131 23. 4 [1 .71 24.4 1.01 23. 4 2. 01 213 1.11 23.1 1. 51 1.3 ?7'0 Female 5.1 1117a 3-1 0. 3) 5.0 1+ 0.2)11+ 1 1) 341+ 0. 3) 0+10 2.3 31.113401) Both 21.0 24 3 3. 31 24.2 0.3?.4 ?7?0 1131 AK Male 33. 2 {r113} 33.1 4. 91 33.9 0.31 40 1 {4.1112140 1 0.11 42 9 2. 31 1.4 9/13 1134.01} Female 3.3011611 93(? 131 11.1{+ 21 1.21 +13% 013 Both 1?.81013) 13. 19.1 0.51131 (- 0.0) 20.4 1.31 20. 9 0. 51 1.0 ?fa {pt-1.011 15 3.1 {321 +113 ?701421 AZ Male 23.3 30. 2 1. 001 30.3 0.41 30.2 0.51 32. 0 1.31 32.4 0. 41 0.3 We {[34:05} Female 7.1 (1113) .5+1 +0 4) 2 1+ 0.7) 3 31+ 0.5) 3 2112.2 31. 11:14.01) Both 15.5 {?131 15. 3 0. 031 13.2 3. 51 17. 3 1.41 19.2 1.31 21.2 2. 01 2.2 "in 12 5.71141 33.3 "/01151 AH Male 2631013) 23. 2T2 0.5123.2(+ 1.01 31. 7' 3. 51 33.5 91 1.3 {pt-1.051 Female 5.61013)91+ 0. 031 21+ 0.41 911+ .1 3.3 2.11 3.3 ?35 {[34:01} 30111 10.31n7a) 1131+ 0. 7) 11. 010.3) 12. 0 1+ 1.0) 1131.1) 12.1 1+ 0. 3) 0.3 31.113305) 45 1.3 143) 14.3 31. 143) CA Male 17.9 (n13) .51 0.?1 10.1 .1 13.2 0.31 +0.5 ?1?0 Female 4.1 1n7a41+ 0.5) 3-10 .1) 5.3 1+ 0.3) 1.7 31. 1114.05) Beth 17.31r17a) 13.2 1+1. 3) 13.010 2) 2001+ 1.0) 2131+ 1.5) 23.2 1+ 1.3) 1.3 31.111401) 3 5.3 112) 34.1 31.122) 130 Male 233111711) 3031.5 1+ 1.0) 3341+ 1.3) 33.3 1+ 2.3) 1.4 31.113401) Female 7.01n7a) 1..11+ 0.3) 10.1 1+ 1.0) 10.4 1+ 0.3) 2.3 31. 1114.01) 30111 3.31n7a131.1) 11.0 1+ 0.3) 11.5 1+ 0.5) 1.3 31. 1114.05) 43 1.3 143) 13.2 31. 134) CT Male 13.41r17a) 14. 311.3) 15.0 1+ 0.4) 3 31+ 1.3) 17.3 1+ 1.0) 17.3 1- 0.3) 0.3 31. Female 3.3111711) 31+ 0.2) 7 1- 0.2) 41+ 0.7) 4.3 1+ 0.5) 3.2 1+ 1.3) 3.5 31.113305) Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change trorn Prior Period) Current Overall Overall State Sex 1:329? State Flate Change 2:313"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 1513113 Rank) 1 (State Hagnk) Both 13.3 1n1a) 12.2 1- 1.4) 11.0 1- 0. 3) 13. 311+ 14.2 1+ 0.3) 14.4 1+ 0.2) 0.3 31. 1115 42 0.3 150) 5.0 33150) DE Male 23.01n1?a} 2022.? 1- 0.4) 23.5 1+ 0.3) 0.3 31. 013 Female 5.3 13.13.} 5.0 1- 0.1.5} 5.2 1- 0.21 1.5 11.15 Bath 5.9 13.13.} 5.4 1+ 0.0.?1 5.9 1+ 0.3} 0.9 ofo 11.15 51 1.0 1481 15.1 01,10 (45} DC Male 10.? {Na} 11.1 1+ 0.1001-23) 11.? 1+ 0.3 1115 Female 1 11113111 2.3 1+ 0.3)11311.0) 3 1- 0.3) 3.5 31. 013 3001 14.8 13.13.} 15.2 1+ 0.1+21. 4} 15.3 1- 0.01 15.4 1+ 0.1} 0.8 ?2101134051 2'9 4- 1.5 1451 10.5 10148} FL Male 24.3 13.13.} 24.4 1+ 0.25.5 1- 0.51 25.5 1- 0.11 0.5 ofo 11.15 Female 5.3 111113.} 5.8 1+ 0.5} 31+ 0. 0} 11+2 0. 3} 7.5 1+ 0.5} 11.8 1+ 0.3} 1.4 ?fa {114.01} Both 12.9 1n13} 1321+ 0.3} 12. 31-0 .91 1321+ 0. 9} 13.? 1+ 0.5} 15.0 1+ 1.3} 0.9 ofo 1113 3'9 2.1 1401 +152 10144} GA Male 22.1 mm} 23.1 1+ 1.0) .31-1.3) 21 .0 1+0. 3) 2231+ 2441+ 0.5 34. 015 Female 5.0 131318-012151-021 0.3} 5.5 1+ 0.8} 2.1 010113405} Both 12.91313} 11. 1 1- 1.81 10. 31-0 .71 14.51+ 4.1} 14.41- 0.11 1521+ 0.8} 2.0 ?fa 1115 35 2.41351 +133 1-11 Male 20.41n1?a} 2 1-3 .1) 15.3 1- 1.0) 21.0 1+ 22.5 1+ 0.5) 24.3 1+ 1.3) 2.1 31. 013 Female 5.41313} 5.0 1- 0.41 5.5 1+ 0.5} 1 1+ 1.5} 5.2 1- 0.91 5.9 1- 0.31 1.2 11.15 Both 17.3 1313} 1921+ 2.0} 18. 3 1- 0. 91 2151+ 3. 3} 2131+ 0.3} 2431+ 2.8} 2.3 ?21011345.. 01} 3 151 51 43.2 1 7} "3 Male 28.411113} 33.1 1+ 4. 7} 3134.71-13.21 38.0 1+ 3.3} 1.15 0110113405} Female 7.2 .11110.5} 11.8 1+ 2.3} 4.4 ?1101134051 Bath 9.9 11113} 9. 8 1- 0.11 71-0511 10. 5 1+ 0. 8} 11.2 1+ 0.5} 12.2 1+ 1.0} 1.5 0210113405} 44 2.3 1381 22.8 ?110132} lL Male 17.1 111.13} 15H1.41 15.21- 0.41 1751+ 1.4} 18.5 1+ 0.9} 19.31+1.3} +1.1 ?1101134051 Female 11113} 3.5 1-0.01810.4} 5.2 1+ 0.5} 2.4 011: {1341.01} Beth 13.011113} 131491+ 0. 5} 13.4 1+ 1.4} 17.1 1+ 0.7} +1.9 ?fa {1:14.011 25 4.1 1231 31.9 ?313125} Male 22.411113} 23.2 1+ 0.8} 24. 4 1+ 1.2} 24. 7 1+ 0. 4} 25.? 1+ 2.0} 28.3 1+ 1.5} 1.5 Female 4.5 111.13} 5.0 1+ 0.0.9} 5.5 1- 0.21 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Flank 5 {State Rank) Ill (State HEnk) 1.4. Both 11.31n2a1 13.21+1.41 1231-04) 14.2 1+ 1.41 15.9 1+ 1.21 13.0 1+ 0.11 +2.1 241134.011 31 +4.31201 33.2 9.1131 1.4 Male 20.3 1n2a1 22.1 1+ 1.51 20.3 1- 1.41 23.3 1+ 2.51 23.0 1+ 2.21 25. 2 1- 0. 31 1.3 12.. 1134.051 Female 3.710131 431+ 1.0} 531+ 0.61 5.51+ 0.21 5.1 1+ 0.5171+ 0 61 3.8 ?20 113-3. 011 Bath 13.31n1?a1 15.1 1+ 1.8} 1581+ 0.71 15.31- 0.51 17.? 1+ 2.4} 19.41+1.51 2.2 ofo 011 19 5.01111 45.0 01120 1 5} KS Male 22.21n2a1 25.0 1+ 2.31 23.5 1+ 151 25.3 1- 0.91 29.1 1+ 3.51 30. 2 1+ 1.31 1.9 12.. 112.4. 011 Female 4.5 10131 5.0 1+ 1.4} 5. 7 1- 0. 31 5.41- 0.31 5.8 1+ 1.4} 3. 4 1+ 1.51 3.2 01120 (134051 Beth 14.1 1l'I1'ia} 15.41+1.3} 3.1 15.21-11.51 18.21+2.0} 19.3 1+1. 11 1.9 ?20 113-3. 011 20 +5.2 1151 +355 10115} KY Male 25.01n2a1 2331+ 1.91 23. 3 1+1 41 22.2 1- 1.01 30.1 1+ 2.9} 31.2 1+ 1 .31 1.4 02.. 11:4. 011 Female 4.8111118} 5210.1} 7.1 1+ 0.9} 711+ 0. 51 3.2 ?2?0 {114.011 Beth 13.1 {We} 12. 91-0 .1 13.41+ 0.41 1351+ 0.31 14.41+ 0.8} 1701+ 2. 51 +1.6 01120 (134051 27 3.8 112?} 29.3 10125} LA Male 22.9 1n2a1 22. 3 1- 0. 31 22.4 1+ 0 11 23.3 1+ 0.31 23.2 1+ 0.51 22.3 1+ 3 31 1.1 02.. 1115 Female 4.8 [0131 10.21 0.1 1+ 1.2} 5 1+ 1 .41 2.8 ?24 {1:14. 051 Both 14.5 1l'l1'ia15.4 1+ 1.0} 18.9 1+ 3.5} 18. 5 1- 0. 41 2.2 ?2?0 {114.051 21 4.01251 27.4 l:51'3129} ME Male 25.01n2a1 22.91.11 24.31+1 21 25.21+1.11 31.1 1+ 5.41 29.31 .31 1.312.. 1134. 051 Female 5.3 10131 5.3 1- 0012-01311 5.0 1+ 0.7} 7.6 1+ 1.5} 91+ 0. 31 3.1 ?20 113-3. 051 33111 10.010131 1031+ 0.31 101 1-0 .21 1021+ 0.11 1021+ 0.51 1031+ 0.11 0.5 0.31114 0514243 0.3149??1 3.5 :34414901 MD Male 17.511113} 1?.31? 0. 51 17.71+0.41 18.21+0.5} 18.0 1* 0.2] +0.2 019 Female 3.5 111131 3.8 1+ 0.4} 3. 9 1+ 0. 01 0.21 4.1 1+ 0.4} 4.5 1+ 0.41 1.3 ?2?0 {1:14.051 Both 1411113.} 1+ 0.1.0} 9.8 1+ 0.4} 10.0 1+ 0.31 2.3 (1214:2011 48 2.5134 111 35.3 %120 1ml) MA Male 12.1 111.13.} 12,181+ 0.?1 13 31+ 0. 51 1541+ 2.11 15.21- 0.21 1301+ 0.81 2.0 ?fa 1p<.011 Female 3.3 11113.} 2.9 1- 0.41 4.0 1+ 1.01 3.8 1- 0.11 4.8 1+ 1.0} 51* 0.21 3.0 ?2101134051 Both 11.811113} 1251+ 0.?1 1291+ 0. 41 13.91+1.01 1451+ 0.7} 15 01+1.11 +1.9 ?2?0 1134.011 33 3.9 125} 32.9 31:1241 Ml Male 20.0 11113.} 20.9 1+ 0.9} 21.0 1+ 0. 71 22.8 1+ 1.3} 23.9 1+ 1.0} 25. 0 1+ 1 .21 1.5 1p<.011 Female 4.4 111.13.} 4.8 1+ 0.4} 01+ 0. 21 5.3 1+ 0.5} 5.9 1+ 0.3171+ 0.91 2.8 1p<.011 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period} Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {51131113 Rank) Ill (State Hgnk) H. Both 10.71n13} 11.5 1+ 0.31 12.41+0.31 12. 3 1+0. 51 14.2 1+ 1.31 15.0 1+ 0.31 +2.3 31.. 1114. 011 33 +4.31131 40.3 331 31 MN Male 18.31n1?a} 13.31+1.22.3 1+ 1.31 2331+ 0.41 31. 011 Female 3.011113} 421+ 0.581+ 0.5} 91+ 1.2} 4.2 111-3. 01} Beth 12.911113} 14.1 1+ 1.1551+ 0.1} 15. 21- 0. 31 1.1 ?1151134051 35 2.3135} +173 01,10 (40} MS Male 22.9 11113.} 24.5 1+ 1.1} 25.1 1+ 0. 25. 8 1+ 25.9 1- 0.91 5. 3 1-0 .51 ?2?0 1115 Female 4.3 111130.01 5.4 1+ 0.9} 21- 0. 21 2.4 115113301) Beth 14.711113} 14.1 1- 0. 5} 15.4 1+ 1.3} 1001+ 0.7} 17.8 1+ 1.1} 2001+ 2. 3} 2.2 ?151134.011 10 5.3115} 35.4 11?} MD Male 25.3 11113.} 23.71-1 .51 25. 5 1+ 1.9} 20.6 1+ 1.0} 23.9 1+ 2.3} 32. 2 1+ 3. 3} 1.8 ?1151134051 Female 5.4111181} 5.41+ 0.1} 11+ 0. 7} 531+ 0. 2} 7.41+1.1} 3.2 ?fa 1131101} Both 21.1 1013} 22.3 1+ 1.41 23.31+10.1 11 23.? 1+ 2.01 2321+2.51 +2.1 031132.011 1 +3.01 21 33.0 :3.1111 MT Male 35.9 11118.} 37.3 1+ 0.4} 39. 3 1+ 2. 5} 39271-0 .11 41.0 1+ 1.4} 45. 5 1+ 1.3 ?151134.011 Female 371111.11 3.4 1+ 1.31 3.4 1- 0.11 10.0 1+ 1.31 12.3 1+ 2.31 13.1 1+ 0. 451 4.3 0.1. 1134.011 Both 12.71n1?a} 12.2 1- 0.51 12.3 1+ 0.41 11.71- 0.31 13.5 1+ 1.2.1 1421 13.2 :131431 NE Male 22.2 1013} 20.71- 1.51 20.3 1- 0.41 13.3 1- 0 51 22.0 1+ 2.21 23. 3 1+ 1 31 0.3 31. 013 Female 3.3 11118.} 4.2 1+ 0.4} 5.1 1+ 0.1.4} 81+ 0 3} 2.0 1115 B13111 23.3 11113.} 22.5 1- 0.51 22.1 1- 0.51 22.0 1+ 0.5} 21.41- 1.21 23. 1 1+ 1.0} - 0.2 1113 9 - 0.2151} - 1.0 (?10 1511 N11 Male 38.3 111151} 3071-17} 35.1 1- 1.8} 35.6 1+ 0.5} 32.5 1- 3.0.7 ?51: 1113 Female 8.911113} 951+ 0 5} 951+ 0.1} 1001+ 0.4} 1031+ 0.0} 1121+ 4010. +1.5 ?fa {114.01} 30111 13.511113} 12. 51- 1.01 1331+ 0.8} 15.21+1.9} 1531+ 0.5} 20 01+ 2.7 010113405} 17 5.51 81 48.3 1101 3} NH Male 22.5 11113.} 21.1 1-1 .41 21.7 1+ 0.0} 24.3 1+ 3.1} 25.4 1+ 0.5} 30. 6 1+4 5 2} 2.2 0.11:1 1134:. 05} Female 5 3 111131.0} 5.2 1+ 0.4} 5.0 1+ 0.4} 9. 8 1+ 3. 2} 3.9 011: {pt-1. 051 B13111 7.8 11113.} 1- 0.0.9} 9. 2 1+ 0 4} 1.3 ?101114.051 50 1.5 {47} 19.2 313135} NJ Male 13.011113} 13.1 1+ 0.0} 12.010 .51 1371+ 1 1} 14.51+0.8} 14.61+0.1} Female 3 2 11113.} 9 1- 0.31 001+ 9-01.11 3.8 1+ 0.9} 4. 4 1+ 0. 0} 2.3 1115 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2018 Age-Adjusted Annual Rate per 100,000 Persons [Change 1mm Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2008 2010 2011 2013 2014 2016 Rank 5 1513113 Rank) Ill (State Hgnk) H. Both 22.0 (n13) 22.0 1- 0.1) 21.0 1- 0.2) 23.0 1+ 1.2) 24.1 1+ 1. 1) 20.0 1+ 1 .0) 1.1 01.113405) 4 4.0 124) 13.3 =14. 130) NM Male 38.8 111131.2} 35.8 1- 0.8} 87.1 1+ 1.8} 40.7 1+ 8.8} 0.4 810 1115 Female 8511113.} 1.1} 8.21+0.7} 10.71+2.8} 12.0 1+ 0.8} +3.8 1114. 05} Beth 2.2111151) 1-01 .1) 7111+1. 1) 31- 0.1) 2.1 c1011:1401) 40 2.1 141) 20.3 01.12?) NY Male 12.51n13} 12.210 3) 13.01.+10) 15..41+14) 1451-00) +1.4%1p4.05} Female [010} 01-0 .1) 3.01+0.3) 3.5 4.01+0.5) +4.2 01. 1p4 01) 80111 18.811113} 18.51-13.11 18.71+0.1} 14.21+0.5} 14.51+0.4} 15.31+0.8} +0.8ofo 1114.01} 84 +1.7144} +127 810141} NC Male 22.711113} 22.? 1+ 0.0} 22.2 1- 0.8} 23. 3 1+ 1.1} 28. 3 1+ 0.0} 23. '9 1+ 0. 8} 0.4 ofo 1115 Female 5.0 11113.} 5.5 1- 0.2} 8.2 1+ 0.8} 8.0 1- 0.2.0 ?191134.05} 80111 18.811113} 14.8 1+ 1.8} 10.0 1+ 1.4} 1881+ 0.8} 18.4 1+ 1.9} 2091+ 2. 5} 2.9 810113401} 14 1.81 5} 57.8 8?31 1} ND Male 21.41n1a) 24.0 1+ 3.2) 20.0 1+ 3.4) 2?.1 1- 0.2.5 c1.4113401) Female 5.8 11113.} 4.5 1- 1.0} 8.71- 0.8} 5.7 1+ 2.0} 8. 1 1+ 1.0} 8. 5 1+ 1.8} 8.9 0er 1115 80111 11.011118} 1281+ 0.8} 18.1 1+ 0.8} 13.41+ 0.2} 14. 8 1+ 1 15.81+ 1.0} 2.0 ?19 1134. 01} 82 4.2 121} 88.0 ?10119} 01-1 Male 20.41n1a) 20.0 1+ 0.5) 22.2 1+ 1.3) 22.1 1- 0.1) 24. 2 1+ 2.1) 25. 5 1+ 1.3) 1.5 0.1.1134 01) Female 4.011113} 1+ 0. 4.91+ 0.1} 581+ 0.3.4 1114. 01} 80111 17.011113} 18. 51-0 1721+ 0.8} 18.41+1.1} 20. 7 1+2. 8} 28.51+2.8} +2.8 1% 1134. 05} 7 8.4 110} 87.8%: 112} UK Male 28.5 11113.} 27. 8 1- 1. 2} 27.8 1+ 0.5} 80.8 1+ 2.5} 88. 4 1+ 8.1} 37. 8 1+ 8. 8} 2.0 810113405} Female 8.8 11113.} 8.41-0.21 5 1+ 1 1.0 1- 0.5} 8. 5 1+ 1.8} 10. 8 1+ 1.8} 2.9 1134. 05} 80111 18.411113} 11.? 1+ 1.8} 17 71- 0.0} 18.81+ 0.9} 19.81+1.2} 21.1 1+ 1.8} +1.8 1134. 01} 18 4.8118} 28.2 tT113128} OH Male 21.411113} 2951+ 2.1} 28.51- 0. 9} 2951+ 1.0} 81.4 1+ 1.8} 38.0 1+ 1.8} +1.1 0110113401} Female 8.511113} 1.1 1+ 0.8} 71+ 0. 8} 841+ 0.7} 8. 8 1+ 0. 4} 881+ 0. 9} 2.7 0.11: 1134. 01} 80111 12.1 11113.} 12.5 1+ 0.4} 12.81+0.8} 18.91+1.1} 15.0 1+1. 1} 18.81+1.2} +2.0 ?10 1114.01} 30 +4.1 122} +848 ?310121} PA Male 21.011113} 2131+ 0.8} 2191+ 0. 8} 28.1 1+ 1.2} 24 11+1.7} 28.1 1+ 1.8} +1.5 1134. 01} Female 4.2 11113.} 4.8 1+ 0.8} 81+ 0. 0} 5.4 1+ 0.9} 8. 0 1+ 0.8} 1+ 11} 8.5 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {State Hank) Ill (State Hgnk) H. Bath 9.4 {ma} 9.0 (- 0.3} 9.0 (- 0.0} 12. 51+ 3. 5} 11.9 (- 0.9} 12. 511+ 0. 7} 2.5 92. 032.05} 43 3.2 (30 34.1 35 (23 at Male 15.4 {ma} 15.2 0.2} 14.5 1- 0.3} 21.2 5.4} 19.2 1- 2.11.5 Female 4.0 {Na} 3.3 (- 0.7} 3.3 0.4} 5.1 1.3} 5.1 0.0} 1.0} (p4. 05} Beth 12.301113} 13.0 0.2} 13.7 0.7} 18.0 11} 2.3 ofo (D4. 01} 23 4.9 33.3 We (10} 80 Male 21.3 {ma} 2251+ 1 22.31- 0.1} 2451+ 2.2} 25.1 1+ 1.5} 25.0 1+ 1 9} 1.5 95 {52. 01} Female 5.401.113} ?(ill 6.0 1.3} 5.2 0.1.4} 3.4 ofo (p4. 05} Beth 15.701113} 17.1 {[3401} 10 +44.5 ?Vc? 5} SD Male 2?.5 {ma} 2531.3} 229 1+ 1.5} 30.11.5} 1.5 54. {p4. 01} Femaie 4.2 {ma} 5.5 5.4 1+ 0.1.(p2. 01} Beth 14.501113} 15.2 0.6} 16.1 0.8} 1?.2 1.1} 17.2 0.0} +1.4 ofo (p4. 01} 22 3.5128} 24.2 3?3 (31} TN Male 25.1 {ma} 25.4 1+ 0.3} 25.5 1+ 1.3} 25.0 1+ 1.2} 25.5 1+ 0.5} 29. 5 1+ 1.2} 1.2 54. (52. 01} Female 5.4 {Na} 5.3 0.9} 6.7 0.4} 7.5 0.8} 6.9 0.6} 16 0. 7} 1.9 ofo (D4. 05} Both 12.20118} 12.? 0.6} 12. 0. 4} 13.2 0.9} 13.6 0.3} 14. 5 0. 9} 1.1 ?2?5 01} 41 2.3 (37} +139 We (36} TX Male 20.4 {Na} 20.9 0.5} 20. 4 (- 0. 5} 22.0 1.6} 22.2 0.3} 23.1 0. 9} 0.9 ofo (p4. 05} Female 4.3 {Na} 5.4 0.5} 5.0 (- 0.4} 5.2 0.2} 5.6 0.4} 0. 8} 1.6 (p4. 05} Both 17.2 (1115} 19.0 18.2 (- 0.7} 20.2 2.0} 24.0 3.8.01: 3 W) 45.5 4 11} UT Male 28.2 (0.15} 31.1 2.9} 29.4 (- 1.7} 32.1 2.7} 37.8 5.7} 38. 0 0.2} 2.1 011: 05} Female 6.3 [015} 7.4 0.6} 7.5 0.1} 8.5 10.6 2.1} 12. 6 2. 0} 4.4 ?2?5 01} Both 18.2 14.9 1.3} 18.? 2.1} 19.? +2.4 01} 13 9} +436 Wed 2} VT Male 23.6 (1115} 28.3 4.6} 24. 3 (- 4. 0} 27.3 3.0} 31.0 3.7} 32. 5 1.9 4% (D4. 05} Female 4.3 (11.15} 5. 2 0. 9} 6.4 1.3} 5.6 0.2} 7.3 0.7} 7. 6 0.3} 3.8 011: 01} Both 12.81015} 12. 12.9 0.3} 13.6 0.7} 14.6 0.9} 15. 0 0 5} +1.2 ?2?0 01} 37 2.2 (39} +174 3?5 (41} VA Male 21.6 {015} 21.3 0. 2} 21.0 0.4} 22.5 1.5} 23.6 23. 9 0. 2} 0.9 Female 5.3 {015} Ht, 5 9 0.7} 6 (- 0.3} 6.4 0.8} 5. 9 0. 5} 1.3 (D4. 05} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period) Current Overall Overall State Sex 1? State Rate Change 2:33"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Rank 5 (State Hank) (State Hagnkji Both 14.3 1n1a} 15.4 1+ 3.5} 14. 3 1-3 15. 711+ 3. 31 16.6 1+ 3.3} 17.6 1+ 1.3} 1.1 331133.351 24 2.3 1331 13.3 :13137} WA Male 24.71nra1 25.2 1+ 3.5} 24.1 11.11 25.1 1+ 1.3} 23.3 1+ 3.3} 27.1 1+ 1.1} 3.6 33 1113 Female 5.9 111.13.} 5.4 1+ 0.0.8} 3.5 1+ 0.8} 2.5 112M011 Both 15.31nra} 17.21+ 1.6} 16. 71- 3. 51 16.31.71 1321+ 3.2} 21.41+ 2.2} +1.3 33 11 5.3113} 37.133114} wv Male 27.2 {ms} 33.1 1+ 2.3} 2331-15) 27. 31- 1. 31 3151+ 3.3} 33.5 1+ 2.3} 1.1 33 1115 Female 5.3 111.13.} 5.5 1+ 0.1} 5.8 1+ 0.3} 5.3 1- 0.5} 7.5 1+ 2.3} 9.8 1+ 2.2} :1er 1115 Both 13.1 13.5 1+ 0.4} 14.0 1+ 0.5} 15.0 1+ 1.0} 15.3 1+ 0.3} 15.5 1+ 1.2} 1.5 112M011 23 3.4129} 25.8 10130} w1 Male 21.71nra} 22.2 1+ 3.5} 22.7 1+ 3.5} 24.3 1+ 1.2} 24.4 1+ 3.4} 25.7 1+ 1.3} 1.1 33 1133.31 1 Female 5.1 {hrs} 5.3 1+ 3.2} 5.6 1+ 3.4} 341+ 3.71 3.5 1+ 3.1} 7.5 1+ 1.3} 2.5 33153.31} Both 20.71nra1 23.4 1+ 2.7} 22.5 1- 3.31 25.4 1+ 2.3} 23.3 1+ 3.5} 23.3 1- 3.11 2.3 031133.311 3 3.1 1 11 33.3 =13 1 3} WY Male 34.3 39.3 1+ 4.5} 35.3 1- 3.0} 41.5 1+ 5.2} 47.1 1+ 5.6} 44.5 1- 2.4} 1.8 112M051 Female 7.7111131} 3.2 1+ 3.6} 3.2 1+ 3.3} 3.4 1+ 3.2} 13.7 1+ 1.4} 12.3 1+ 1.3} 3.2 33 11:13.31 1 Rates are age?adjusted to the US. year 2000 standard. 1 Model?estimated average annual percentage change based on all reporting periods; p?value indicates statistical significance of trend; indicates trend not significant. ?5 Current state rank (50 states and the District of Columbia} is for the reporting period 2014 2016. Ranks are from highest rate (11 to lowest rate (511. Different ranks do not necessarily imply a statistically significant difference. 1 Overall rate change is between the first (1999 20011 and last [2014 20161 reporting periods. Hanks are from largest increase {11 to largest decrease 1511. Different ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the first 11999 20011 and last (2014 2015) reporting periods. Ranks are from largest percentage increase 111to largest percentage decrease 1511. Different ranks do not necessarily imply a statistically significant difference. TT Hate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. till Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. State Abbreviations: AL Alabama; AK Alaska; AZ Arizona; AR Arkansas; CA California; CO Colorado; CT Connecticut; DE Delaware; DC District of Columbia; FL Florida; GA Georgia; HI Hawaii; ID Idaho; IL Illinois; IN Indiana; IA Iowa; KS Kansas; KY Kentucky; LA Louisiana; ME Maine; MD Maryland; MA Massachusetts; MI Michigan; MN Minnesota; MS Mississippi; MO Missouri; MT Montana; NE Nebraska; NV Nevada; NH New Hampshire; NJ New Jersey; NM New Mexico; NY New York; NC North Carolina; ND North Dakota; OH Ohio; OK Oklahoma; OR Oregon; PA Fthode island; SC South Carolina; SD South Dakota; TN Tennessee; TX Texas; UT Utah; VT Vermont; VA Virginia; WA Washington; WV West Virginia; Wisconsin; WY Wyoming. #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 From: Rich mond-Crum, Malia Sent: 7 Jun 2018 09:30:26 -0400 To: Stone, Deborah Subject: Embargoed until 1pm June i: Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Attachments: Signs_ Suicide_6.7.2018_article.pdf, MMWR Supplemental table_VS Suicide_ FACT Here you go. Feel free to add your own note before sending to personalize. The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C.. examines contributing factors to suicide in 27' states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e?mail contains advance copies of several Vital Signs materials, including the Morbidity! and Morioiizy Wackiv Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four?page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, one 7, 2018, at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older I From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than halfof people who died by suicide did not have a known mental health condition -A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, ?nancial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Viioi Signs information broadly with your colleagues and partners. Visit the Vitoi Sions Webpage to find the MM WR article, fact sheet, and other materials. Take advantage of social media tools, such as the Viioi Signs buttons and email updates. Visit CDC Public Health Media Library at and search on the term Vital Signs. We also invite you tojoin us for the Wrai Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Viioi Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Weekly/Vol. 67 i No. 22 June 8, 2018 Vital Signs: Trends in State Suicide Rates United States, 1999?201 6 and Circumstances Contributing to Suicide 27 States, 2015 Deborah M. Stone. 5:th 'l?homas R. Simon l?hDi; Katherine A. Fowler, l?th; Scott R. Kegler, Pth; Keniing Yuan, Kristin M. Holland, Asha Z. hey-Stephenson, I?th; Alex E. Crosby, Abstract Introduction: Suicide rates in the United States have risen nearly 30% since 1999., and mental health conditions are one of several factors contributing to suicide. Examining stateelevel trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. Methods: Trends in age-adjusted suicide rates among persons aged :10 years, by state and sex, across six consecutive 3-year periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data From the National Violent Death Reporting System, covering 27 states in 20! 5, were used to examine contributing circumstances among decedents with and without known mental health conditions. Results: During 1999?20 16, suicide rates moreased signi?cantly in 44 states, with 25 states experiencing mcreases Rates increased significantly among males and females in 34 and 43 states, rmpectively. Fifty-four percent ofdecedents in 27 states in 201 5 did not have a known mental health condition. Among decedents with available information, several circumstances were signi?cantly more likely among those without known mental health conditions than INSIDE among those with mental health conditions, including 625 Invasive Methicillin-Resistant Staphylococcus oureus relationship problemsi'loss (45.1% versus life Infections Among Persons Who Inject Drugs Six Sites, 2005?201 6 629 Tobacco Product Use Among Middle and High School Students United States, 2011?2017 634 Update: Influenza Activity in the United States During stressors (50.5% versus and recent! impending crises (32.9% versus but these circumstances were common across groups. Conclusions: Suicide rates increased significantly the 201??18 Season and Composition ofthe 2018?19 across most states during 1999?2016. Various Influenza Vaccine circumstances contributed to suicides among persons 643 Update: ACIP Recommendations for the Use of With and without known mental health conditions. Quadrivalent Live Attenuated Influenza Vaccine Implications for Public Health Practice: States United Sis??95: 2018?19 Influenza 59350" can use a comprehensivg evidence?based public 646 Notes from the Hemorrhagic health approach to prevent suicide risk before it Fever Outbreak?Central Uganda, August?September occurs, identify and support persons at risk, prevent 201? reattempts, and help friends and family members in 6?48 QuickStats the aftermath of a suicide. Continuing Education examination available at infolitmliiweekly. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Introduction in 2016. nearly 45,000 suicides population [age-adjusted? occurred in the United States among persons aged :10 years From 1999 to 2015. suicide rates increased among both sexes, ail racial/ ethnic groups, and all urbanization levels (2.3). Suicide rates have also increased among persons in all age groups <75 years, with adults aged 45?64 having the largest absolute rate increase (from 13.2 per 100,000 persons [1999] to 19.2 per 100,000 [2016]) and the greatesr number ofsuicides (232,108) during the same period (1.3). Suicide is the tenth leading cause ofdeath and is one ofjust three leading causes that are increasing in addition, rates ofemergency department visits for nonfatal self-harm, a main risk factor for suicide, increased 42% from 2001 to 2016 (1). Together, suicides and self-harm injuries cost the nation approximately $730 billion per year in direct medical and work loss costs if}. The National Strategy for Suicide Prevention calls for a public health approach to suicide prevention with efforts span? ning multiple levels (individual, famiiyfrelationship, community, and societal]. Such a comprehensive approach underscores that suicide is rarely caused by any single factor. but rather, is deter? mined by multiple factors. Despite this call to action, suicide prevention largely focuses on identifying and tefEtring suicidal persons to mental health treatment and preventing reattempts (6). in addition to mental health conditions and prior suicide attempts, other contributing circumstances include social and economic problems, access to lethal means (eg, substances, firearms) among persons at risk, and poor coping and problem- solving skills Expanded awareness of these additional circum- stances contributing to suicide risk and action to address them can be] reach the national goal, established by the National Action Alliance of Suicide Prevention and the American Foundation for Suicide Prevention, of reducing the annual suicide rate 20% by 2025 To assist states in achieving this goal, CDC analyzed state?specific trends in suicide rates and assessed the multiple contributing factors to suicide; this report presents options for strategies to include in comprehensive suicide prevention efi'orts that are based on the best available evidence. Methods Suicide rates were analyzed for persons aged :10 years because determining suicidal intent in younger children can be difficult (8). Ageaspecific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (International Class?imrion ofDireiases, Fitme- Revision, underlying?cause?ofdeath codes ?37.0. Age? specific population estimates were obtained from U.S. Census Bureau/National Center for Health Statistics bridged?race population data releases. National and staterlevel suicide rate estimates were calculated for six consecutive 3?year aggregate periods spanning i999? 2016 (1999?2001; 2002?2004; 2005?2007; 2003?2010; 2011?2013; and 2014-2016). Rate estimates were age- adjusted to the U.S. 2000 standard population and expressed The of publications is published by the Center for Surveillance. Epidemiology, and Laboratory Services. Centers For Disease Control and Prevention US. Department DE Health and Human Services, Atlanta, GA 30329-4027. Suggc?ed citation: [nudist tomes; first three. then ct .1L. if more than steel [Report title]. MMWR Morb Mortal Wkly Rep 2018;67:linc1usive page numbers]. Centers for Disease Control and Prevention Robert R. Redfield, MD, Dir-retal- Annc Schucllat. MD. Principe! Depend Dirmor Leslie Dauphin. Acting Arterial? Diremar?r .S'rz?mcr Joanne Conn. MD. 542M, Dir-emu [wire 43am.- Quality Chesiey L. Richards, MD. MPH. Deputy Public Health Erin-tri?e 5mm: Michael F. ladetnaico. MD. MPH. Din-am: Center?rr Epidemiology mm'LdiEremmq Service: MMWR Editorial and Produetion Staff [Weaklyl Charlotte K. Kent. MPH. Acting Edimn'n Chief: Executive Editor- Jacqueline Gladier. MD. Editor Mary Dotr, MD. MPH, (Julius Editor Temsa F. Rutledge. Managing fairer Douglas W. Weathuwax. Lead Tat?nimi? Wtr??f?ar Glenn Damon. Soumya Dunworth, Teresa M. Hood. MS. manual Writer-a?oat: Martha F. Boyd. Lew} Visual Specialise Maureen A. Lei-ally. Julie C. Mnrtinroe. SmphenR. Spriggs. Tong Yang. Vitae! In?rmetfm Sammie: 'Quang M. Dean. MBA. H. King. Terraye M. Starr, Mona Yang, In?ramim spa-area MMWR Editorial Boon! Timothy F. Jones. MD. Matthew L. Buuitoo. MD. MPH Virginia A. Cains. MD Katherine Daniel. PM) Jonathan E. Fielding, IulD. MPH, NIBA David Fleming. MD eta MMWR Jun88,2018 r' Vol.6? No.22 William E. Helper-in. MD. DIPH. MPH King K. Holmes. MD. Robin Ikrda. MD. MPH Rim-.1 F. Khabbaz. MD Meadows. MSN. RN Jewel Mullen. MD. MPH. MFA Patricia Quinlislt. MD. MPH Patrick L. Remington. MD. MPH Carlos R'oig. M5. MA Wait-.1.? L. Roper. MD. MPH William Seha?iter. MD US Department of Health and Human ServicesiCemers for Disease Control and Prevention Morbidity and Mortality Weekly Report per 100,000 persons per?year. Age-adjusted suicide rate trends were modeled using the same 3-year data aggregates, employ- ing weighted least-squares regression with inverse-variance weighting. Modeled rate trends are reported in terms oF average annual percentage changes. Characteristics oF persons aged 1:10 years who died by suicide, with and without known mental health conditions, and the circumstances surrounding the suicides were compared in the 27 states? with complete data participating in CDC's National Violent Death Reporting System in 2015. defines mental health conditions as disorders and listed in the Diagnostic and Statistical Manual Disorders, Farr; Edition (9), with the exception oF problematic alcohol use and other subsranee use that are captured separately in VDRS aggregates data From three primary data sources: death certi?cates, coroneri'medical examiner reports (including toxi? cologyl, and law en Forcement reports. A range oF circumstances (relationship problems, life stressors, and recent or impending crises)I have been identi?ed as potential risk Factors For suicide in Circumstances captured are those identi?ed as con? tributing to suicide in coronerfmeclical examiner or law en Force? ment reports, which re?ect inForntation provided by Family and Friends at the time oF death. Decedents could have experienced multiple circumstances. Decedents with and without known mental health conditions were compared using chi-square tests. Logistic regression analyses were used to estimate adjusted odds ratios (aORsl with 95% confidence intervals (Cls), controlling For sex, age group, and tacoll ethnicity. Results The most recent overall suicide rates (representing 2014? 2016} varied FourFold, From 6.9 (District oF Columbia]I to 29.2 (Montana) per [00,000 persons per year (Supplementary Table; Across the study period, rates increased in all states except Nevada (where the rate was consistently high throughout the study period}, with absolute increases ranging From 0.8 per 100,000 (Delaware) to (Wyoming). Percentage increases in rates ranged From 5.9% (Delaware) to 57.6% (North Dakota), with increases >50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2013 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:31:? State Flate Change 2:33"; 1999 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Flank (State Rank} 1l (State Rink} 35111 12.3 We) 12.7 1+ 0.4) 12.3 1+ 0.2) 13.3 1+ 0.3) 14.5 1+ 0.3) 15.4 1+ 0.3) 1.5 31. 1p<.01) Na 3.1 0172.) 25.4 31.1mm 0.8. Male 20.311173) 2121+ 0.4) 21.3 1+ 0.0) 22.5 1+1.3) 23.5 1+ 1.0) 2451+ 1.0) 1.1 31. 1154.01) Female 4.7111711) 5.0 1+ 0.3) 5.3 1+ 0.2) 5.7 1+ 0.4) 3.2 1+ 0.5) 3.3 1+ 0.7) 2.3 31. 111.401) Both 14.31013) 13.4[ 0.91 14.1 0.31 153{+1. 31 13.4 0.71 11 25 +3.1 (311 ?1?0 [331 AL Male 25.1 {?131 23. 4 [1 .71 24.4 1.01 23. 4 2. 01 213 1.11 23.1 1. 51 1.3 ?7'0 Female 5.1 1117a 3-1 0. 3) 5.0 1+ 0.2)11+ 1 1) 341+ 0. 3) 0+10 2.3 31.113401) Both 21.0 24 3 3. 31 24.2 0.3?.4 ?7?0 1131 AK Male 33. 2 {r113} 33.1 4. 91 33.9 0.31 40 1 {4.1112140 1 0.11 42 9 2. 31 1.4 9/13 1134.01} Female 3.3011611 93(? 131 11.1{+ 21 1.21 +13% 013 Both 1?.81013) 13. 19.1 0.51131 (- 0.0) 20.4 1.31 20. 9 0. 51 1.0 ?fa {pt-1.011 15 3.1 {321 +113 ?701421 AZ Male 23.3 30. 2 1. 001 30.3 0.41 30.2 0.51 32. 0 1.31 32.4 0. 41 0.3 We {[34:05} Female 7.1 (1113) .5+1 +0 4) 2 1+ 0.7) 3 31+ 0.5) 3 2112.2 31. 11:14.01) Both 15.5 {?131 15. 3 0. 031 13.2 3. 51 17. 3 1.41 19.2 1.31 21.2 2. 01 2.2 "in 12 5.71141 33.3 "/01151 AH Male 2631013) 23. 2T2 0.5123.2(+ 1.01 31. 7' 3. 51 33.5 91 1.3 {pt-1.051 Female 5.61013)91+ 0. 031 21+ 0.41 911+ .1 3.3 2.11 3.3 ?35 {[34:01} 30111 10.31n7a) 1131+ 0. 7) 11. 010.3) 12. 0 1+ 1.0) 1131.1) 12.1 1+ 0. 3) 0.3 31.113305) 45 1.3 143) 14.3 31. 143) CA Male 17.9 (n13) .51 0.?1 10.1 .1 13.2 0.31 +0.5 ?1?0 Female 4.1 1n7a41+ 0.5) 3-10 .1) 5.3 1+ 0.3) 1.7 31. 1114.05) Beth 17.31r17a) 13.2 1+1. 3) 13.010 2) 2001+ 1.0) 2131+ 1.5) 23.2 1+ 1.3) 1.3 31.111401) 3 5.3 112) 34.1 31.122) 130 Male 233111711) 3031.5 1+ 1.0) 3341+ 1.3) 33.3 1+ 2.3) 1.4 31.113401) Female 7.01n7a) 1..11+ 0.3) 10.1 1+ 1.0) 10.4 1+ 0.3) 2.3 31. 1114.01) 30111 3.31n7a131.1) 11.0 1+ 0.3) 11.5 1+ 0.5) 1.3 31. 1114.05) 43 1.3 143) 13.2 31. 134) CT Male 13.41r17a) 14. 311.3) 15.0 1+ 0.4) 3 31+ 1.3) 17.3 1+ 1.0) 17.3 1- 0.3) 0.3 31. Female 3.3111711) 31+ 0.2) 7 1- 0.2) 41+ 0.7) 4.3 1+ 0.5) 3.2 1+ 1.3) 3.5 31.113305) Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change trorn Prior Period) Current Overall Overall State Sex 1:329? State Flate Change 2:313"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 1513113 Rank) 1 (State Hagnk) Both 13.3 1n1a) 12.2 1- 1.4) 11.0 1- 0. 3) 13. 311+ 14.2 1+ 0.3) 14.4 1+ 0.2) 0.3 31. 1115 42 0.3 150) 5.0 33150) DE Male 23.01n1?a} 2022.? 1- 0.4) 23.5 1+ 0.3) 0.3 31. 013 Female 5.3 13.13.} 5.0 1- 0.1.5} 5.2 1- 0.21 1.5 11.15 Bath 5.9 13.13.} 5.4 1+ 0.0.?1 5.9 1+ 0.3} 0.9 ofo 11.15 51 1.0 1481 15.1 01,10 (45} DC Male 10.? {Na} 11.1 1+ 0.1001-23) 11.? 1+ 0.3 1115 Female 1 11113111 2.3 1+ 0.3)11311.0) 3 1- 0.3) 3.5 31. 013 3001 14.8 13.13.} 15.2 1+ 0.1+21. 4} 15.3 1- 0.01 15.4 1+ 0.1} 0.8 ?2101134051 2'9 4- 1.5 1451 10.5 10148} FL Male 24.3 13.13.} 24.4 1+ 0.25.5 1- 0.51 25.5 1- 0.11 0.5 ofo 11.15 Female 5.3 111113.} 5.8 1+ 0.5} 31+ 0. 0} 11+2 0. 3} 7.5 1+ 0.5} 11.8 1+ 0.3} 1.4 ?fa {114.01} Both 12.9 1n13} 1321+ 0.3} 12. 31-0 .91 1321+ 0. 9} 13.? 1+ 0.5} 15.0 1+ 1.3} 0.9 ofo 1113 3'9 2.1 1401 +152 10144} GA Male 22.1 mm} 23.1 1+ 1.0) .31-1.3) 21 .0 1+0. 3) 2231+ 2441+ 0.5 34. 015 Female 5.0 131318-012151-021 0.3} 5.5 1+ 0.8} 2.1 010113405} Both 12.91313} 11. 1 1- 1.81 10. 31-0 .71 14.51+ 4.1} 14.41- 0.11 1521+ 0.8} 2.0 ?fa 1115 35 2.41351 +133 1-11 Male 20.41n1?a} 2 1-3 .1) 15.3 1- 1.0) 21.0 1+ 22.5 1+ 0.5) 24.3 1+ 1.3) 2.1 31. 013 Female 5.41313} 5.0 1- 0.41 5.5 1+ 0.5} 1 1+ 1.5} 5.2 1- 0.91 5.9 1- 0.31 1.2 11.15 Both 17.3 1313} 1921+ 2.0} 18. 3 1- 0. 91 2151+ 3. 3} 2131+ 0.3} 2431+ 2.8} 2.3 ?21011345.. 01} 3 151 51 43.2 1 7} "3 Male 28.411113} 33.1 1+ 4. 7} 3134.71-13.21 38.0 1+ 3.3} 1.15 0110113405} Female 7.2 .11110.5} 11.8 1+ 2.3} 4.4 ?1101134051 Bath 9.9 11113} 9. 8 1- 0.11 71-0511 10. 5 1+ 0. 8} 11.2 1+ 0.5} 12.2 1+ 1.0} 1.5 0210113405} 44 2.3 1381 22.8 ?110132} lL Male 17.1 111.13} 15H1.41 15.21- 0.41 1751+ 1.4} 18.5 1+ 0.9} 19.31+1.3} +1.1 ?1101134051 Female 11113} 3.5 1-0.01810.4} 5.2 1+ 0.5} 2.4 011: {1341.01} Beth 13.011113} 131491+ 0. 5} 13.4 1+ 1.4} 17.1 1+ 0.7} +1.9 ?fa {1:14.011 25 4.1 1231 31.9 ?313125} Male 22.411113} 23.2 1+ 0.8} 24. 4 1+ 1.2} 24. 7 1+ 0. 4} 25.? 1+ 2.0} 28.3 1+ 1.5} 1.5 Female 4.5 111.13} 5.0 1+ 0.0.9} 5.5 1- 0.21 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Flank 5 {State Rank) Ill (State HEnk) 1.4. Both 11.31n2a1 13.21+1.41 1231-04) 14.2 1+ 1.41 15.9 1+ 1.21 13.0 1+ 0.11 +2.1 241134.011 31 +4.31201 33.2 9.1131 1.4 Male 20.3 1n2a1 22.1 1+ 1.51 20.3 1- 1.41 23.3 1+ 2.51 23.0 1+ 2.21 25. 2 1- 0. 31 1.3 12.. 1134.051 Female 3.710131 431+ 1.0} 531+ 0.61 5.51+ 0.21 5.1 1+ 0.5171+ 0 61 3.8 ?20 113-3. 011 Bath 13.31n1?a1 15.1 1+ 1.8} 1581+ 0.71 15.31- 0.51 17.? 1+ 2.4} 19.41+1.51 2.2 ofo 011 19 5.01111 45.0 01120 1 5} KS Male 22.21n2a1 25.0 1+ 2.31 23.5 1+ 151 25.3 1- 0.91 29.1 1+ 3.51 30. 2 1+ 1.31 1.9 12.. 112.4. 011 Female 4.5 10131 5.0 1+ 1.4} 5. 7 1- 0. 31 5.41- 0.31 5.8 1+ 1.4} 3. 4 1+ 1.51 3.2 01120 (134051 Beth 14.1 1l'I1'ia} 15.41+1.3} 3.1 15.21-11.51 18.21+2.0} 19.3 1+1. 11 1.9 ?20 113-3. 011 20 +5.2 1151 +355 10115} KY Male 25.01n2a1 2331+ 1.91 23. 3 1+1 41 22.2 1- 1.01 30.1 1+ 2.9} 31.2 1+ 1 .31 1.4 02.. 11:4. 011 Female 4.8111118} 5210.1} 7.1 1+ 0.9} 711+ 0. 51 3.2 ?2?0 {114.011 Beth 13.1 {We} 12. 91-0 .1 13.41+ 0.41 1351+ 0.31 14.41+ 0.8} 1701+ 2. 51 +1.6 01120 (134051 27 3.8 112?} 29.3 10125} LA Male 22.9 1n2a1 22. 3 1- 0. 31 22.4 1+ 0 11 23.3 1+ 0.31 23.2 1+ 0.51 22.3 1+ 3 31 1.1 02.. 1115 Female 4.8 [0131 10.21 0.1 1+ 1.2} 5 1+ 1 .41 2.8 ?24 {1:14. 051 Both 14.5 1l'l1'ia15.4 1+ 1.0} 18.9 1+ 3.5} 18. 5 1- 0. 41 2.2 ?2?0 {114.051 21 4.01251 27.4 l:51'3129} ME Male 25.01n2a1 22.91.11 24.31+1 21 25.21+1.11 31.1 1+ 5.41 29.31 .31 1.312.. 1134. 051 Female 5.3 10131 5.3 1- 0012-01311 5.0 1+ 0.7} 7.6 1+ 1.5} 91+ 0. 31 3.1 ?20 113-3. 051 33111 10.010131 1031+ 0.31 101 1-0 .21 1021+ 0.11 1021+ 0.51 1031+ 0.11 0.5 0.31114 0514243 0.3149??1 3.5 :34414901 MD Male 17.511113} 1?.31? 0. 51 17.71+0.41 18.21+0.5} 18.0 1* 0.2] +0.2 019 Female 3.5 111131 3.8 1+ 0.4} 3. 9 1+ 0. 01 0.21 4.1 1+ 0.4} 4.5 1+ 0.41 1.3 ?2?0 {1:14.051 Both 1411113.} 1+ 0.1.0} 9.8 1+ 0.4} 10.0 1+ 0.31 2.3 (1214:2011 48 2.5134 111 35.3 %120 1ml) MA Male 12.1 111.13.} 12,181+ 0.?1 13 31+ 0. 51 1541+ 2.11 15.21- 0.21 1301+ 0.81 2.0 ?fa 1p<.011 Female 3.3 11113.} 2.9 1- 0.41 4.0 1+ 1.01 3.8 1- 0.11 4.8 1+ 1.0} 51* 0.21 3.0 ?2101134051 Both 11.811113} 1251+ 0.?1 1291+ 0. 41 13.91+1.01 1451+ 0.7} 15 01+1.11 +1.9 ?2?0 1134.011 33 3.9 125} 32.9 31:1241 Ml Male 20.0 11113.} 20.9 1+ 0.9} 21.0 1+ 0. 71 22.8 1+ 1.3} 23.9 1+ 1.0} 25. 0 1+ 1 .21 1.5 1p<.011 Female 4.4 111.13.} 4.8 1+ 0.4} 01+ 0. 21 5.3 1+ 0.5} 5.9 1+ 0.3171+ 0.91 2.8 1p<.011 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period} Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {51131113 Rank) Ill (State Hgnk) H. Both 10.71n13} 11.5 1+ 0.31 12.41+0.31 12. 3 1+0. 51 14.2 1+ 1.31 15.0 1+ 0.31 +2.3 31.. 1114. 011 33 +4.31131 40.3 331 31 MN Male 18.31n1?a} 13.31+1.22.3 1+ 1.31 2331+ 0.41 31. 011 Female 3.011113} 421+ 0.581+ 0.5} 91+ 1.2} 4.2 111-3. 01} Beth 12.911113} 14.1 1+ 1.1551+ 0.1} 15. 21- 0. 31 1.1 ?1151134051 35 2.3135} +173 01,10 (40} MS Male 22.9 11113.} 24.5 1+ 1.1} 25.1 1+ 0. 25. 8 1+ 25.9 1- 0.91 5. 3 1-0 .51 ?2?0 1115 Female 4.3 111130.01 5.4 1+ 0.9} 21- 0. 21 2.4 115113301) Beth 14.711113} 14.1 1- 0. 5} 15.4 1+ 1.3} 1001+ 0.7} 17.8 1+ 1.1} 2001+ 2. 3} 2.2 ?151134.011 10 5.3115} 35.4 11?} MD Male 25.3 11113.} 23.71-1 .51 25. 5 1+ 1.9} 20.6 1+ 1.0} 23.9 1+ 2.3} 32. 2 1+ 3. 3} 1.8 ?1151134051 Female 5.4111181} 5.41+ 0.1} 11+ 0. 7} 531+ 0. 2} 7.41+1.1} 3.2 ?fa 1131101} Both 21.1 1013} 22.3 1+ 1.41 23.31+10.1 11 23.? 1+ 2.01 2321+2.51 +2.1 031132.011 1 +3.01 21 33.0 :3.1111 MT Male 35.9 11118.} 37.3 1+ 0.4} 39. 3 1+ 2. 5} 39271-0 .11 41.0 1+ 1.4} 45. 5 1+ 1.3 ?151134.011 Female 371111.11 3.4 1+ 1.31 3.4 1- 0.11 10.0 1+ 1.31 12.3 1+ 2.31 13.1 1+ 0. 451 4.3 0.1. 1134.011 Both 12.71n1?a} 12.2 1- 0.51 12.3 1+ 0.41 11.71- 0.31 13.5 1+ 1.2.1 1421 13.2 :131431 NE Male 22.2 1013} 20.71- 1.51 20.3 1- 0.41 13.3 1- 0 51 22.0 1+ 2.21 23. 3 1+ 1 31 0.3 31. 013 Female 3.3 11118.} 4.2 1+ 0.4} 5.1 1+ 0.1.4} 81+ 0 3} 2.0 1115 B13111 23.3 11113.} 22.5 1- 0.51 22.1 1- 0.51 22.0 1+ 0.5} 21.41- 1.21 23. 1 1+ 1.0} - 0.2 1113 9 - 0.2151} - 1.0 (?10 1511 N11 Male 38.3 111151} 3071-17} 35.1 1- 1.8} 35.6 1+ 0.5} 32.5 1- 3.0.7 ?51: 1113 Female 8.911113} 951+ 0 5} 951+ 0.1} 1001+ 0.4} 1031+ 0.0} 1121+ 4010. +1.5 ?fa {114.01} 30111 13.511113} 12. 51- 1.01 1331+ 0.8} 15.21+1.9} 1531+ 0.5} 20 01+ 2.7 010113405} 17 5.51 81 48.3 1101 3} NH Male 22.5 11113.} 21.1 1-1 .41 21.7 1+ 0.0} 24.3 1+ 3.1} 25.4 1+ 0.5} 30. 6 1+4 5 2} 2.2 0.11:1 1134:. 05} Female 5 3 111131.0} 5.2 1+ 0.4} 5.0 1+ 0.4} 9. 8 1+ 3. 2} 3.9 011: {pt-1. 051 B13111 7.8 11113.} 1- 0.0.9} 9. 2 1+ 0 4} 1.3 ?101114.051 50 1.5 {47} 19.2 313135} NJ Male 13.011113} 13.1 1+ 0.0} 12.010 .51 1371+ 1 1} 14.51+0.8} 14.61+0.1} Female 3 2 11113.} 9 1- 0.31 001+ 9-01.11 3.8 1+ 0.9} 4. 4 1+ 0. 0} 2.3 1115 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2018 Age-Adjusted Annual Rate per 100,000 Persons [Change 1mm Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2008 2010 2011 2013 2014 2016 Rank 5 1513113 Rank) Ill (State Hgnk) H. Both 22.0 (n13) 22.0 1- 0.1) 21.0 1- 0.2) 23.0 1+ 1.2) 24.1 1+ 1. 1) 20.0 1+ 1 .0) 1.1 01.113405) 4 4.0 124) 13.3 =14. 130) NM Male 38.8 111131.2} 35.8 1- 0.8} 87.1 1+ 1.8} 40.7 1+ 8.8} 0.4 810 1115 Female 8511113.} 1.1} 8.21+0.7} 10.71+2.8} 12.0 1+ 0.8} +3.8 1114. 05} Beth 2.2111151) 1-01 .1) 7111+1. 1) 31- 0.1) 2.1 c1011:1401) 40 2.1 141) 20.3 01.12?) NY Male 12.51n13} 12.210 3) 13.01.+10) 15..41+14) 1451-00) +1.4%1p4.05} Female [010} 01-0 .1) 3.01+0.3) 3.5 4.01+0.5) +4.2 01. 1p4 01) 80111 18.811113} 18.51-13.11 18.71+0.1} 14.21+0.5} 14.51+0.4} 15.31+0.8} +0.8ofo 1114.01} 84 +1.7144} +127 810141} NC Male 22.711113} 22.? 1+ 0.0} 22.2 1- 0.8} 23. 3 1+ 1.1} 28. 3 1+ 0.0} 23. '9 1+ 0. 8} 0.4 ofo 1115 Female 5.0 11113.} 5.5 1- 0.2} 8.2 1+ 0.8} 8.0 1- 0.2.0 ?191134.05} 80111 18.811113} 14.8 1+ 1.8} 10.0 1+ 1.4} 1881+ 0.8} 18.4 1+ 1.9} 2091+ 2. 5} 2.9 810113401} 14 1.81 5} 57.8 8?31 1} ND Male 21.41n1a) 24.0 1+ 3.2) 20.0 1+ 3.4) 2?.1 1- 0.2.5 c1.4113401) Female 5.8 11113.} 4.5 1- 1.0} 8.71- 0.8} 5.7 1+ 2.0} 8. 1 1+ 1.0} 8. 5 1+ 1.8} 8.9 0er 1115 80111 11.011118} 1281+ 0.8} 18.1 1+ 0.8} 13.41+ 0.2} 14. 8 1+ 1 15.81+ 1.0} 2.0 ?19 1134. 01} 82 4.2 121} 88.0 ?10119} 01-1 Male 20.41n1a) 20.0 1+ 0.5) 22.2 1+ 1.3) 22.1 1- 0.1) 24. 2 1+ 2.1) 25. 5 1+ 1.3) 1.5 0.1.1134 01) Female 4.011113} 1+ 0. 4.91+ 0.1} 581+ 0.3.4 1114. 01} 80111 17.011113} 18. 51-0 1721+ 0.8} 18.41+1.1} 20. 7 1+2. 8} 28.51+2.8} +2.8 1% 1134. 05} 7 8.4 110} 87.8%: 112} UK Male 28.5 11113.} 27. 8 1- 1. 2} 27.8 1+ 0.5} 80.8 1+ 2.5} 88. 4 1+ 8.1} 37. 8 1+ 8. 8} 2.0 810113405} Female 8.8 11113.} 8.41-0.21 5 1+ 1 1.0 1- 0.5} 8. 5 1+ 1.8} 10. 8 1+ 1.8} 2.9 1134. 05} 80111 18.411113} 11.? 1+ 1.8} 17 71- 0.0} 18.81+ 0.9} 19.81+1.2} 21.1 1+ 1.8} +1.8 1134. 01} 18 4.8118} 28.2 tT113128} OH Male 21.411113} 2951+ 2.1} 28.51- 0. 9} 2951+ 1.0} 81.4 1+ 1.8} 38.0 1+ 1.8} +1.1 0110113401} Female 8.511113} 1.1 1+ 0.8} 71+ 0. 8} 841+ 0.7} 8. 8 1+ 0. 4} 881+ 0. 9} 2.7 0.11: 1134. 01} 80111 12.1 11113.} 12.5 1+ 0.4} 12.81+0.8} 18.91+1.1} 15.0 1+1. 1} 18.81+1.2} +2.0 ?10 1114.01} 30 +4.1 122} +848 ?310121} PA Male 21.011113} 2131+ 0.8} 2191+ 0. 8} 28.1 1+ 1.2} 24 11+1.7} 28.1 1+ 1.8} +1.5 1134. 01} Female 4.2 11113.} 4.8 1+ 0.8} 81+ 0. 0} 5.4 1+ 0.9} 8. 0 1+ 0.8} 1+ 11} 8.5 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {State Hank) Ill (State Hgnk) H. Bath 9.4 {ma} 9.0 (- 0.3} 9.0 (- 0.0} 12. 51+ 3. 5} 11.9 (- 0.9} 12. 511+ 0. 7} 2.5 92. 032.05} 43 3.2 (30 34.1 35 (23 at Male 15.4 {ma} 15.2 0.2} 14.5 1- 0.3} 21.2 5.4} 19.2 1- 2.11.5 Female 4.0 {Na} 3.3 (- 0.7} 3.3 0.4} 5.1 1.3} 5.1 0.0} 1.0} (p4. 05} Beth 12.301113} 13.0 0.2} 13.7 0.7} 18.0 11} 2.3 ofo (D4. 01} 23 4.9 33.3 We (10} 80 Male 21.3 {ma} 2251+ 1 22.31- 0.1} 2451+ 2.2} 25.1 1+ 1.5} 25.0 1+ 1 9} 1.5 95 {52. 01} Female 5.401.113} ?(ill 6.0 1.3} 5.2 0.1.4} 3.4 ofo (p4. 05} Beth 15.701113} 17.1 {[3401} 10 +44.5 ?Vc? 5} SD Male 2?.5 {ma} 2531.3} 229 1+ 1.5} 30.11.5} 1.5 54. {p4. 01} Femaie 4.2 {ma} 5.5 5.4 1+ 0.1.(p2. 01} Beth 14.501113} 15.2 0.6} 16.1 0.8} 1?.2 1.1} 17.2 0.0} +1.4 ofo (p4. 01} 22 3.5128} 24.2 3?3 (31} TN Male 25.1 {ma} 25.4 1+ 0.3} 25.5 1+ 1.3} 25.0 1+ 1.2} 25.5 1+ 0.5} 29. 5 1+ 1.2} 1.2 54. (52. 01} Female 5.4 {Na} 5.3 0.9} 6.7 0.4} 7.5 0.8} 6.9 0.6} 16 0. 7} 1.9 ofo (D4. 05} Both 12.20118} 12.? 0.6} 12. 0. 4} 13.2 0.9} 13.6 0.3} 14. 5 0. 9} 1.1 ?2?5 01} 41 2.3 (37} +139 We (36} TX Male 20.4 {Na} 20.9 0.5} 20. 4 (- 0. 5} 22.0 1.6} 22.2 0.3} 23.1 0. 9} 0.9 ofo (p4. 05} Female 4.3 {Na} 5.4 0.5} 5.0 (- 0.4} 5.2 0.2} 5.6 0.4} 0. 8} 1.6 (p4. 05} Both 17.2 (1115} 19.0 18.2 (- 0.7} 20.2 2.0} 24.0 3.8.01: 3 W) 45.5 4 11} UT Male 28.2 (0.15} 31.1 2.9} 29.4 (- 1.7} 32.1 2.7} 37.8 5.7} 38. 0 0.2} 2.1 011: 05} Female 6.3 [015} 7.4 0.6} 7.5 0.1} 8.5 10.6 2.1} 12. 6 2. 0} 4.4 ?2?5 01} Both 18.2 14.9 1.3} 18.? 2.1} 19.? +2.4 01} 13 9} +436 Wed 2} VT Male 23.6 (1115} 28.3 4.6} 24. 3 (- 4. 0} 27.3 3.0} 31.0 3.7} 32. 5 1.9 4% (D4. 05} Female 4.3 (11.15} 5. 2 0. 9} 6.4 1.3} 5.6 0.2} 7.3 0.7} 7. 6 0.3} 3.8 011: 01} Both 12.81015} 12. 12.9 0.3} 13.6 0.7} 14.6 0.9} 15. 0 0 5} +1.2 ?2?0 01} 37 2.2 (39} +174 3?5 (41} VA Male 21.6 {015} 21.3 0. 2} 21.0 0.4} 22.5 1.5} 23.6 23. 9 0. 2} 0.9 Female 5.3 {015} Ht, 5 9 0.7} 6 (- 0.3} 6.4 0.8} 5. 9 0. 5} 1.3 (D4. 05} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period) Current Overall Overall State Sex 1? State Rate Change 2:33"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Rank 5 (State Hank) (State Hagnkji Both 14.3 1n1a} 15.4 1+ 3.5} 14. 3 1-3 15. 711+ 3. 31 16.6 1+ 3.3} 17.6 1+ 1.3} 1.1 331133.351 24 2.3 1331 13.3 :13137} WA Male 24.71nra1 25.2 1+ 3.5} 24.1 11.11 25.1 1+ 1.3} 23.3 1+ 3.3} 27.1 1+ 1.1} 3.6 33 1113 Female 5.9 111.13.} 5.4 1+ 0.0.8} 3.5 1+ 0.8} 2.5 112M011 Both 15.31nra} 17.21+ 1.6} 16. 71- 3. 51 16.31.71 1321+ 3.2} 21.41+ 2.2} +1.3 33 11 5.3113} 37.133114} wv Male 27.2 {ms} 33.1 1+ 2.3} 2331-15) 27. 31- 1. 31 3151+ 3.3} 33.5 1+ 2.3} 1.1 33 1115 Female 5.3 111.13.} 5.5 1+ 0.1} 5.8 1+ 0.3} 5.3 1- 0.5} 7.5 1+ 2.3} 9.8 1+ 2.2} :1er 1115 Both 13.1 13.5 1+ 0.4} 14.0 1+ 0.5} 15.0 1+ 1.0} 15.3 1+ 0.3} 15.5 1+ 1.2} 1.5 112M011 23 3.4129} 25.8 10130} w1 Male 21.71nra} 22.2 1+ 3.5} 22.7 1+ 3.5} 24.3 1+ 1.2} 24.4 1+ 3.4} 25.7 1+ 1.3} 1.1 33 1133.31 1 Female 5.1 {hrs} 5.3 1+ 3.2} 5.6 1+ 3.4} 341+ 3.71 3.5 1+ 3.1} 7.5 1+ 1.3} 2.5 33153.31} Both 20.71nra1 23.4 1+ 2.7} 22.5 1- 3.31 25.4 1+ 2.3} 23.3 1+ 3.5} 23.3 1- 3.11 2.3 031133.311 3 3.1 1 11 33.3 =13 1 3} WY Male 34.3 39.3 1+ 4.5} 35.3 1- 3.0} 41.5 1+ 5.2} 47.1 1+ 5.6} 44.5 1- 2.4} 1.8 112M051 Female 7.7111131} 3.2 1+ 3.6} 3.2 1+ 3.3} 3.4 1+ 3.2} 13.7 1+ 1.4} 12.3 1+ 1.3} 3.2 33 11:13.31 1 Rates are age?adjusted to the US. year 2000 standard. 1 Model?estimated average annual percentage change based on all reporting periods; p?value indicates statistical significance of trend; indicates trend not significant. ?5 Current state rank (50 states and the District of Columbia} is for the reporting period 2014 2016. Ranks are from highest rate (11 to lowest rate (511. Different ranks do not necessarily imply a statistically significant difference. 1 Overall rate change is between the first (1999 20011 and last [2014 20161 reporting periods. Hanks are from largest increase {11 to largest decrease 1511. Different ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the first 11999 20011 and last (2014 2015) reporting periods. Ranks are from largest percentage increase 111to largest percentage decrease 1511. Different ranks do not necessarily imply a statistically significant difference. TT Hate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. till Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. State Abbreviations: AL Alabama; AK Alaska; AZ Arizona; AR Arkansas; CA California; CO Colorado; CT Connecticut; DE Delaware; DC District of Columbia; FL Florida; GA Georgia; HI Hawaii; ID Idaho; IL Illinois; IN Indiana; IA Iowa; KS Kansas; KY Kentucky; LA Louisiana; ME Maine; MD Maryland; MA Massachusetts; MI Michigan; MN Minnesota; MS Mississippi; MO Missouri; MT Montana; NE Nebraska; NV Nevada; NH New Hampshire; NJ New Jersey; NM New Mexico; NY New York; NC North Carolina; ND North Dakota; OH Ohio; OK Oklahoma; OR Oregon; PA Fthode island; SC South Carolina; SD South Dakota; TN Tennessee; TX Texas; UT Utah; VT Vermont; VA Virginia; WA Washington; WV West Virginia; Wisconsin; WY Wyoming. #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 From: Richmond-Crum, Malia Sent: 6 Jun 2018 16:35:29 -0400 To: Jack, Shane P. Davis Cc: Blair, Janet Deborah Erin Marie R. (CDCXOPHPRIDD) Subject: EMBARGOED UNTIL 1PM June 7: Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Attachments: MMWR Supplemental table_?v?S 5uicide_ 6.7.2018_final.pdf, Signs_ Suicide_5.7.2018_article.pdf, TPs.docx Shane Here is the email {below} and attachments to share with tomorrow morning at 9am {please do not send out before 9am}. As requested by the principle investigators, I?ve also attached internal talking points that thev my use if they choose. Malia Dear Principle investigators: The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and 0.0., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This email contains advance copies of several Vital Signs materials, including the Morbidity and ii/iortoiitj.r Weekiy Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four?page consumer fact sheet. This latest edition of CDC Vito! Signs will be released today, Thursdav,1une 2013, at 1:00 pm following a media telebriefing at noon; all attached materials are EMBARGOED until 1pm EST. Kev points in the Vitoi Signs report include: I In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older I From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition IA range of factors contributes to suicide beyond mental health conditions alone, including relationship. substance use. physical health. job, ?nancial, and legal problems. After the embargo is lifted today at 1 pm please share the CDC Vita:f Signs information broadly with your colleagues and partners. Visit the Vita! Sions Webpageto find the MMWR article, fact sheet, and other materials. Take advantage of CDC's sogngg-zgiitoglg, such as the Vital Signs buttons and email updates. Visit CDC's Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vita! Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Social Media Handles and Twitter Chat: Please save the date for our upcoming Twitter chat: The Twitter chat, scheduled for June from 2-3PM ET, will be co-hosted by CDC and The National Action Alliance for Suicide Prevention [@Action Alliance). Day: Monday, June 11th Time: ET Place: Twitter.com from your computer or mobile device and search the hashtag #SuicideChat During the chat, you'll be able to: I Gain key insights into the most recent @CDCInjury Vital Signs issue . Ask questions of experts from @CDCInjury and @ActionFAlliance I Share your own prevention resources and stories Spread the Word - Tweet: Join the @CDCinjury 8.: @ActionAlliance #SuicideChat on Monday June 11 2-3PM ET. Topics covered include the latest @CDCgov #VitalSigns issue and rates of #suicide in the US. Additionally, watch for social posts from these handles: 0 CDC Facebook CDC Twitter 0 CDC eHealth Twitter 0 CDC lniury Twitter 0 CDC Veto?v?iolence Facebook CDC Linkedln Moogla CDC Pinterest CDC lnstagram [check the stories after 1pm 0 CDC Director Twitte_r Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2013 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:31:? State Flate Change 2:33"; 1999 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Flank (State Rank} 1l (State Rink} 35111 12.3 We) 12.7 1+ 0.4) 12.3 1+ 0.2) 13.3 1+ 0.3) 14.5 1+ 0.3) 15.4 1+ 0.3) 1.5 31. 1p<.01) Na 3.1 0172.) 25.4 31.1mm 0.8. Male 20.311173) 2121+ 0.4) 21.3 1+ 0.0) 22.5 1+1.3) 23.5 1+ 1.0) 2451+ 1.0) 1.1 31. 1154.01) Female 4.7111711) 5.0 1+ 0.3) 5.3 1+ 0.2) 5.7 1+ 0.4) 3.2 1+ 0.5) 3.3 1+ 0.7) 2.3 31. 111.401) Both 14.31013) 13.4[ 0.91 14.1 0.31 153{+1. 31 13.4 0.71 11 25 +3.1 (311 ?1?0 [331 AL Male 25.1 {?131 23. 4 [1 .71 24.4 1.01 23. 4 2. 01 213 1.11 23.1 1. 51 1.3 ?7'0 Female 5.1 1117a 3-1 0. 3) 5.0 1+ 0.2)11+ 1 1) 341+ 0. 3) 0+10 2.3 31.113401) Both 21.0 24 3 3. 31 24.2 0.3?.4 ?7?0 1131 AK Male 33. 2 {r113} 33.1 4. 91 33.9 0.31 40 1 {4.1112140 1 0.11 42 9 2. 31 1.4 9/13 1134.01} Female 3.3011611 93(? 131 11.1{+ 21 1.21 +13% 013 Both 1?.81013) 13. 19.1 0.51131 (- 0.0) 20.4 1.31 20. 9 0. 51 1.0 ?fa {pt-1.011 15 3.1 {321 +113 ?701421 AZ Male 23.3 30. 2 1. 001 30.3 0.41 30.2 0.51 32. 0 1.31 32.4 0. 41 0.3 We {[34:05} Female 7.1 (1113) .5+1 +0 4) 2 1+ 0.7) 3 31+ 0.5) 3 2112.2 31. 11:14.01) Both 15.5 {?131 15. 3 0. 031 13.2 3. 51 17. 3 1.41 19.2 1.31 21.2 2. 01 2.2 "in 12 5.71141 33.3 "/01151 AH Male 2631013) 23. 2T2 0.5123.2(+ 1.01 31. 7' 3. 51 33.5 91 1.3 {pt-1.051 Female 5.61013)91+ 0. 031 21+ 0.41 911+ .1 3.3 2.11 3.3 ?35 {[34:01} 30111 10.31n7a) 1131+ 0. 7) 11. 010.3) 12. 0 1+ 1.0) 1131.1) 12.1 1+ 0. 3) 0.3 31.113305) 45 1.3 143) 14.3 31. 143) CA Male 17.9 (n13) .51 0.?1 10.1 .1 13.2 0.31 +0.5 ?1?0 Female 4.1 1n7a41+ 0.5) 3-10 .1) 5.3 1+ 0.3) 1.7 31. 1114.05) Beth 17.31r17a) 13.2 1+1. 3) 13.010 2) 2001+ 1.0) 2131+ 1.5) 23.2 1+ 1.3) 1.3 31.111401) 3 5.3 112) 34.1 31.122) 130 Male 233111711) 3031.5 1+ 1.0) 3341+ 1.3) 33.3 1+ 2.3) 1.4 31.113401) Female 7.01n7a) 1..11+ 0.3) 10.1 1+ 1.0) 10.4 1+ 0.3) 2.3 31. 1114.01) 30111 3.31n7a131.1) 11.0 1+ 0.3) 11.5 1+ 0.5) 1.3 31. 1114.05) 43 1.3 143) 13.2 31. 134) CT Male 13.41r17a) 14. 311.3) 15.0 1+ 0.4) 3 31+ 1.3) 17.3 1+ 1.0) 17.3 1- 0.3) 0.3 31. Female 3.3111711) 31+ 0.2) 7 1- 0.2) 41+ 0.7) 4.3 1+ 0.5) 3.2 1+ 1.3) 3.5 31.113305) Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change trorn Prior Period) Current Overall Overall State Sex 1:329? State Flate Change 2:313"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 1513113 Rank) 1 (State Hagnk) Both 13.3 1n1a) 12.2 1- 1.4) 11.0 1- 0. 3) 13. 311+ 14.2 1+ 0.3) 14.4 1+ 0.2) 0.3 31. 1115 42 0.3 150) 5.0 33150) DE Male 23.01n1?a} 2022.? 1- 0.4) 23.5 1+ 0.3) 0.3 31. 013 Female 5.3 13.13.} 5.0 1- 0.1.5} 5.2 1- 0.21 1.5 11.15 Bath 5.9 13.13.} 5.4 1+ 0.0.?1 5.9 1+ 0.3} 0.9 ofo 11.15 51 1.0 1481 15.1 01,10 (45} DC Male 10.? {Na} 11.1 1+ 0.1001-23) 11.? 1+ 0.3 1115 Female 1 11113111 2.3 1+ 0.3)11311.0) 3 1- 0.3) 3.5 31. 013 3001 14.8 13.13.} 15.2 1+ 0.1+21. 4} 15.3 1- 0.01 15.4 1+ 0.1} 0.8 ?2101134051 2'9 4- 1.5 1451 10.5 10148} FL Male 24.3 13.13.} 24.4 1+ 0.25.5 1- 0.51 25.5 1- 0.11 0.5 ofo 11.15 Female 5.3 111113.} 5.8 1+ 0.5} 31+ 0. 0} 11+2 0. 3} 7.5 1+ 0.5} 11.8 1+ 0.3} 1.4 ?fa {114.01} Both 12.9 1n13} 1321+ 0.3} 12. 31-0 .91 1321+ 0. 9} 13.? 1+ 0.5} 15.0 1+ 1.3} 0.9 ofo 1113 3'9 2.1 1401 +152 10144} GA Male 22.1 mm} 23.1 1+ 1.0) .31-1.3) 21 .0 1+0. 3) 2231+ 2441+ 0.5 34. 015 Female 5.0 131318-012151-021 0.3} 5.5 1+ 0.8} 2.1 010113405} Both 12.91313} 11. 1 1- 1.81 10. 31-0 .71 14.51+ 4.1} 14.41- 0.11 1521+ 0.8} 2.0 ?fa 1115 35 2.41351 +133 1-11 Male 20.41n1?a} 2 1-3 .1) 15.3 1- 1.0) 21.0 1+ 22.5 1+ 0.5) 24.3 1+ 1.3) 2.1 31. 013 Female 5.41313} 5.0 1- 0.41 5.5 1+ 0.5} 1 1+ 1.5} 5.2 1- 0.91 5.9 1- 0.31 1.2 11.15 Both 17.3 1313} 1921+ 2.0} 18. 3 1- 0. 91 2151+ 3. 3} 2131+ 0.3} 2431+ 2.8} 2.3 ?21011345.. 01} 3 151 51 43.2 1 7} "3 Male 28.411113} 33.1 1+ 4. 7} 3134.71-13.21 38.0 1+ 3.3} 1.15 0110113405} Female 7.2 .11110.5} 11.8 1+ 2.3} 4.4 ?1101134051 Bath 9.9 11113} 9. 8 1- 0.11 71-0511 10. 5 1+ 0. 8} 11.2 1+ 0.5} 12.2 1+ 1.0} 1.5 0210113405} 44 2.3 1381 22.8 ?110132} lL Male 17.1 111.13} 15H1.41 15.21- 0.41 1751+ 1.4} 18.5 1+ 0.9} 19.31+1.3} +1.1 ?1101134051 Female 11113} 3.5 1-0.01810.4} 5.2 1+ 0.5} 2.4 011: {1341.01} Beth 13.011113} 131491+ 0. 5} 13.4 1+ 1.4} 17.1 1+ 0.7} +1.9 ?fa {1:14.011 25 4.1 1231 31.9 ?313125} Male 22.411113} 23.2 1+ 0.8} 24. 4 1+ 1.2} 24. 7 1+ 0. 4} 25.? 1+ 2.0} 28.3 1+ 1.5} 1.5 Female 4.5 111.13} 5.0 1+ 0.0.9} 5.5 1- 0.21 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Flank 5 {State Rank) Ill (State HEnk) 1.4. Both 11.31n2a1 13.21+1.41 1231-04) 14.2 1+ 1.41 15.9 1+ 1.21 13.0 1+ 0.11 +2.1 241134.011 31 +4.31201 33.2 9.1131 1.4 Male 20.3 1n2a1 22.1 1+ 1.51 20.3 1- 1.41 23.3 1+ 2.51 23.0 1+ 2.21 25. 2 1- 0. 31 1.3 12.. 1134.051 Female 3.710131 431+ 1.0} 531+ 0.61 5.51+ 0.21 5.1 1+ 0.5171+ 0 61 3.8 ?20 113-3. 011 Bath 13.31n1?a1 15.1 1+ 1.8} 1581+ 0.71 15.31- 0.51 17.? 1+ 2.4} 19.41+1.51 2.2 ofo 011 19 5.01111 45.0 01120 1 5} KS Male 22.21n2a1 25.0 1+ 2.31 23.5 1+ 151 25.3 1- 0.91 29.1 1+ 3.51 30. 2 1+ 1.31 1.9 12.. 112.4. 011 Female 4.5 10131 5.0 1+ 1.4} 5. 7 1- 0. 31 5.41- 0.31 5.8 1+ 1.4} 3. 4 1+ 1.51 3.2 01120 (134051 Beth 14.1 1l'I1'ia} 15.41+1.3} 3.1 15.21-11.51 18.21+2.0} 19.3 1+1. 11 1.9 ?20 113-3. 011 20 +5.2 1151 +355 10115} KY Male 25.01n2a1 2331+ 1.91 23. 3 1+1 41 22.2 1- 1.01 30.1 1+ 2.9} 31.2 1+ 1 .31 1.4 02.. 11:4. 011 Female 4.8111118} 5210.1} 7.1 1+ 0.9} 711+ 0. 51 3.2 ?2?0 {114.011 Beth 13.1 {We} 12. 91-0 .1 13.41+ 0.41 1351+ 0.31 14.41+ 0.8} 1701+ 2. 51 +1.6 01120 (134051 27 3.8 112?} 29.3 10125} LA Male 22.9 1n2a1 22. 3 1- 0. 31 22.4 1+ 0 11 23.3 1+ 0.31 23.2 1+ 0.51 22.3 1+ 3 31 1.1 02.. 1115 Female 4.8 [0131 10.21 0.1 1+ 1.2} 5 1+ 1 .41 2.8 ?24 {1:14. 051 Both 14.5 1l'l1'ia15.4 1+ 1.0} 18.9 1+ 3.5} 18. 5 1- 0. 41 2.2 ?2?0 {114.051 21 4.01251 27.4 l:51'3129} ME Male 25.01n2a1 22.91.11 24.31+1 21 25.21+1.11 31.1 1+ 5.41 29.31 .31 1.312.. 1134. 051 Female 5.3 10131 5.3 1- 0012-01311 5.0 1+ 0.7} 7.6 1+ 1.5} 91+ 0. 31 3.1 ?20 113-3. 051 33111 10.010131 1031+ 0.31 101 1-0 .21 1021+ 0.11 1021+ 0.51 1031+ 0.11 0.5 0.31114 0514243 0.3149??1 3.5 :34414901 MD Male 17.511113} 1?.31? 0. 51 17.71+0.41 18.21+0.5} 18.0 1* 0.2] +0.2 019 Female 3.5 111131 3.8 1+ 0.4} 3. 9 1+ 0. 01 0.21 4.1 1+ 0.4} 4.5 1+ 0.41 1.3 ?2?0 {1:14.051 Both 1411113.} 1+ 0.1.0} 9.8 1+ 0.4} 10.0 1+ 0.31 2.3 (1214:2011 48 2.5134 111 35.3 %120 1ml) MA Male 12.1 111.13.} 12,181+ 0.?1 13 31+ 0. 51 1541+ 2.11 15.21- 0.21 1301+ 0.81 2.0 ?fa 1p<.011 Female 3.3 11113.} 2.9 1- 0.41 4.0 1+ 1.01 3.8 1- 0.11 4.8 1+ 1.0} 51* 0.21 3.0 ?2101134051 Both 11.811113} 1251+ 0.?1 1291+ 0. 41 13.91+1.01 1451+ 0.7} 15 01+1.11 +1.9 ?2?0 1134.011 33 3.9 125} 32.9 31:1241 Ml Male 20.0 11113.} 20.9 1+ 0.9} 21.0 1+ 0. 71 22.8 1+ 1.3} 23.9 1+ 1.0} 25. 0 1+ 1 .21 1.5 1p<.011 Female 4.4 111.13.} 4.8 1+ 0.4} 01+ 0. 21 5.3 1+ 0.5} 5.9 1+ 0.3171+ 0.91 2.8 1p<.011 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period} Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {51131113 Rank) Ill (State Hgnk) H. Both 10.71n13} 11.5 1+ 0.31 12.41+0.31 12. 3 1+0. 51 14.2 1+ 1.31 15.0 1+ 0.31 +2.3 31.. 1114. 011 33 +4.31131 40.3 331 31 MN Male 18.31n1?a} 13.31+1.22.3 1+ 1.31 2331+ 0.41 31. 011 Female 3.011113} 421+ 0.581+ 0.5} 91+ 1.2} 4.2 111-3. 01} Beth 12.911113} 14.1 1+ 1.1551+ 0.1} 15. 21- 0. 31 1.1 ?1151134051 35 2.3135} +173 01,10 (40} MS Male 22.9 11113.} 24.5 1+ 1.1} 25.1 1+ 0. 25. 8 1+ 25.9 1- 0.91 5. 3 1-0 .51 ?2?0 1115 Female 4.3 111130.01 5.4 1+ 0.9} 21- 0. 21 2.4 115113301) Beth 14.711113} 14.1 1- 0. 5} 15.4 1+ 1.3} 1001+ 0.7} 17.8 1+ 1.1} 2001+ 2. 3} 2.2 ?151134.011 10 5.3115} 35.4 11?} MD Male 25.3 11113.} 23.71-1 .51 25. 5 1+ 1.9} 20.6 1+ 1.0} 23.9 1+ 2.3} 32. 2 1+ 3. 3} 1.8 ?1151134051 Female 5.4111181} 5.41+ 0.1} 11+ 0. 7} 531+ 0. 2} 7.41+1.1} 3.2 ?fa 1131101} Both 21.1 1013} 22.3 1+ 1.41 23.31+10.1 11 23.? 1+ 2.01 2321+2.51 +2.1 031132.011 1 +3.01 21 33.0 :3.1111 MT Male 35.9 11118.} 37.3 1+ 0.4} 39. 3 1+ 2. 5} 39271-0 .11 41.0 1+ 1.4} 45. 5 1+ 1.3 ?151134.011 Female 371111.11 3.4 1+ 1.31 3.4 1- 0.11 10.0 1+ 1.31 12.3 1+ 2.31 13.1 1+ 0. 451 4.3 0.1. 1134.011 Both 12.71n1?a} 12.2 1- 0.51 12.3 1+ 0.41 11.71- 0.31 13.5 1+ 1.2.1 1421 13.2 :131431 NE Male 22.2 1013} 20.71- 1.51 20.3 1- 0.41 13.3 1- 0 51 22.0 1+ 2.21 23. 3 1+ 1 31 0.3 31. 013 Female 3.3 11118.} 4.2 1+ 0.4} 5.1 1+ 0.1.4} 81+ 0 3} 2.0 1115 B13111 23.3 11113.} 22.5 1- 0.51 22.1 1- 0.51 22.0 1+ 0.5} 21.41- 1.21 23. 1 1+ 1.0} - 0.2 1113 9 - 0.2151} - 1.0 (?10 1511 N11 Male 38.3 111151} 3071-17} 35.1 1- 1.8} 35.6 1+ 0.5} 32.5 1- 3.0.7 ?51: 1113 Female 8.911113} 951+ 0 5} 951+ 0.1} 1001+ 0.4} 1031+ 0.0} 1121+ 4010. +1.5 ?fa {114.01} 30111 13.511113} 12. 51- 1.01 1331+ 0.8} 15.21+1.9} 1531+ 0.5} 20 01+ 2.7 010113405} 17 5.51 81 48.3 1101 3} NH Male 22.5 11113.} 21.1 1-1 .41 21.7 1+ 0.0} 24.3 1+ 3.1} 25.4 1+ 0.5} 30. 6 1+4 5 2} 2.2 0.11:1 1134:. 05} Female 5 3 111131.0} 5.2 1+ 0.4} 5.0 1+ 0.4} 9. 8 1+ 3. 2} 3.9 011: {pt-1. 051 B13111 7.8 11113.} 1- 0.0.9} 9. 2 1+ 0 4} 1.3 ?101114.051 50 1.5 {47} 19.2 313135} NJ Male 13.011113} 13.1 1+ 0.0} 12.010 .51 1371+ 1 1} 14.51+0.8} 14.61+0.1} Female 3 2 11113.} 9 1- 0.31 001+ 9-01.11 3.8 1+ 0.9} 4. 4 1+ 0. 0} 2.3 1115 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2018 Age-Adjusted Annual Rate per 100,000 Persons [Change 1mm Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2008 2010 2011 2013 2014 2016 Rank 5 1513113 Rank) Ill (State Hgnk) H. Both 22.0 (n13) 22.0 1- 0.1) 21.0 1- 0.2) 23.0 1+ 1.2) 24.1 1+ 1. 1) 20.0 1+ 1 .0) 1.1 01.113405) 4 4.0 124) 13.3 =14. 130) NM Male 38.8 111131.2} 35.8 1- 0.8} 87.1 1+ 1.8} 40.7 1+ 8.8} 0.4 810 1115 Female 8511113.} 1.1} 8.21+0.7} 10.71+2.8} 12.0 1+ 0.8} +3.8 1114. 05} Beth 2.2111151) 1-01 .1) 7111+1. 1) 31- 0.1) 2.1 c1011:1401) 40 2.1 141) 20.3 01.12?) NY Male 12.51n13} 12.210 3) 13.01.+10) 15..41+14) 1451-00) +1.4%1p4.05} Female [010} 01-0 .1) 3.01+0.3) 3.5 4.01+0.5) +4.2 01. 1p4 01) 80111 18.811113} 18.51-13.11 18.71+0.1} 14.21+0.5} 14.51+0.4} 15.31+0.8} +0.8ofo 1114.01} 84 +1.7144} +127 810141} NC Male 22.711113} 22.? 1+ 0.0} 22.2 1- 0.8} 23. 3 1+ 1.1} 28. 3 1+ 0.0} 23. '9 1+ 0. 8} 0.4 ofo 1115 Female 5.0 11113.} 5.5 1- 0.2} 8.2 1+ 0.8} 8.0 1- 0.2.0 ?191134.05} 80111 18.811113} 14.8 1+ 1.8} 10.0 1+ 1.4} 1881+ 0.8} 18.4 1+ 1.9} 2091+ 2. 5} 2.9 810113401} 14 1.81 5} 57.8 8?31 1} ND Male 21.41n1a) 24.0 1+ 3.2) 20.0 1+ 3.4) 2?.1 1- 0.2.5 c1.4113401) Female 5.8 11113.} 4.5 1- 1.0} 8.71- 0.8} 5.7 1+ 2.0} 8. 1 1+ 1.0} 8. 5 1+ 1.8} 8.9 0er 1115 80111 11.011118} 1281+ 0.8} 18.1 1+ 0.8} 13.41+ 0.2} 14. 8 1+ 1 15.81+ 1.0} 2.0 ?19 1134. 01} 82 4.2 121} 88.0 ?10119} 01-1 Male 20.41n1a) 20.0 1+ 0.5) 22.2 1+ 1.3) 22.1 1- 0.1) 24. 2 1+ 2.1) 25. 5 1+ 1.3) 1.5 0.1.1134 01) Female 4.011113} 1+ 0. 4.91+ 0.1} 581+ 0.3.4 1114. 01} 80111 17.011113} 18. 51-0 1721+ 0.8} 18.41+1.1} 20. 7 1+2. 8} 28.51+2.8} +2.8 1% 1134. 05} 7 8.4 110} 87.8%: 112} UK Male 28.5 11113.} 27. 8 1- 1. 2} 27.8 1+ 0.5} 80.8 1+ 2.5} 88. 4 1+ 8.1} 37. 8 1+ 8. 8} 2.0 810113405} Female 8.8 11113.} 8.41-0.21 5 1+ 1 1.0 1- 0.5} 8. 5 1+ 1.8} 10. 8 1+ 1.8} 2.9 1134. 05} 80111 18.411113} 11.? 1+ 1.8} 17 71- 0.0} 18.81+ 0.9} 19.81+1.2} 21.1 1+ 1.8} +1.8 1134. 01} 18 4.8118} 28.2 tT113128} OH Male 21.411113} 2951+ 2.1} 28.51- 0. 9} 2951+ 1.0} 81.4 1+ 1.8} 38.0 1+ 1.8} +1.1 0110113401} Female 8.511113} 1.1 1+ 0.8} 71+ 0. 8} 841+ 0.7} 8. 8 1+ 0. 4} 881+ 0. 9} 2.7 0.11: 1134. 01} 80111 12.1 11113.} 12.5 1+ 0.4} 12.81+0.8} 18.91+1.1} 15.0 1+1. 1} 18.81+1.2} +2.0 ?10 1114.01} 30 +4.1 122} +848 ?310121} PA Male 21.011113} 2131+ 0.8} 2191+ 0. 8} 28.1 1+ 1.2} 24 11+1.7} 28.1 1+ 1.8} +1.5 1134. 01} Female 4.2 11113.} 4.8 1+ 0.8} 81+ 0. 0} 5.4 1+ 0.9} 8. 0 1+ 0.8} 1+ 11} 8.5 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {State Hank) Ill (State Hgnk) H. Bath 9.4 {ma} 9.0 (- 0.3} 9.0 (- 0.0} 12. 51+ 3. 5} 11.9 (- 0.9} 12. 511+ 0. 7} 2.5 92. 032.05} 43 3.2 (30 34.1 35 (23 at Male 15.4 {ma} 15.2 0.2} 14.5 1- 0.3} 21.2 5.4} 19.2 1- 2.11.5 Female 4.0 {Na} 3.3 (- 0.7} 3.3 0.4} 5.1 1.3} 5.1 0.0} 1.0} (p4. 05} Beth 12.301113} 13.0 0.2} 13.7 0.7} 18.0 11} 2.3 ofo (D4. 01} 23 4.9 33.3 We (10} 80 Male 21.3 {ma} 2251+ 1 22.31- 0.1} 2451+ 2.2} 25.1 1+ 1.5} 25.0 1+ 1 9} 1.5 95 {52. 01} Female 5.401.113} ?(ill 6.0 1.3} 5.2 0.1.4} 3.4 ofo (p4. 05} Beth 15.701113} 17.1 {[3401} 10 +44.5 ?Vc? 5} SD Male 2?.5 {ma} 2531.3} 229 1+ 1.5} 30.11.5} 1.5 54. {p4. 01} Femaie 4.2 {ma} 5.5 5.4 1+ 0.1.(p2. 01} Beth 14.501113} 15.2 0.6} 16.1 0.8} 1?.2 1.1} 17.2 0.0} +1.4 ofo (p4. 01} 22 3.5128} 24.2 3?3 (31} TN Male 25.1 {ma} 25.4 1+ 0.3} 25.5 1+ 1.3} 25.0 1+ 1.2} 25.5 1+ 0.5} 29. 5 1+ 1.2} 1.2 54. (52. 01} Female 5.4 {Na} 5.3 0.9} 6.7 0.4} 7.5 0.8} 6.9 0.6} 16 0. 7} 1.9 ofo (D4. 05} Both 12.20118} 12.? 0.6} 12. 0. 4} 13.2 0.9} 13.6 0.3} 14. 5 0. 9} 1.1 ?2?5 01} 41 2.3 (37} +139 We (36} TX Male 20.4 {Na} 20.9 0.5} 20. 4 (- 0. 5} 22.0 1.6} 22.2 0.3} 23.1 0. 9} 0.9 ofo (p4. 05} Female 4.3 {Na} 5.4 0.5} 5.0 (- 0.4} 5.2 0.2} 5.6 0.4} 0. 8} 1.6 (p4. 05} Both 17.2 (1115} 19.0 18.2 (- 0.7} 20.2 2.0} 24.0 3.8.01: 3 W) 45.5 4 11} UT Male 28.2 (0.15} 31.1 2.9} 29.4 (- 1.7} 32.1 2.7} 37.8 5.7} 38. 0 0.2} 2.1 011: 05} Female 6.3 [015} 7.4 0.6} 7.5 0.1} 8.5 10.6 2.1} 12. 6 2. 0} 4.4 ?2?5 01} Both 18.2 14.9 1.3} 18.? 2.1} 19.? +2.4 01} 13 9} +436 Wed 2} VT Male 23.6 (1115} 28.3 4.6} 24. 3 (- 4. 0} 27.3 3.0} 31.0 3.7} 32. 5 1.9 4% (D4. 05} Female 4.3 (11.15} 5. 2 0. 9} 6.4 1.3} 5.6 0.2} 7.3 0.7} 7. 6 0.3} 3.8 011: 01} Both 12.81015} 12. 12.9 0.3} 13.6 0.7} 14.6 0.9} 15. 0 0 5} +1.2 ?2?0 01} 37 2.2 (39} +174 3?5 (41} VA Male 21.6 {015} 21.3 0. 2} 21.0 0.4} 22.5 1.5} 23.6 23. 9 0. 2} 0.9 Female 5.3 {015} Ht, 5 9 0.7} 6 (- 0.3} 6.4 0.8} 5. 9 0. 5} 1.3 (D4. 05} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period) Current Overall Overall State Sex 1? State Rate Change 2:33"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Rank 5 (State Hank) (State Hagnkji Both 14.3 1n1a} 15.4 1+ 3.5} 14. 3 1-3 15. 711+ 3. 31 16.6 1+ 3.3} 17.6 1+ 1.3} 1.1 331133.351 24 2.3 1331 13.3 :13137} WA Male 24.71nra1 25.2 1+ 3.5} 24.1 11.11 25.1 1+ 1.3} 23.3 1+ 3.3} 27.1 1+ 1.1} 3.6 33 1113 Female 5.9 111.13.} 5.4 1+ 0.0.8} 3.5 1+ 0.8} 2.5 112M011 Both 15.31nra} 17.21+ 1.6} 16. 71- 3. 51 16.31.71 1321+ 3.2} 21.41+ 2.2} +1.3 33 11 5.3113} 37.133114} wv Male 27.2 {ms} 33.1 1+ 2.3} 2331-15) 27. 31- 1. 31 3151+ 3.3} 33.5 1+ 2.3} 1.1 33 1115 Female 5.3 111.13.} 5.5 1+ 0.1} 5.8 1+ 0.3} 5.3 1- 0.5} 7.5 1+ 2.3} 9.8 1+ 2.2} :1er 1115 Both 13.1 13.5 1+ 0.4} 14.0 1+ 0.5} 15.0 1+ 1.0} 15.3 1+ 0.3} 15.5 1+ 1.2} 1.5 112M011 23 3.4129} 25.8 10130} w1 Male 21.71nra} 22.2 1+ 3.5} 22.7 1+ 3.5} 24.3 1+ 1.2} 24.4 1+ 3.4} 25.7 1+ 1.3} 1.1 33 1133.31 1 Female 5.1 {hrs} 5.3 1+ 3.2} 5.6 1+ 3.4} 341+ 3.71 3.5 1+ 3.1} 7.5 1+ 1.3} 2.5 33153.31} Both 20.71nra1 23.4 1+ 2.7} 22.5 1- 3.31 25.4 1+ 2.3} 23.3 1+ 3.5} 23.3 1- 3.11 2.3 031133.311 3 3.1 1 11 33.3 =13 1 3} WY Male 34.3 39.3 1+ 4.5} 35.3 1- 3.0} 41.5 1+ 5.2} 47.1 1+ 5.6} 44.5 1- 2.4} 1.8 112M051 Female 7.7111131} 3.2 1+ 3.6} 3.2 1+ 3.3} 3.4 1+ 3.2} 13.7 1+ 1.4} 12.3 1+ 1.3} 3.2 33 11:13.31 1 Rates are age?adjusted to the US. year 2000 standard. 1 Model?estimated average annual percentage change based on all reporting periods; p?value indicates statistical significance of trend; indicates trend not significant. ?5 Current state rank (50 states and the District of Columbia} is for the reporting period 2014 2016. Ranks are from highest rate (11 to lowest rate (511. Different ranks do not necessarily imply a statistically significant difference. 1 Overall rate change is between the first (1999 20011 and last [2014 20161 reporting periods. Hanks are from largest increase {11 to largest decrease 1511. Different ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the first 11999 20011 and last (2014 2015) reporting periods. Ranks are from largest percentage increase 111to largest percentage decrease 1511. Different ranks do not necessarily imply a statistically significant difference. TT Hate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. till Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. State Abbreviations: AL Alabama; AK Alaska; AZ Arizona; AR Arkansas; CA California; CO Colorado; CT Connecticut; DE Delaware; DC District of Columbia; FL Florida; GA Georgia; HI Hawaii; ID Idaho; IL Illinois; IN Indiana; IA Iowa; KS Kansas; KY Kentucky; LA Louisiana; ME Maine; MD Maryland; MA Massachusetts; MI Michigan; MN Minnesota; MS Mississippi; MO Missouri; MT Montana; NE Nebraska; NV Nevada; NH New Hampshire; NJ New Jersey; NM New Mexico; NY New York; NC North Carolina; ND North Dakota; OH Ohio; OK Oklahoma; OR Oregon; PA Fthode island; SC South Carolina; SD South Dakota; TN Tennessee; TX Texas; UT Utah; VT Vermont; VA Virginia; WA Washington; WV West Virginia; Wisconsin; WY Wyoming. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Weekly/Vol. 67 i No. 22 June 8, 2018 Vital Signs: Trends in State Suicide Rates United States, 1999?201 6 and Circumstances Contributing to Suicide 27 States, 2015 Deborah M. Stone. 5:th 'l?homas R. Simon l?hDi; Katherine A. Fowler, l?th; Scott R. Kegler, Pth; Keniing Yuan, Kristin M. Holland, Asha Z. hey-Stephenson, I?th; Alex E. Crosby, Abstract Introduction: Suicide rates in the United States have risen nearly 30% since 1999., and mental health conditions are one of several factors contributing to suicide. Examining stateelevel trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. Methods: Trends in age-adjusted suicide rates among persons aged :10 years, by state and sex, across six consecutive 3-year periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data From the National Violent Death Reporting System, covering 27 states in 20! 5, were used to examine contributing circumstances among decedents with and without known mental health conditions. Results: During 1999?20 16, suicide rates moreased signi?cantly in 44 states, with 25 states experiencing mcreases Rates increased significantly among males and females in 34 and 43 states, rmpectively. Fifty-four percent ofdecedents in 27 states in 201 5 did not have a known mental health condition. Among decedents with available information, several circumstances were signi?cantly more likely among those without known mental health conditions than INSIDE among those with mental health conditions, including 625 Invasive Methicillin-Resistant Staphylococcus oureus relationship problemsi'loss (45.1% versus life Infections Among Persons Who Inject Drugs Six Sites, 2005?201 6 629 Tobacco Product Use Among Middle and High School Students United States, 2011?2017 634 Update: Influenza Activity in the United States During stressors (50.5% versus and recent! impending crises (32.9% versus but these circumstances were common across groups. Conclusions: Suicide rates increased significantly the 201??18 Season and Composition ofthe 2018?19 across most states during 1999?2016. Various Influenza Vaccine circumstances contributed to suicides among persons 643 Update: ACIP Recommendations for the Use of With and without known mental health conditions. Quadrivalent Live Attenuated Influenza Vaccine Implications for Public Health Practice: States United Sis??95: 2018?19 Influenza 59350" can use a comprehensivg evidence?based public 646 Notes from the Hemorrhagic health approach to prevent suicide risk before it Fever Outbreak?Central Uganda, August?September occurs, identify and support persons at risk, prevent 201? reattempts, and help friends and family members in 6?48 QuickStats the aftermath of a suicide. Continuing Education examination available at infolitmliiweekly. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Introduction in 2016. nearly 45,000 suicides population [age-adjusted? occurred in the United States among persons aged :10 years From 1999 to 2015. suicide rates increased among both sexes, ail racial/ ethnic groups, and all urbanization levels (2.3). Suicide rates have also increased among persons in all age groups <75 years, with adults aged 45?64 having the largest absolute rate increase (from 13.2 per 100,000 persons [1999] to 19.2 per 100,000 [2016]) and the greatesr number ofsuicides (232,108) during the same period (1.3). Suicide is the tenth leading cause ofdeath and is one ofjust three leading causes that are increasing in addition, rates ofemergency department visits for nonfatal self-harm, a main risk factor for suicide, increased 42% from 2001 to 2016 (1). Together, suicides and self-harm injuries cost the nation approximately $730 billion per year in direct medical and work loss costs if}. The National Strategy for Suicide Prevention calls for a public health approach to suicide prevention with efforts span? ning multiple levels (individual, famiiyfrelationship, community, and societal]. Such a comprehensive approach underscores that suicide is rarely caused by any single factor. but rather, is deter? mined by multiple factors. Despite this call to action, suicide prevention largely focuses on identifying and tefEtring suicidal persons to mental health treatment and preventing reattempts (6). in addition to mental health conditions and prior suicide attempts, other contributing circumstances include social and economic problems, access to lethal means (eg, substances, firearms) among persons at risk, and poor coping and problem- solving skills Expanded awareness of these additional circum- stances contributing to suicide risk and action to address them can be] reach the national goal, established by the National Action Alliance of Suicide Prevention and the American Foundation for Suicide Prevention, of reducing the annual suicide rate 20% by 2025 To assist states in achieving this goal, CDC analyzed state?specific trends in suicide rates and assessed the multiple contributing factors to suicide; this report presents options for strategies to include in comprehensive suicide prevention efi'orts that are based on the best available evidence. Methods Suicide rates were analyzed for persons aged :10 years because determining suicidal intent in younger children can be difficult (8). Ageaspecific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (International Class?imrion ofDireiases, Fitme- Revision, underlying?cause?ofdeath codes ?37.0. Age? specific population estimates were obtained from U.S. Census Bureau/National Center for Health Statistics bridged?race population data releases. National and staterlevel suicide rate estimates were calculated for six consecutive 3?year aggregate periods spanning i999? 2016 (1999?2001; 2002?2004; 2005?2007; 2003?2010; 2011?2013; and 2014-2016). Rate estimates were age- adjusted to the U.S. 2000 standard population and expressed The of publications is published by the Center for Surveillance. Epidemiology, and Laboratory Services. Centers For Disease Control and Prevention US. Department DE Health and Human Services, Atlanta, GA 30329-4027. Suggc?ed citation: [nudist tomes; first three. then ct .1L. if more than steel [Report title]. MMWR Morb Mortal Wkly Rep 2018;67:linc1usive page numbers]. Centers for Disease Control and Prevention Robert R. Redfield, MD, Dir-retal- Annc Schucllat. MD. Principe! Depend Dirmor Leslie Dauphin. Acting Arterial? Diremar?r .S'rz?mcr Joanne Conn. MD. 542M, Dir-emu [wire 43am.- Quality Chesiey L. Richards, MD. MPH. Deputy Public Health Erin-tri?e 5mm: Michael F. ladetnaico. MD. MPH. Din-am: Center?rr Epidemiology mm'LdiEremmq Service: MMWR Editorial and Produetion Staff [Weaklyl Charlotte K. Kent. MPH. Acting Edimn'n Chief: Executive Editor- Jacqueline Gladier. MD. Editor Mary Dotr, MD. MPH, (Julius Editor Temsa F. Rutledge. Managing fairer Douglas W. Weathuwax. Lead Tat?nimi? Wtr??f?ar Glenn Damon. Soumya Dunworth, Teresa M. Hood. MS. manual Writer-a?oat: Martha F. Boyd. Lew} Visual Specialise Maureen A. Lei-ally. Julie C. Mnrtinroe. SmphenR. Spriggs. Tong Yang. Vitae! In?rmetfm Sammie: 'Quang M. Dean. MBA. H. King. Terraye M. Starr, Mona Yang, In?ramim spa-area MMWR Editorial Boon! Timothy F. Jones. MD. Matthew L. Buuitoo. MD. MPH Virginia A. Cains. MD Katherine Daniel. PM) Jonathan E. Fielding, IulD. MPH, NIBA David Fleming. MD eta MMWR Jun88,2018 r' Vol.6? No.22 William E. Helper-in. MD. DIPH. MPH King K. Holmes. MD. Robin Ikrda. MD. MPH Rim-.1 F. Khabbaz. MD Meadows. MSN. RN Jewel Mullen. MD. MPH. MFA Patricia Quinlislt. MD. MPH Patrick L. Remington. MD. MPH Carlos R'oig. M5. MA Wait-.1.? L. Roper. MD. MPH William Seha?iter. MD US Department of Health and Human ServicesiCemers for Disease Control and Prevention Morbidity and Mortality Weekly Report per 100,000 persons per?year. Age-adjusted suicide rate trends were modeled using the same 3-year data aggregates, employ- ing weighted least-squares regression with inverse-variance weighting. Modeled rate trends are reported in terms oF average annual percentage changes. Characteristics oF persons aged 1:10 years who died by suicide, with and without known mental health conditions, and the circumstances surrounding the suicides were compared in the 27 states? with complete data participating in CDC's National Violent Death Reporting System in 2015. defines mental health conditions as disorders and listed in the Diagnostic and Statistical Manual Disorders, Farr; Edition (9), with the exception oF problematic alcohol use and other subsranee use that are captured separately in VDRS aggregates data From three primary data sources: death certi?cates, coroneri'medical examiner reports (including toxi? cologyl, and law en Forcement reports. A range oF circumstances (relationship problems, life stressors, and recent or impending crises)I have been identi?ed as potential risk Factors For suicide in Circumstances captured are those identi?ed as con? tributing to suicide in coronerfmeclical examiner or law en Force? ment reports, which re?ect inForntation provided by Family and Friends at the time oF death. Decedents could have experienced multiple circumstances. Decedents with and without known mental health conditions were compared using chi-square tests. Logistic regression analyses were used to estimate adjusted odds ratios (aORsl with 95% confidence intervals (Cls), controlling For sex, age group, and tacoll ethnicity. Results The most recent overall suicide rates (representing 2014? 2016} varied FourFold, From 6.9 (District oF Columbia]I to 29.2 (Montana) per [00,000 persons per year (Supplementary Table; Across the study period, rates increased in all states except Nevada (where the rate was consistently high throughout the study period}, with absolute increases ranging From 0.8 per 100,000 (Delaware) to (Wyoming). Percentage increases in rates ranged From 5.9% (Delaware) to 57.6% (North Dakota), with increases >50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 TALKING POINTS and FAQs for Principle Investigators Only DO NOT DISTRIBUTE Overall key messages: I Nearly 45,000 lives were lost to suicide in 2016 alone, about one suicide every 12 minutes. I Between 1999 and 2016, suicide rates increased among all age groups younger than 75 years. I Suicide rates have also been rising in nearly every state. I There are a range of factors and circumstances that contribute to suicide risk. 0 EMBARGOED: CDC found that more than half of people who died by suicide did not have a known diagnosed mental health condition at the time of death. Factors that contribute to suicide risk: Relationship problems or loss, substance misuse; physical health problems; and job, money, legal or housing stress. The problem: I Suicide is the 10th leading cause of death and is one ofjust three leading causes that are on the rise. I Suicide is more than a mental health condition. 0 EM BARGOED: findings show that fewer than half of the people who lost their life to suicide had a known mental health condition and in many of cases, other factors were involved. I There are many opportunities for prevention in addition to treating those with mental health conditions: teaching coping and problem-solving skills to help people manage life challenges; :22: promoting safe and supportive environments, including safe storage of medications and firearms among people at risk; providing temporary help for people struggling to make ends meet, and encouraging connectedness so people are less likely to feel alone or isolated. I Using a comprehensive approach can help the nation reach its goal of reducing the annual suicide rate 20 percent by 2025. Study details: I CDC analyzed data from the National Vital Statistics System to look at trends in suicide rates for all 50 states and 0C. 0 Between 1999 and 2016, trends in suicide rates were assessed among people ages 10 and above, and by state and sex. CDC then looked at data from National Violent Death Reporting System i which covered 2? states in 2015 - to examine circumstances around suicides among people with and without known mental health conditions. I EM BARGOED: CDC found that suicide rates increased in almost all states. 0 The increases ranged from almost 6 percent in Delaware to nearly 58 percent in North Dakota, with increases of more than 30 percent in 25 states. 0 EM BARGOED: CDC also found that 54% of people who died by suicide did not have a known mental condition. This group suffered from relationship problems and other life stresses such as criminal legal matters, evictionfloss of home, and recent or impending crises. 0 However, these factors were common to all people who died by suicide, whether or not they had a diagnosed mental health condition. I Firearms were the most common method of suicide used by those with and without a known diagnosed mental health condition. Actions: I Federal government: CDC is tracking the problem to understand trends and identify the groups at greatest risk. 0 CDC released a technical package on suicide prevention that describes strategies and approaches based on the best available evidence. This can help inform states and communities as they make decisions about prevention activities and priorities. I Some ofthe strategies are designed to prevent suicide risk before it emerges (teaching problem-solving skills, encouraging connectedness, etc.), while others are aimed at supporting those who are already struggling through effective treatment and crisis intervention. I The package also describes approaches to prevent future suicide risk among those who have made an attempt, or lost someone to suicide. 0 States and communities are: [Suggest customizing to work your state is doing to prevent suicide} 0 identifying and supporting people at risk of suicide. Promoting safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. Connecting people at risk to effective and coordinated mental and physical healthcare. Expand options for temporary assistance for those struggling to make ends meet. I Healthca re systems can: :3 Provide high-quality, ongoing care focused on patient safety and suicide prevention. Make sure affordable and effective mental and physical healthcare is available where people live. 0 Train providers in adopting proven treatments for patients at risk of suicide. Employers can: Promote employee health and well-being; support employees at risk; and have plans in place to respond to people showing warning signs. 0 Provide referrals to mental health, substance use, legal or financial counseling services as needed. II Everyone can: Ask someone you're worried about ifthey?re thinking about suicide. 0 Keep them safe by reducing access to lethal means for those at risk. 0 Be there and listen. 0 Encourage them to seek help, or help them connect with ongoing support, such as the National Suicide Prevention Lifeline (800-273-TALK or 8255} 0 Follow up with them by phone or in person to see how they are doing. 0 Visit BeThelTo.com to learn the warning signs of suicide. National Violent Death Surveillance System collects the most comprehensive data on the circumstances surrounding violent deaths in the United States. Currently it exists in 40 states, Puerto Rico, and the District of Columbia. 0 links death certificates, coroner/medical examiner reports and law enforcement reports for both single victim and multiple victim incidents to obtain the most comprehensive data available in a single surveillance system. All manner of violent deaths - including suicide and homicide are captured. I data help state suicide prevention efforts by providing information on circumstances mental health problems; recent problems with ajob, finances, school, relationships); demographics; method of death hanging/suffocation, firearms, poisoning); victim-suspect relationship; toxicology; and location. General FAQs I How does using the National Violent Death Reporting System help to make suicide statistics more complete? Although limited to the 27 states participating in during the time period of the study, data from provide the only detailed information available on the circumstances surrounding these deaths, therefore taking the findings beyond reporting numbers and rates and providing unique information on the context in which people die from suicide. Why did only look at suicide circumstances in 27 states? - In 2015, the National Violent Death Reporting System collected data from 2? states. The data collected from these states were used for the analysis. More current data is not yet available. I In 2016, collected data from 40 states, D.C. and Puerto Rico however data are not yet available. What are the leading ways that people die by suicide? Firearms are the mechanism for about half ofall suicides in the United States. 0 The next leading methods are suffocation and poisoning. Reducing access to lethal means of suicide among people at risk for suicide is a proven intervention. This includes: Intervening at suicide hotspots such as bridges 0 Counseling on how to safely store medications, firearms, or other household products. These interventions can be combined with other strategies for a comprehensive approach to prevention. What is known about which groups are experiencing increases? The current study found that rates of suicide are increasing, overall, and for males and females. Rates among females increased significantly in 43 states and rates among males increased significantly in 34 states. II In general, suicide rates in the US. have increased by nearly 30% since 1999. i. Increases were observed for both women and men in all age groups under 75. 0 Certain groups have had particularly high greatest increases since 1999, including: i. Working-age adults 35-64 ii. Non-Hispanic whites, and non-Hispanic American Indians I Alaska Natives and People living in rural areas. iv. Rates have increased for males and female however the rate for males is consistently 3- 5 times higher than the rate for females For some states, the reported percentage increase in the suicide rate is quite large. Is this due simply to fluctuations in small numbers of suicides? The percentages represent increases in rates between the first three-year reporting period {1999-2001) and the last three-year reporting period (2014-2016]. By aggregating the data into three-year periods, small suicide counts were avoided. How did CDC define a mental health condition? The National Violent Death Reporting System defines a mental health condition as disorders and listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with the exception of alcohol and other substance use problems, which are captured separately in the system. a. Data on mental health conditions are abstracted from the investigative reports included within and that are associated with each suicide. b. Investigative reports are those filed by law enforcement and coroners/medical examiners which reflect information provided by family and friends. c. Information obtained from these reports is dependent upon the extent of informant knowledge that may impact data completeness and accuracy. Some decedents might have mental health conditions that were not diagnosed or reported. The high prevalence of diverse contributing circumstances among those with and without known mental health conditions suggests the importance of addressing the broad range of factors that contribute to suicide. Are the people without mental health conditions just people who haven?t been diagnosed with a mental health conditions? It is possible that the people without mental health conditions in this study had a diagnosable mental health condition but had not been diagnosed, or that their mental health conditions was unknown to informants who provided circumstantial information to law enforcement. Studies including more in- depth interviews with next-of?kin often cite greater attributions to mental disorders, however many methodological variations across studies exist. It is likely that some people without known mental health conditions in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. Nonetheless, the high prevalence ofdiverse contributing circumstances among those with and without known mental health conditions suggests the importance of addressing the broad range of factors that contribute to suicide. A lot of the problems mentioned as contributing to suicide in this study seem very common, how can someone tell who?s at risk? Many people think that suicide unexplainable, when, in reality, many known risk factors exist. These include: 0 History of previous suicide attempts I Family history of suicide - History of child maltreatment - History of depression or other mental illness 0 Alcohol or drug abuse Feelings of hopelessness or isolation Impulsive or aggressive tendencies Stressful life event or loss - Easy access to lethal methods 0 Exposure to the suicidal behavior of others 0 Isolation, lack of social connectedness Researchers agree that suicidal behavior results from an interaction of factors and is rarely due to a single cause. What can be done to prevent suicide? Suicide is preventabie. CDC released a technical package of policies, programs, and practices to prevent suicide to help communities focus on a core set of strategies that have the best available evidence and greatest prevention potential. The technical package includes examples of programs that local implementers might tailor to fit the needs of their community. The technical package includes 7 strategies designed to work together to achieve the greatest impact possible. vi. vii. Strengthen economic supports Strengthen access and delivery of suicide care Create protective environments Promote connectedness Teach coping and problem?solving skills Identify and support people at risk Lessen harms and prevent future risk Preventing Suicide: A Traci-mica.l Package of Paiicy, Programs, and Practices: From: Stone, Deborah Sent: 22 Mar 2018 23:48:26 +0000 To: Simon, Thomas Scott R. Katherine A. Keming Asha Z. Kristin Alexander Subject: Feedback on Pre-clearance Draft of Suicide Vital Signs MMWR Attachments: Suicide Vital Signs MMWR Text 3.19.18 v3 (pre-clearancel_CF_EB MRC.docx, MMWR Table 1 and Figure 1_CF.docx, Copy of Copy of Tables {23} Suicide Vital Signs Hi Everyone, I wanted to thank everyone again for the hard work on our ore-clearance draft. We received feedback from Jim, Erin, Malia, and Cory. See emails below and attached documents. The feedback was largely very positive but there are comments to address, of course. The goal is to make revisions and get the next draft into clearance on Tuesday, 3/27. To make that happen, my plan is to revise the attached draft and send out a new draft to all of you by C08 [Friday]. I was then hoping to go through final edits with you on Monday, 3,126 (invite to follow) at 10 am. I know this may mean you have to review the revised version early on Monday or maybe over the weekend.* Gulp. If you have a conflict with Monday, then please send me your comments on Monday as soon as you can, but no later than 3:00 so that I can consider them prior to Submitting final into clearance. Thank you for your patience with this quick turnaround. We?re definitely going to take time to celebrate at some point soon but not too soon as tojinx ourselves! Deb *If you prefer to get started commenting right away, then feel free to review the attached draft and provide your comments to me in an email or via tracked changes on Friday. Sorry ifthis seems overly complex, I just want to give you options given the short turnaround. From: Richmond?Crum, Malia Sent: Thursday, March 22, 2018 4:47 PM To: Black, Erin Stone, Deborah Cc: Simon, Thomas Mercy, James Ferdon, Corinne Subject: RE: Pre-clearance Draft of Suicide Vital Signs MMWR Thanks for the opportunity to review and for all your hard work on this MMWR. It?s really exciting to see the final draft! I think this is going to be very important info for states. I had some minor comments for your consideration that I added to Erin and Cory?s feedback (attached). No feedback on the tables and figures. Thought the map of the US that showed the percent change in states was nicely done and easy to understand. Malia From: Black, Erin Sent: Thursday, March 22, 2013 3:25 PM To: Stone, Deborah Cc: Simon, Thomas (CDCIDNDIEHINCIPC) Mercy, James Ferdon, Corinne (CDCIONDIEHXNCIPQ Richmond-Crum, Malia Subject: RE: Pre-clearance Draft of Suicide Vital Signs MMWR FABULOUS job Deb! This was very exciting and compelling to read! Congratulations on this huge milestone! I agree with Jim?s comment about emphasizing more the increase in female vs. male rates. I also provided some mostly editorial questionsfcomments and suggested edits in track changes summarized below: I Sometimes it is referred to as a ?contributing circumstance? and sometimes its referred to as a ?contributing factor?. I wonder if its best to be consistent so as not to confuse the reader that the two are different. From a plain language perspective, I prefer contributing factors? Also, sometimes it is referred to a just ?contributing factor? while other times it is referred to as ?contributing risk factor?. Also, sometime it is referred to as ?contributing? and sometimes as ?associated?. Should we be consistent? I ?Suicide is the 1E)"h leading cause of death and is among the only leading causes to be increasing.? Can we be more specific? is it the only or is it only one of 2 leg.) leading causes increasing ?among the only? is vague? - Is it better to say the current ?social ecology? (which I think many think of social, environmental and economic) versus I think what is used most often the ?social ecological model? (individual, family/relationship, community, and societal). - "can help reach the nation?s goal of reducing suicide rates 20% by 2025? 4 is it really the ?nation?s goal? versus the goal set by the American Foundation for Suicide Prevention. - ?Across the entire study period, rates increased in all but one state (Nevada}." Per our discussion in our last VS group meeting, should we add a note that despite NV not increasing, they still have a significantly high rate of suicide? oSometimes criminal-legal is hyphenated and sometimes it?s not. 0 ?Nearly half of suicide decedents in had a known I would add the actual percentage in parenthesis (X96). 0 People with known MHP also experienced other life stressors such as job and/or financial, relationship, and/or physical health problems. Should this be ?and?, ?or? or ?andg?or?? I ?It is likely that some people without known MHP in the current study were experiencing mental health challenges at the time of death that were either not known or reported by informants." Do you mean reported by informants? From: Ferdon, Corinne Sent: Thursday, March 22, 2018 2:25 PM To: Mercy, James (CDCIONDIEHINCIPC) Stone, Deborah Black, Erin Richmond-Crum, Malia cdc. ov> Cc: Simon, Thomas Subject: RE: Pre-clearance Draft of Suicide Vital Signs MMWR Deb, Congratulations to you and the entire vital signs writing team to getting to this point! It is an enormous achievement. I really like the direction the analyses have gone in. I know there is a considerable amount of work ahead, but you have a solid platform to build on. I offer in the attachments some suggestions. Track changes are not easily done in the excel file sol highlight words in red to draw your attention to things to consider. In the text, I think there are a few numbers to double check, a few data points and clarifications to be added in, and the references to the tables/figure adjusted. I do like the balance that is currently in there on the versus aORs. Mental health problems as a driver of suicide jumped out to me as one of the main messages since the text kept coming back to it. I think there are some subtle reorganization or broader phrasing that could be used in some places to modify this if the communication goal is different; I offer some ideas in comment boxes. I recognize that I am suggesting adding some clarifying text in some places and word count is always an issue, so I did try to identify some places to potentially cut. Please review this as suggestions and ta kefleave what feels right. in a meeting I was in with the MMWR editors yesterday they said they prefer little to no use of acronyms. So, in a few places suggest taking a couple out but I did leave in the MHP one since that is necessary for word count. Cory From: Mercy, James Sent: Thursday, March 22, 2018 12:34 PM To: Stone, Deborah Ferdon, Corinne Black, Erin Richmond-Crum, Malia Cc: Simon, Thomas Subject: RE: Pre-clearance Draft of Suicide Vital Signs MMWR Hi Deb, This is outstanding. Thank you and everyone else for this really nice and clear statement about suicide and its prevention. have just a few general 1. One finding that you don?t make much of, but I think is important, is that suicide rates across states are increasing faster for females relative to males. Overall, of course, this is a problem still dominated by males, but that appears to be changing. And that?s not surprising in terms of societal changes around gender roles and norms. I realize you can?t highlight everything, but that is very interesting and may signal a longer term trend that?s worth noting. 2. You may have to cut back the word number some and if you do I think you can get away without the second sentence in the results that focusses on absolute changes in rates. People understand the meaning of changes much easier, so no biggie, but that could be dropped if needed. 3. In regards to the first sentence in the last paragraph, I wondering if the last clause could be changed to but is only one of Ifwe say one of "many? then the argument is that we can?t focus on everything so we should focus on the most important risk factor. I'm not wedded to this, but clearly we are emphasizing the need to focus on factors beyond mental illness (but not excluding mental illness) and I think this sentence could be made a little stronger in support of that, especially because it ties things up at the end. Thanks that is all I had. Thanks so much and can?t wait until this comes out. Jim From: Stone, Deborah Sent: Thursday, March 22, 2013 8:14 AM To: Ferdon, Corinne Cc: Simon, Thomas Subject: Pre-clearance Draft of Suicide Vital Signs MMWR Importance: High Hi Jim, Cory, Erin, and Malia, Just a friendly reminder to please send your feedback on the MMWR by COB today. Your time and insights are greatly appreciated! Deb Hi Everyone, Please find attached a draft of our suicide Vital Signs MMWR for pre-clearance. Thank you for previously agreeing to review it with a quick turnaround of C03 3,022. We are still working out one outstanding issue?whether to report percentages andfor aORs pertaining to results. Right now we opt for percentages however we may also include and Cl?s. Please send your edits in tracked changes. if you have any questions, please let me know. We look forward to your feedback! And thanks to the whole team for a whole lot of time, thought, and expertise dedicated to this draft! Thanks again! Deb Deb Stone, MSW, MPH Centers for Disease Control and Preyerwtion National Center for Iniury Prevention and Comml liriylsion of Violence Prevention Bolcido, Youth Violence Elclel' IVIaII'rearmern Team ??Li.i?i88. 3942 sisleosj?s ?15101 CDC's Injury Center Preventing Injuries and Violence Through Science and Action LinRev 3.19.18 v3 Short title: Vital Signs: increasing Trends in State Suicide Rates and ontributing Circumstances Deborah M. Stone, Thomas R. Simon Katherine A. Fowler, PhD;l Scott R. Kegler, Keming Yuan, Comment Sometimes it is referred to as a rcontrilziuting circumstance? and sometimes its referred lvlS;1 Kristin M. Holland, Asha Z. Ivey-Stephenson, Alex E. Crosby, lle1 Structured abstract {2552529150 words?this word count is not included in the 1800 max for the remainder) Comment Can a couple 9f words be added here to reflect a date Since rates Background: Over all ssuicide rates have been rising in the United States 199L?Examining state? level trends have been rising. seeword count suicide and its multiple contributing circumstances can inform comprehensive git-d- prevention lannin Comment Style consideration. Since focus on suicide and states is clear, Methods: Trends in age?adjusted suicide rates. byEstatci and sex, among people aged 210 years. were assessed these words Ml?e i? sentence usmg data from the National Vital Statistics System Changes In rates were examined across so: consecutive ?arr?W?s . . omment transition rom I to three year periods from 1999 2016 :9 National Violent Death Reporting System I ?cpven?gg? reading covers states to states, was used to examine Ina-precipitating circumstances among suicide decedents With and without known methods to the first line in the results Enental health problems ?t Comment Unclear ifthis was Results: rates inereases?anrgased ai. from 1999- supposed to be a reference or can come 2015 iI"i .14 states. In 25 states, rates increased by 30% or more. Male suicide rates increased signi?cantly In 34 out states, I_444le#Femaie rates increased significantly in 43 states?eople with and without known MHP ?hrc a I ommen I U5 5? ES lOI'i an had both differing and similar circumstances precipitating suicide. Several circumstance, such as any 7i? may not be feasible, but would suggest relationship problemsfloss [39.6 and 45.1%, any life stressorsfloss [49.7 and 54.2%, 5 and recent ?t?Hn not using MHP through the document. crises {26.0 and 32.9%, 5 respectively, were more likely among those without known l'leP. but were I a common across groups. Comment Ithink this is a Significant finding should we say more Conclusions: Suicide rates rose significantly across most states from 1999?2016. Varied circumstances beyond about it the fact that it is increasing more lv'lHP alone contributed to suicides among people with and without known MHP. Nomadic-n? 3? Comment I think edits are needed Implications for Public Health Practice: States can use a comprehensive public health approach based on the here for a few reasons. I am finding the best available evidence to prevent suicide risks before they occur, identify and support people already at risk, statements that there are differences and prevent- reattempts, and help after a suicide occurs. 5 Comment Please double check. INTRODUCTION ,3 [am getting 15.9 from WISCLARS BACKGROUND AND PURPOSE words] i? i Comment Can we be more ,e specific is it the only or is it one of only in 2016, nearly 45,000 suicides occurred in the United States among people all] years old r' 3: leading causes increasing- ?among the 15 Suicide is the 10th leading cause of death and isEamong the onlyleading causes to be increasing Cummt??t Please double Additionally, rates of Emergency Department visits for nonfatal self-harm injury, a key risk factor for suicide, wonder if ??15 might. h'fwe been increased more thank??between 2001 and 2015 Together, suicides and self-harm injuries cost the nation It, for all ages and mt ?mum to am years" 3, more than $59 billion in direct medical and work loss costs ,"[C0mment IJRVSI: Suggest identifying this as a US Surgeon General report. 1, lihs Nation? mm, .5 beta, ,0 mg, prevention With efforts spanning across multiple levels e. ., individual, family/relationship, community, and It,? ecology [which i think many think of societal}, of theEocial ecolog?." Such an approach underscores that s_uici_de Is rarel_y caused by any single factor If social, environmental and economic} alone, but rather, is multi- determined. Despite the NSSP guidance, suicide prevention efforts largely focus on identifying and treating individuals with mental health problems lOther asseeiateel?conttibutingrisle factors include social and economic problems, access to lethal means leg, substances, firearms, bridges] among people at risk, poor coping and problem?solving skills. and prior suicide attempts, Expanded Ftev 3.19.18 v3 40 awareness of the additional circumstances that contribute to suicide risk apart from MHP. can help reach the 4' E?atiunts 42 state-specific trends in suicide rates, assesses the multiple contributing and 43 provides recommendations for multirlevel comprehensive suicide prevention. 44 METHODS @260 words} 45 Suicide rates were analyzed for those aged 10 years and older [because of variability in attributions of suicidal as intent, younger children are excluded] Age?specific suicide counts were tabulated based on National Vital 4? Statistics System coded death certificate records [international Classification of Diseases 10'? Revision 48 underlying-cause-of death codes Age-specific population estimates were obtained from 49 US. Census Bureaquational Center for Health Statistics bridged?race population data releases. 50 5 National and statEvlevel suicide rate estimates were calculated for six consecutive three-year aggregate periods 52 from 1999-2015. Rate estimates were age?adjusted to the U.S. year 2000 standard population and expressed per 53 100,000 persons per year. Age?adjusted suicide rate trends were modeled using the same three?year data 54 aggregates, employing weighted least squares regression with inverse?variance weighting. Modeled rate trends 55 are reported in terms of average annual percentage changes 50 I 5? beta from 2015 from the 2? states with complete data participating in shaggy; National iiv'iolent Death 58 Reporting System ages 10 and older, were used to compare the characteristics among suicide I 59 decedents with and without known current menial health-nodule ms 60 disorders and listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 6 5} except alcohol and other substance use disorders [captured aggregates data from three primary data sources: death certi?cates, coronerfmedical examiner reports [including toxicology], and law 63 enforcement reports. Decedents with and without known MHP were compared using Chi-square tests; logistic 64 regression was used to estimate adjusted odds ratios with 95% confidence intervals controlling for age 65 group, sex, and racelethnicity. as RESULTS (5121591 words] 6? The most recent overall suicide rates (representing 2014-2016] ranged from 6.9 (District of Columbia] to 29.2 (58 {Montana} per 100,000 persons per year, a four-fold difference liable ill-?Acres thesetire . increased in all but one state {luevaddlt Hith??i?i?l?i109319-535. +3.1 [Wyoming] pr" 70 per 100,000. Percentage increases in rates ranged from +59% [Delaware] to 67.6% {North Dakota}, with TI percentage increases of at least 30% observed in 25 states. 1?2 7?3 Modeled suicide rate trends indicated significant increases for 44 states, as well as for the U.S. overall {Table T4 By sex, modeled rate trends indicated significant increases in 34 states for males and in 43 states for females. 75 Nationally, the model-estimated AAPC for the overall suicide rate was By sex, the national MPO was 7's +11% for males and +16% for females. T8 Suicide decedents with and without [N=11,039l known MHP were i9 were predominately male and non-Hispanic white. .sSuicide decedents without known MHP relative to inns-r: 80 ti". known I'viI-ii- were more likely to be male [83.5% vs. p5.01,l. and racialf'ethnic minorities (odds ratio 81 range: Cl range also had 33 firearm suicide 1.6, 95% CI and of positive toxicology results for alcohol 1.2, 95% CI ad served or were 34 1-1" 13}- [19.12.954.51 Hill]. 511.959.9103}; 59.9392351353qu 85 serving sewed-in the us. military. '82 significantly greater odds of perpetrating homicide-suicide {adjusted odds ratio 2.gclearer. Tracked is an idea. i LA. f. exception is described. DEM-5 does have I if two ?Table 1? in attachments state I r: still have a signi?cantly high rate of I words so you may not be able to do this .1 Commant Is It really the 'nation?s goal? - versus the goal set by the American Foundation for Suicide ,Prevention. 1 Comment Sentence has a lot of different points. it may be easier to read if it were two sentences. Suggestion: Data from the National Violent Death Reporting System were used to compare characteristics among suicide decedents with and without known current mental health programs. Complete data from 2? states participating in in 2015 were used ,for this analyses. Comment lam confUSed by how i the alcohol and substance use disorder an alcohol use disorder diagnosis and a Lsuhstance use disorder dx. 1 Comment Some labeling of the tables and how reflected in the text need some modi?cation. There are current trends: select demographics}. The two d..l a hlilh?f d. r? Comment IBEU: Per our discussion in our last VS group meeting, should we add I a note that despite NV not increases, they Lsuicidei' x? Comment Please double check. ,Table reflects +0.3 Comment Suggest revising in ,3 order to allow in the next sentence the .i comparison group to be clear and the I order the should be considered Comment Wonder if need to be i clear here this is limited to 18+. Tracked might be a simple approach to consider. have seen MMWR want to present 96?s Comment IJRVEI: I realize this adds 4? but the "ever? in the original sentence at. In. Jk E'l'll I was block to me as a i read. Not sure ifthe additional language WW If]? [08 ?m9 Illi Ill ?2 113 ?4 H5 Ilf) 117 its i 9 l20 22 [23 IE4 IRS [20 Hey 3.19.18 y3 Although firearms were used most often in both groups, decedents with known MHP died by poisoning more than those without known MHP {19.8% vs. 10.4%: 5 most frequently by over-the-counterfotherwise f: unclassified Eirugs opioids antidepressants or benzodiazepines (25.1% . All suicide decedents with known MHP lN=9,407} and approximately 35% without had precipitating circumstances 2 on People with known MHF were more likely to have any substance abuse problems [31.6% vs. 25%, 5 While two-thirds of those with known MHP had a history of MH or substance abuse treatment just over half were in current treatment at the time of their deaths. Decedents without known MHP, versus those with known MHP had a greater likelihood of any relationship problemfloss {45,199. aadvs 39.5%, 5 specifically intimate partner problems [30.2% 24.1%, 5 andys 13.6%, pg and recently perpetrating interpersonal violence [3.0225 as.dy_s_ f, They were also more likely to have experienced other life stressors, such as bosses {197?s ass Elites ?01! estates431951902919. assesses. iiases?iessj be: assesses" likely to have had a crisis within the preceding or upcoming two weeks {32.9% antly_s_. 26.0%, Among Both grows, the most common crises were intimate partner and physical health problems. i? ?1 Comment I think the comparison group 96?s are needed. For instance, drugs (35.8% vs. I think the presentation of the 93's would be easier here and later on in the results if the p's came out and the text could simply reflect ?significant differences? or some variation of indicating in the groups ,were different. JL Comment Sometimes criminal? legal is hyphenated and sometimes it?s Ln DL .2 Comment IFCU: The all reported in this sentence appear to be only for the groUp with MHPs. Based on the sentence wording, the 96 for both groups need to Decedents without known MHP had signi?cantly lower odds of recent release from any institution, but among those who were recently released, those without a known MHP were more likely to be released from a correctional facility {25.7% vs. p501) or hospital (43.7% vs. 33.0%, p501} than those with a known Mi-lP. Among decedents with known MHP recently released from an institution 42.8% were released from facilities. Suicide decedents without known MHP were more likely than tl?io?se Without known lyii ii? to leave a suicide note i35-1i'i it?d? were more likely to have a history of suicidal ideation [40.3% vs. 23.0%, 5 .01] and attempts (29.4% vs. 10.3%, p5 .Dli? i I .rcm? N?HF-ri-r? wo-H-?iDO-lwn .-.-- Conclusions and Comments [655(215 wordsi From 1999-2015, ?14 states saw significant suicide rate increases. Half of the states experienced increases of 30% or more. Rates increased significantly in 34 states among males and 43 states among females. More research into the causes of these trends is necessary MHP. This group was challenged by comorbid substance abuse problems and histories of suicidal ideation and attempts While two-thirds of people with known MHP had a history of MH andfor ?a substance abuse treatment and over half Were in treatment at the time of their deaths, additional support eeald m_ay_he p address the needs of this vulnerable population. This includes broader implementation of affordable and evidence-based treatments, such as doctor?patient collaborative care models and cognitive-behavioral therapy. Additionally, greater access to behavioral health providers, especially in underserved areas is important, as is healthcare systems changethat supports suicide prevention and patient safety through care transitions While mental health problems are a significant contributor to suicide, 54% of suicide decedents in this study did not have a known MHP. This group suffered more relationship problems and life stressors such as criminal?legal matters, evictionlloss of home, and recent or impending crises. This is noteworthy in light of findings that suggest manyi suicides and attempts occur with minimal deliberation time, particularly among people without mental health disorders and who faced impending life crises 3 r{illuminant Please double check ,be reported. JL. number. Table reflects 33.3% Comment My two cents: I think we should do more to raise attention to the fact that almost a quarter of both groups disclosed suicide intent. This is a true prevention opportunity sol think this is a common risk to highlight. Knowing space constraints, I think this is more important to highlight than the presence of a suicide note which often doesn't inform prevention. I suggest adding into Lresults and into discussion. Comment lfeel typically don?t do a lot of repeat of the specific data findings in the discussion. I think the numbers could come out here. i think it would be helpful to put this into a larger context, indicating whether this is l__consistent with other research. I also .Jk Comment lwould add the Lpercentage in parenthesis [28 I29 I30 l3l 132 I33 l34 I35 36 137 I38 I39 I40 I4I I42 I44 I45 I46 14? I48 I49 I50 I5I I52 I53 I54 I55 l56 I58 159 I60 I6l I62 I63 I64 I65 166 167r I68 169 Rev 3.19.18 v3 Heople with known MHP also Experienced other life stressors such asjob andfor financialL-pseblemss; conditions associated with mental health problems in the first place and the need to support people with known MHP to decrease theirEIulnerability}o poor social, health, and economic outcomes 2? These results underscore the importance of comprehensive In! beyond a focus on maturing} health treatment alone. Prevention strategies may include: strengthening It economic supports housing stabilization policies, household ?nancial teaching coping and ?y problem-solving skills, especially early in life to manage everyday stressors and prevent future relationship problems; and promoting social connectedness to increase a sense of belongingness and access to informational, tangibie, emotional, and social sopport,eeneeded. Other strategies indicated lay these result:- include creating protective environments leg, reducing access to lethal means among people at risk, creating organizational and workplace policies to promote help-seeking and positive social norms}, supporting family and friends after a suicide?has?taieen?piaee, and assuring safe reporting by the media in order to prevent suicide contagion [ll?Some states, such as Colorado, are planning and implementing a comprehensive we?w?e approach to The steelyfindings have at least three limitations. in the state-level analysis, rankings for four states (MD, MA, RI, might have been impacted by large proportions of injury deaths of undetermined intent, For by decreased percentages of such deaths over timt-i which likely include some unrecognized suicides. Second, is not yet nationally representative, and incl udedes 2? states that represent hair?itiBE?iI?ui of the U5. population. Third, abstractors of data are limited to data included in invEstigative reports. For exampie. and MHmor'Ital Ill'?l? information are rial. records?eat g?from key informants leg, family, friends} via coronerfmedical examiner reports and can impacts sheared completeness and accuracy, of tfieanformation reported, and Some studies including in?depth interviews with family members It is likely that some people without known l'leP in the current study were experiencing mental health challenges at the time of death that were either not known or i?eported by menial nee-oi a dcii'essing-i-he-Fa-nge ~0i-ceni-r-i bet-ing- Suicide is a growing public health problem. [Nkntal illness is an important risk factor for suicide, and is one of many requiring preventive action. Data from and resources such as Preventing Suicide: a Technicai Package of Policies, Programs, and Practices [11] can help states and communities better understand their a suicide problem and prioritize comprehensive suicide prevention. Acknowledgments The authors acknowledge Robert Anderson, Holly Hedegaard, and Margaret Warner from the Division of Vital Statistics, National Center for Health Statistics, CDC, for their statistical consultation. Con?ict of Interest No conflicts of interest were reported. Corresponding author: Deborah M. Stone, i30-488-3942 Author Affiliations: Comment suggest pulling this out into a separate paragraph. If contained in the above, it seems to undercut the main point that many suicides don't have MPH. A new paragraph might need a lead?in sentence or maybe start with the current last sentence to frame points about common ,risks. Comment Should this he 'and?, L?or? or ?andfor?? JL. Comment Suggest using "risk of" rather than "vulnerabifity to?, as vulnerability sometimes can have negative connotations aligned with ,weakness. i- Comment IFCU: I think it is fine that the TP strategies are presented in different areas of the discussion. i don?t easily see "identify and support people at-risk?. I think that can go in the proposed paragraph immediately above when talking about common risk factors. In adding that, suggest adding so me examples of approaches leg, crisis Lintervention, gatekeeper training). Comment [17ka I am not easily following this point. Can this be stated more simply such as by variations of undetermined injury deaths, which To help wfword count, offer a couple of suggestions in next few sentences to streamline. Certainly takej'leave what you tlike and check for accuracy. ., Comment Do you mean ?reported by informants? JL Comment To me, this sentence puts the spotlight pack on mental illness and makes it likely it will be the take home message of media reporting. If that isn?t the goal of this V5, suggest framing broadly. ideas: Effective approaches are Lavailobie to prevent or ameliorate many 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 Rev 3.19.18 v3 1Division of Violence Prevention, National Center for Injury Prevention and Control, 2Division of Analysis, Research, and Practice Integration, National Center for Injury Prevention and Control, CDC References: 1. 10. 11. 12. 13. 14. 15. Centers for Disease Control and Prevention, Web-based injury Statistics Query and Reporting System Atianto, GA: Nationai Center for injury Prevention and Controi. Retrieved March 15, 2018. 2016. Ivey-Stephenson, A.Z., et al., Suicide Trends Among and Within Urbanization Leveis by Sex, Race/Ethnicity, Age Group, and Mechanism of Death - United States, 2001-2015. MMWR Surveill Summ, 2017. 66118): p. 1-15. Kegler, S.R., OM. Stone, and KM. Holland, Trends in suicide by ievei of urbanization?United States, 1999?2015. MMWR. Morbidity and mortality weekly report, 2017. 65(10): p. 270. Kochanek, K., et al., Mortaiity in the United States, 2015. NCHS Data Brief, no 293. National Center for Health Statistics, 2017. Office of the Surgeon General and National Action Alliance for Suicide Prevention, 2012 Nationai strategy for suicide prevention: goais and objectives for action: a report of the US Surgeon Genera.f and of the Nationai Action for Suicide Prevention. 2012. Rosenman, 5.1., Preventing suicide: what work and what not. The Medical Journal of Australia, 1998. 169(2): 100?102. Torguson, K. and A. O'Brien, Leading Suicide Prevention Efforts Unite to Address Rising Nationai Suicide Rate. 2017: Washington, D.C. Crepeau-Hobson, F., The Autopsy and Determination of Chiid Suicides: A Survey of Medicai Examiners. Archives of Suicide Research, 2010. 14(1): p. 2434. American Association, Diagnostic and statistical manuai ofmentai disorders 2013: American Pub. Li, 2., et al., Attributobie risk of and socio?economic factors for suicide from individuoi?ievei, popuiation-based studies: A systematic review. Social Science Medicine, 2011. 72(4): p. 608616. Stone, D.M., et al., Preventing suicide: A technicai package ofpoiicies, programs, and practice. 2017. Simon, T.R., et a1, Characteristics of impuisive suicide attempts and attempters. Suicide and Life- Threatening Behavior, 2002. 32(51): 49-59. World Health Organization, Risks to mentai heaith: An overview of and risk factors. Geneva: WHO, 2012. Caine, E.D., et al., Comprehensive, integrated approaches to suicide prevention: practicai guidance. Injury prevention, 2017: p. injuryprev?2017?042366. Hawton, K., et al., The autopsy approach to studying suicide: or review of methodoiogicai issues. Affect Disord, 1993. 50(23): p. 269-76. Tables and Figures (attachments) Table 1 and Figure 1.doc Tables 2 and 3.pdf Word Count: 1826/ 1800 Table 1. Trends in Suicide Rates among Persons 2 10 Years of Age. by EtatJ?end-Sem-??wm state 59x Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period] hr: Egg-:31 Raguglrlil;ge 1999 - 2001 2002 2004 2005 - 2007 2008 2010 2011 - 2013 2014 2015 Rank {State Rank] 1 (?State Ragnk] Both 12.311113] 1271+ 0.4] 1291+ 0.2] 1351+ 0.9] 1451+ 0.5] 1541+ 0.9] 1.5 31: 1p<.01] ni'a 3.1 {rite} 25.4 %1n1ai US. Male 20.91nia] 2121+ 0.4] 21.31+ 0.0] 22.5 2351+ 1.0] 2451+ 1.0] 1.1 1p<.01] Female 4.71nia] 5.01+ 0.3] 531+ 0.2] 571+ 0.4] 521+ 0.5] 591+ 0.7] 2.5 1p<.01] Eloth 14.31nia] 13.41- 0.9] 1411+ 0.5] 1551+ 1.5] 15.41+ 0.7] 17.51+1.1] +1.5 ?its 1p<.05] 25 3.1 131] +219 913133} AL Male 25.1 1nia] 23.41-17] 24.41+1.0] 2541+ 2.0] 27.51+1.1] 29.1 1+ 1.5] 1.3 0A1p<.05} Female 5.1 1nia] 4.31- 0.3] 501+ 0.2] 5.1 1+ 1.1] 541+ 0.3] 701+ 0.7] 25 '31: Both 21.01nia] 2451+ 3.5] 24.21- 05] 2501+ 1.7] 25.41- 0.5] 2351+ 3.4] 1.7 ?fa 1p<.051 2 7-31 41 37.4 113] AK Male 33.21n1a] 35.1 1+ 4.9] 3591+ 0.5] 40.1 1+ 1.2] 40.1 1- 0.1] 4291+ 2.5] 1.4 ?i?a 1p<.01] Female 5.51nie] 1141+ 2.9] 9.51-1.51 11.1 1+ 1.2] 9.91- 1.2] 1321+ 3.4] 1.7 r115 Both 17.51n1a] 1551+ 0.7] 19.1 1+ 0.5] 19.1 1- 0.0] 20.41+1.3] 2091+ 0.5] 1.0 0111(pc.01} 15 3.1 132] +113 ?11: 142] AZ Male 29.31nia] 3021+ 1.0] 3051+ 0.4] 30.21? 0.5] 3201+ 1.9] 3241+ 0.4] 0.5 ?In 104.05] Female 7.1 1n1a] 7.51+ 0.4] 521+ 0.7] 551+ 0.5] 921+ 0.5] 991+ 0.5] 2.2 1p<.01] Both 15.5 (rite) 1531+ 03] 1521+ 0.5] 1751+ 1.4] 19.21+1.5] 2121+ 2.0] 2.2 12 5.7114] 35.5 ?xi: 115] AR Male 25.?1nia] 25.? 1+ 0.0] 2721+ 0.5] 3171+ 3.5] 3351+ 1.9] 1.5 ?it: 1p<.05] Female 5.51nia] 591+ 521+ 0.4] 791+ 1.7] 7.51- 0.4] 951+ 2.1] 3.5 991p{.01] Both 10.51nia] 1131+ 0.7] 11.01- 0.3] 1201+ 1.0] 11.31- 0.1] 12.1 1+ 0.3] 0.9 0:1: 1p<.05] 45 +1.5145] 14.3 145] CA Male 17.91n1a] 1341+ 0.5] 1171+ 0.7] 19.1 1+ 1.4] 15.912 0.2] 1921+ 0.3] 0.5 1115 Female 4.1 We] 501+ 0.9] 4.91? 0.1] 541+ 0.5] 5.31? 0.1] 551+ 0.3] 1.7 Both 17.31n1a) 1921+ 1.9] 19.01- 0.2] 2001+ 1.0] 21.51+1.5] 2321+ 1.5} 1.3 ?it: 1p<.01] 5 5.9112] 34.1 31: 122] CD Male 25.51n1a] 3091+ 2.3] 30.51- 0.4] 3151+ 1.0] 33.41+1.9] 3531+ 2.9} 1.4 925113?5111] Female 7.011113] 321+ 1.3] 821+ 0.0] 9.1 1+ 0.9] 10.1 1+ 1.0] 1041+ 0.3] 2.5 113101] Both 9.51nia] 5.91? 0.7] 9.1 1+ 0.2] 10.21+ 1.1] 1101+ 0.5] 1151+ 0.5] 1.5 ?fu1ps.05] 45 +1.9143] 19.2 ?it: 134] CT Male 15.41n1a] 1451-15] 1501+ 0.4] 15.51+ 1.5] 17.51+1.0] 17.31- 0.3] 0.9 n15 Female 3.51nl?a] 351+ 0.2] 3.71- 0.2] 4.41+ 0.7] 491+ 0.5] 521+ 1.3} 3.5 %1p<.05] decrease 151]. Differences between ranks do not necessarily imply a statistically signi?cant difference. 1'1 Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the ?rst and last periods and might have contributed to lower reported rates. Rates are age-adjusted to the U5. year 2000 standard. Modelaestimaled average annual percentage change based on all reporting periods; p-value indicates statistical signi?cance of trend; nis indicates trend not significant 15 Current state rank 150 states and the District of Columbia] is forthe reporting period 2014 - 2015. Ranks are from highest rate 11] to lowest rate 151]. Differences between ranks do not necessarily imply a statistically signi?cant difference. Dyerell rate change is between the ?rst 11999 2001 i and Iast12014 2015] reporting periods. Ranks are from largest increase 11] to largest decrease 151]. Differences bent-teen ranks do not necessarily imply a statisticall signi?cant differenceComment Wonder ifin a revised title or footnote ifit needs to be revised to reflect this also includes District of Columbia. Comment Suggest being clear on what these period, similar to how done In another footnote. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, 1999 2016 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period) Current Overall Overall State Sex State Rate Change 2:21:19"; 1999 2001 2002 2004 2005 2007 2008 2010 2011 2013 2014 - 2016 Rank 5 {State Rank) 1? (State ank) Both 13.6 (nia) 12. 211 .4) 11.91; 0.3) 13.61+ 1.7) 14.21+ 0.6) 14.41+ 0.2) 0.9 42 0.8150) 5.9 311150) DE Male 23. 0 (Na) 20. 31-2 .7) 19.91- 0.4) 23.1 1+ 3.2) 22. 7 1- 0. 4) 2351+ 0.8) 0.6 ?fa nis Female 31nla) 010.2) 4.614 0.4) 91+ 0.3) 6. 41 1 5.) 21- 0.2) 1.6 his Both 91nla) 641+ 0.5) 6.41? 0.0) 31+ 0.6) 6?01.7) 6.91+ 0.3) 0.9 36 nis 51 1.0146) 16.1 ?is 145) DC Male 10.7 (nla) 11.11+ 0.4) 10.31; 0.8) 1271+ 2.4) 10. 012 .6) 11. 71+ 1.7) 0.3 ?it: nis Female 1.7 i1riia)?FT 231+ 0.6) if 3.31+ 1.0) 61- 0.7) 3.61+ 1.0) 810.8) 3.5 ?fa nis Both 14.8 (nia) 1521+ 0.4) 14.91- 0.3) 16. 3 1+ 1.4) 1631.0) 16.41+ 0.1) 0.8 361p<.05) 29 1.6145) 10.6 i13146) FL Male 24.3 (We) 24.41+ 0.1) 23.61- 0.8) 26. 2 1+ 2.6) 25. 61 0. 6) 25.6 1) 0.5 36 nis Female 6.3 (nia) 6.61+ 0.5) 681+ 0.0) 11+ 0.3) 7.61+ 0.5) 81+ 0.3) 1.4 901p<.01) Both 12.91nla) 13.21+ 0.3) 12.31? 0.9) 13. 2 1+ 0.9) 13.71+ 0.5) 1501+ 1.3) 0.9 ?it; nis 39 2.1 140) +162 13144} GA Male 22.1 (his) 23.1 1+ 1 0.) 21.3 1? 1.8) .91+ 0.6) 2261+ 0.7) 24.-41+ 1.7) 0.5 ?fa his Female 5.0 (Na) 810.2) 4.6 1- 0.2) 51+ 0.9) 5.8 1+ 0.3) 6.6 1+ 0.8) 2.1 ?fa 1p<.05) Both 12.91nla) 11. 1 11.6) 10.31- 0.7) 14.51+ 4.1) 14.41? 0.1) 1521+ 0.8) 2.0 ?fa nis 35 2.4135) +183 I1111136) HI Male 20.4 (Ma) 17. 21-3 .1) 15.3 1- 1.9) 21. 91+ 6.7) 2251+ 0.5) 24.31+ 1.8) 2.1 ?fa nis Female 5.4 (We) 010.4) 5.51+ 0.5) 11+ 1.5) 21- 0 9) 5.91- 0.3) 1.2 ?fa his Both 17.3 (nia) 1921+ 2.0) 16.31? 0.9) 21. 61+ 3.3) 2191+ 0.3) 2471+ 2.8) 2.3 3611:1101) 6 7.51 6) 43.2 1 7) ID Male 28.4 (nia) 33.1 1+ 4.7) 31.1 1? 2.0) 3 .91+ 3.8) 71- 0 2) 3801+ 3.3) 1.6 301p<.05) Female 7.2 (Na) 6.1 1- 1.1) 6.1 1+ 0.0) 01+ 2.9) 9.51+ 0.5) 1181+ 2.3) 4.4 1p<.05) Both 9.9 (nia) 9.81? 0.1) 9.71- 0.1) 10. 6 1+ 0.8) 11.2 1+ 0.6) 12.21+ 1.0) 1.5 i5131p<.05) 44 2.3138) 22.8 ?it (32) IL Male 17.1 (We) 16.71? 0.4) 16.2 1- 0.4) 17. 61+ 1.4) 1851+ 0.9) 1981+ 1.3) 1.1 3611:1105) Female 3.7 (nla) 3.814 0.0) 381+ 0.2) 21+ 0.4) 4.51+ 0.4) 521+ 0.6) 2.4 301p<.01) Both 13.01n1a) 13.71+ 0.7) 14. 4 1+ 0. 7) 14.91+ 0.5) 16.41+1.4) 17.11+ 0.7) +1.9 1p<.01) 26 4.1123) 31.9 13125} IN Male 22.4 (his) 2321+ 0.8) 24. 41+ 1 .2) 24. 71+ 0.4) 2671+ 2.0) 2831+ 1.6) 1.5 3611:1101) Female 4.6 (We) 501+ 0.4) 531+ 0.2) 91+ 0.6) 681+ 0.9) 6.61? 0.2) 2.7 3611:1101) Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change 1AAPC) based on all reporting periods; p-yalue indicates statistical signi?cance of trend; his indicates trend not significant. Current state rank (50 states and the District of Columbia) is for the reporting period 2014 2016. Ranks are from highest rate 11) to lowest rate 151 Differences between ranks do not necessarily imply a statistically signi?cant difference. ?7 Overall rate change is between the first (1999 2001) and last (2014 2016) reporting periods. Ranks are from largest increase 11) to largest decrease Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst and last periods. Ranks are from largest percentage increase 11) to largest percentage decrease 151). Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. -2- Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, 1999 2016 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex [10:35? State Rate Change 2:21:19"; 1999 2001 2002 2004 2005 200? 2008 2010 2011 2013 2014 - 2016 Rank 5 (State Rank) 17 (State ank) Both 11.8 (nia) 13.2 1.4) 12 8 0.4) 14.2 1.4) 15.9 16.0 0.1) 2.1 31 4.3 (20) 36.2 ?it: (18) IA Male 20.6 (nia) 22.1 1.5) 20.8 .4) 23.3 2.5) 26.0 25.7 (0 3.) 1.6 ?fa Female (nia) 4.7 1.0) 30(+ .6) 0.2) 0.6) 0.6) 3.8 Both 13.3 (nfa) 15.1 15.3( 0.5) 2.4) 19.4 1.6) +2.2 19 +6.0(11) +450 5) KS Male 22.? (nia) 25.0 2.29.1 3.5) 30.? 1.6) 1.9 Female 4.6 (nia) 6.0 1.4) 7(0 3) 4( 0. 3) 6.8 1.4) 8.4 1.6) 3.2 ?fa Both 14.1 (nta) 15.4 1.3) 16. 7 1 .3) 16.2 (.5) 18.2 2.0) 19.3 1.1) +1.9 31: 20 5.2 (16) 36.6 ?it (16) KY Male 25.0 (nfa) 26.8 1.9) 28. 3 1.4) 6-2( 1. 0) 30.1 2.9) 31.? 1.6) 1.4 ?fa Female 4.8 (nia) 0 .4) 0. 8) 0.1) 7.1 0.9) 0.6) 3.2 Both 13.1 (nia) 12.9 0.2) 13. 4 0 .4) 13.6 0 3) 14.4 0.8) 17.0 2.5) +1.6 31; 27 3.8 29.3 as (26) LA Male 22.9 (nfa) 3 0. 6) 22. 4 0.1) 3. 3 0. 8) 23.? 0.5) 27.3 3.6) 1.1 ?fa nis Female 4.8 (nfa) 7( 0.1) 0. 5) 9( 0. 2) 6.1 1.2) 7.5 1.4) 2.8 3?0 Both 14.5 (nia) 1310) 18.9 3.5) 18. 0.4) 2.2 31: 21 4.0 (25) 2?.4 ?it; (29) ME Male 25.0 (nia) 22. 9 2. 1) 24.6 1.7) 25. 7 1.1) 31. 5 .4) 29. 8(1 .3) +1.8 ?fa Female 5.3 (nfa) 5.3 (- 0.0) 2( 0.1) 0.7) 6( 1.6) 7.9 0.3) 3.1 ?it. Both 10.0 (nfa) 10.3 0.3) 10.1 0.2) 10.2 0.1) 10.? 0.5) 10. 8 0.Male 17.6 (nia) 17.8 0.4.) 18.2 0.5) 18.0 .2) 0.2 nis Female 3.5 (nia) 3.8 0.4) 0.0) 7(0.2) 4.1 0.4) 4.5 0.4) 1.3 ?fa Both 7.4 (nia9.8 0.4) 10.0 0.3) 2.3 31: 48 2.6 (34 35.3 (20 MA Male 12.1 (nfa) 12.8 15.4 2.1) 15200.2) 16.0 0.8) +2.0 Female 3.3 (nia) 900 . 4) 1.0) 0.0.2) 3.0 Both 11.8 (We) 12.5 0.7) 12. 9 0 .4) 1315.6 1.1) +1.9 31: 33 3.9 (26) 32.9 as (24) Ml Male 20.0 (nia) 20.9 0.9) 21.6 0. 7) .8 1.3) 23. 9( 1.0) 25.0 1.2) 1.5 ?fa Female 4.4 (nfa) 4.8 0.0.9) 2.8 3?0 Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change (AAPC) based on all reporting periods; p-yalue indicates statistical signi?cance of trend; nits indicates trend not significant. Current state rank (50 states and the District of Columbia) is for the reporting period 2014 2016. Ranks are from highest rate (1) to lowest rate (51 Differences between ranks do not necessarily imply a statistically signi?cant difference. 1 Overall rate change is between the first (1999 2001) and last (2014 2016) reporting periods. Ranks are from largest increase (1) to largest decrease (51). Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst and last periods. Ranks are from largest percentage increase (1) to largest percentage decrease (51). Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. -3- Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, 1999 2015 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period}* Current Overall Overall State Sex [10:35? State Rate Change 2:21:19"; 1999 2001 2002 2004 2005 2007 2005 2010 2011 2013 2014 - 2015 Rank 5 {State Rank) 17 (State REnk} Both 10.71n1a1 11.51+ 0.91 12.41+ 0.51 12.91+ 0.51 14.21+ 1.4.31191 40.5 fit-r1 51 MN Male 15.3 1n1a1 1931+ 1.11 20.41+ 1.01 2091+ 0.51 22.9 81+ 1.91 2331+ 0.41 1.7 ?fa 1p<.011 Female 3.5 1n1a1 4.21+ 0.51 51+ 0.51 1 1+ 0.41051 591+ 1.21 4.2 ?fa 1p<.011 Both 12.91n1a1 14.1 (+1.21 14. 7 1+ 0 51 1551+ 0.51 1551+ 0.11 15. 210 .31 +1.1 3011:11051 35 2.31351 17.8 ?55 1401 M5 Male 22.9 1n1a1 24.51+1.71 25.1 1+ 0. 51 2551+ 1.71 25.91.91 25.31.51 0.7 Female 4.3 1n1a1 501+ 0.7151+ 0. 51 51 0. 01 541+ 09121-021 2.4 '11: 1p<.011 Both 14.71n1a1 14.1 1? 0 51 1541+ 131 1501+ 0. 71 1751+ 1.71 20. 0 1+ 2.3] 2.2 i5131p<.011 15 5.31151 35.4 15117} MD Male 25.3 1n1a1 2371+ 1.51 25. 5 1+ 1.91 2551+ 1.01 2591+ 2.31 32. 2 1+ 3.31 1.5 '15 1p<.051 Female 5 4 (ma) 5.41+ 0.1111+ 0. 71 31+ 0.21 7.41+ 1.11 51+ 1.21 3.2 14113401} Both 21.1 1n1a1 22.51+ 1.41 2351+ 101 24.71+1.11 2571+ 2. 01 2921+ 2.51 2.1 1 5.01 21 35.0 351111 MT Male 35.9 1n1a1 3731+ 0.41 39. 5 1+ 2. 51 39.710 11 41 0.1+ 1 .41 4551+ 4.41 1.3 ?fa 1p<.011 Female 5.71n1a1 5.41+1.5141+0.11 10. 0 1+ 1. 51 1251+ 2.51 1311+ 0.51 4.5 551131011 Both 12.71n1a1 122111.71.51 1351+ 1.51 14.51+1.31 +1.0 ?fa 40 2.1 1421 15.2 ?11} 1431 NE Male 22.21n1a1 20.71- 1 51 20 310.2391+ 19.1 0.5 ?fa nis Female 3.5 1n1a1 4.21+ 0.4111+ 0.9101+1.2.5 Both 23.31n1a1 22.51- 0 51 2221.4 21 23.1 1+ 1.51 0.2 ?it. 9 0.21511 +1.0 51.1511 NV Male 35.3 1n1a1 3571+ 1.71 35.1 1+ 1.51 35510.7 51; his Female 5.91n1a1 951+ 0.5151+ 0.11 1001+ 0 .41 10. 5 1+ 0.61 11.21+ 0. 51 +1.5 ?fa 1p<.011 Both 13.51n1a1 12.51 .01 13.31+051 15.21 1. 91 15.51+0.51 20.0 {+4.21 +2.7 501p<.051 17 +5.51 5) +453 %1 31 NH Male 22.5 1n1a1 21.1 1+1 4) 21.71+ 0. 51 24. 5 1+ 3.2.2 551131051 Female 5.3 1n1a15+01.5191+ 1.01213.9 501p<051 Both 7.5 1n1a1 71+01151+ 0.2101.41 1.3 31: 1p<.051 50 1.51471 19.2 351351 NJ Male 13.01n1a1 13.11+ 0.01 12 510.551 13. 71+ 1.1 1 1451+ 0.51 1451+ 0.11 0.9 55151051 Female 3.2 1n1a1 91+ 0.31 3.01+ 0.0191 0.Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change 1AAPC1 based on all reporting periods; p-yalue indicates statistical signi?cance of trend; n15 indicates trend not significant. Current state rank 150 states and the District of Columbia) is for the reporting period 2014 2015. Ranks are from highest rate 111 to lowest rate 1511. Differences between ranks do not necessarily imply a statistically signi?cant difference. ll Overall rate change is between the first (1999 20011 and last (2014 2015) reporting periods. Ranks are from largest increase 111 to largest decrease 1511. Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst and last periods. Ranks are from largest percentage increase 111 to largest percentage decrease 1511. Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. -4- Trends in Suicide Rates among Persons 2 19 Years of Age, by State and Sex, 1999 2916 Age-Adjusted Annual Rate per 199,999 Persons {Change from Prior Period) Current Overall Overall State Sex [10:35? State Rate Change 2:21:19"; 1999 2991 2992 2994 2995 2997 2999 2919 2911 - 2913 2914 2916 Rank 5 {State Rank) 17 (State ank) 55111 22.91n1?a) 22.014 01) 51 02) 2301+ 1.2) 24.11+1.1) 2501+ 1.9) +1.1351p<.05) 4 4.0124) 15.3 35139) NM Male 36.6 1nfa1-1 .2) 35.61 9. 6) 37.1 1+ 1 .3) 49.71+ 3.6) 9.4 35 nis Female 5.5 1n7a) 411.1) 20111.71+ 0. 9) 1201+ 0.3) 3.3 35 11:14.05) 55111 7.21n7a) 110.1+1. 1) 310 .1) 213515401) 49 2.1 141) 25.5 35127) NY Male 12.51n1a) 12.21413) 1291+ 0.7) 1391+ 1. 0) 15.41+ 1.4) 14.5019) 1.4 351p<.05) Female 2.71nfa) 1-9 .1) 391+ 93) 1+ 9. 5) 4.2 1+9. 7) 461+ 9.5) +4.2 35 1p<.91) 55111 13.51nia) 13.4)51 .1) 1371+ 0.1) 14.21+05) 14.5.1+04) 15..31+55) +0.5 3515401) 34 1.7144) 12.7 35 147) 1111; Male 22.7 1n7a) 2271+ 0.0) 22.2 1- 0.5) 2331+ 1.1) 2331n75 Female 5 6 11115) 51 9 2) 621+ 9.2.9 3511:1995) Both 13.31n1a) 1461+ 1.3) 1691+ 1.4) 16. 6 1+ 9 6) 16.41+ 1.9) 29. 9 1+ 2. 5) 2.9 351p<.91) 14 7.61 5) 57.6 351 1) ND Male 21.4 1n1a) 2451+ 3.2) 230129.11:14.01) Female 5.5 1n7a) 51? 1.0) 371- 0.1.0) 551+ 1 .5) 3.9 35 n75 55111 11.5 11115) 1231+ 0.5) 1311+0.5) 1341+ 0.2) 14.51+ 14.) 15.51+1.0) +2.0 35 15401) 32 +4.2121) +350 35119) OH Male 20.4 1n1a) 2091+ 0.5) 2221+ 1.3) 221.3) 1.5 35 1p<.01) Female 4.0 1n1a) 471+ 0.7) 491+ 0.1) 31+ 0. 5) 0.11:14.01) Both 17.91nta) 16. 51116.41+1.1) 2971+ 2. 3) 23.51+ 2.6) 2.3 35111995) 7 6.4119) 37.6 i75112) OK Male 26.5 1nfa) 27. 311 .2) 2761+ 9. 5) 3931+ 2.5) 3341+ 3.1) 3731+ 3.6) 2.9 3511:1995) Female 6.6 1nfa) 19 .2) 7. 5 1+ 1.1) 91- 9.5) 6.51+ 1 6.) 19.31+ 1.6) 2.9 1p<.95) Both 16.41nta) 17.71+1.3) 17. 71-9 .9) 16. 61+ 9.9) 19. 6 1+ 1 .2) 21.1 +1.6 351p<.91) 13 4.6116) 26.2 i55126) OR Male 27.41n7a) 2951+ 2.1) 25.51 0. 9) 29.51+1.0) 31.41+1.5) 33 01+ 1.5) 1.1 35 11:14.01) Female 6.5 11115) 1 1+ 9.6) 7.71+ 9.6) 41+ 9.7) 661+ 9.4) 9. 61+ 9. 9) 2.7 3519491) Both 12.1 1n1a) 1251+ 9.4) 1261+ 9.3) 13. 9 1+ 1.1) 15. 9 1+1. 1) 16.31+1.2) 2.9 351p<.91) 39 4.1 122) 34.3 35121) PA Male 21. 01n nfa a) 2131+ 0.3) 21 .91+05) 231 1+ 1.2) 2471+ 17.) 25.11+1.3) 15351121401) Female 4.2 1n7a) 451+ 0.3) 451+ 0.0) 41+ 0.9) 5. 0 1+ 0. 5) 11+ 1.1) 3.5 35 11:14.01) Rates are age-adjusted to the U5. year 2999 standard. Model-estimated average annual percentage change 1AAPC) based on all reporting periods; p-yalue indicates statistical signi?cance of trend; nits indicates trend not significant. Current state rank 159 states and the District of Columbia) is for the reporting period 2914 2916. Ranks are from highest rate 11) to lowest rate 151 Differences between ranks do not necessarily imply a statistically signi?cant difference. ?7 Overall rate change is between the first (1999 2991) and last (2914 2916) reporting periods. Ranks are from largest increase 11) to largest decrease Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst and last periods. Ranks are from largest percentage increase 11) to largest percentage decrease 151). Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 29 suicides. Percentage of injury deaths for which intent was not determined exceeded 29% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. -5- Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, 1999 2016 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex [10:35? State Rate Change 2:21:19"; 1999 2001 2002 2004 2005 2007 2008 2010 2011 2013 2014 - 2016 Rank 5 (State Rank) 17 (State ank) a, Both 9.4 (nfa11.9 (.3.2 (30) 34.1 ?Va (23) RI Male 15.4 (Ma) .2) 14.8[- 0. 3) 1912?: 2.0) +2.2 ?fa nis Female 4.0 (nfa) 3-0( .7) 0. 4) 1. 3) 00) 6.1 1.0) 3.7 ?fa Both 12.8 (nfa) 13.0 0.2) 1316.0 1.1) 17.7 1.7) 2.3 ?fa 23 4.9 (17) 38.3 ?15(10) SC Male 21.3 (nfa) 22. 5 .2) 22.3 (.1) 24. 6 2. 2) 26.1 1.5) 28. 0( 1 .9) +1.8 ?fa Female 5 4 (Na) 7(-0 .7) 1.3) 0. 2) 7.0 0.8) 8. 4 1.4) 3.4 ?fa Both 15.7 (nfa) 1) 17.1 19.7(+ 0.4) 22.6 +2.5 ?fa 10 7) +445 ?Va( 6) SD Male 27.6 (We) 26.3 (.3) 27. 9 1 .6) 30.1 2. 2) 32.0 1.9) 33. 6 1 .6) 1.6 ?fa Female 4.2 (nfa) 5.8 1.5.8 ?fa Both 14.6 (nfa) 15.2 0.6) 1617.2 0.0) 18. 2 1 .0) +1.4 ?fa 22 3.5 (28) 24.2 ?Va (31) TN Male 25.1 (nfa) 25.4 0.3) 2628.6 0 6) 29. 8 1 .2) 1.2 ?fa Female 5.4 (his) 6.3 0.0.6) 7. 6 0. 7) 1.9 ?fa Both 12.2 (nfa) 12.7 0.6) 12.3 (- 0.14.5 0. 9) 1.1 ?fa 41 2.3 (37) 18.9 ?Va (36) TX Male 20.4 (Ma) 20.9 0.5) 20.4 (- 0.23.1 0. 9) 0.9 ?fa Female 4.8 (nfa) 5.4 0.6) 5.0 (a 0.1.6 ?fa Both 17.2 (nfa) 19.0 1.8) 18.2 0.7) 20. 2 2.0) 24. 0 611+ 3. 8) 25.2 1.2) 2.7 ?fa 5 8.0 3) 46.5 ?if? 4) UT Male 28.2 (nfa) 31.1 2.9) 29401.7) 32 5(+2.1 ?fa Female 6.8 (nfa) 7.4 0.6) 7.5 0.1) 10. 6 2.1) 12.6 2.0) 4.4 ?fa Both 13.2 (nfa) 16.2 14.9 (- 1.3) 16.6 1.7) 18.7 2.1) 19.7 1.0) 2.4 ?fa 18 6.4( 9) 48.6 ?Va( 2) VT Male 23.6 (We) 28. 3 .6) 24.3 (- 4.0) 27.3 3.0) 31.0 3. 7) 32.5 1.5) 1.9 ?fa Female 4.3 (nfa) 2H4 0. 9) 6.4 1.3) 6 6 0.2) 7. 31+ 0. 7) 7.6 0.3) 3.8 ?fa Both 12.8 (nfa) 12.9 0.3) 13.6 0.7) 14. 6 0. 9) 15.0 0.5) +1.2 ?fa 37 2.2 (39) 17.4 ?Va (41) 17.4 Male 21.6 (nfa) 21.3 (- 21.0 (a 0.4) 22.5 1.5) 23. 6( 1 .2) 23.9 0.2) 0.9 ?fa (pa-<05) Female 5.3 (We) 5.2 0.1) 5.9 0.7) 5.6 (- 0.3) 6. 4 0 8) 6.9 0.5) 1.8 ?fa Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change (AAPC) based on all reporting periods; p-yalue indicates statistical signi?cance of trend; indicates trend not significant. Current state rank (50 states and the District of Columbia) is for the reporting period 2014 2016. Ranks are from highest rate (1) to lowest rate (51). Differences between ranks do not necessarily imply a statistically signi?cant difference. ll Overall rate change is between the first (1999 2001) and last (2014 2016) reporting periods. Ranks are from largest increase (1) to largest decrease Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst and last periods. Ranks are from largest percentage increase (1) to largest percentage decrease (51). Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. -5- Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, 1999 2018 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period} Current Overall Overall State Sex State Rate Change 2:21:19"; 1999 2001 2002 - 2004 2005 2007 2008 2010 2011 - 2013 2014 2018 Rank 5 {State Rank) 17 (State ank) Both 14.8 (1115) 15411781+ 1.0) 1.1 55113405) 24 2.8133) 18.8 c111137) WA Male 24.? (nla) 2521+ 5) 2527.1 1+ 1.1) 13.5 '11 Female 5.0 (ma) 8. 4 1+ 0 8) 01+0 .7) 7. 71 0. 8) 851+ 0.8) 2.5 '181p<.01) Both 15.81n1a) 1721+1.8) 1501?0 .7) 19.2.1+32) 21.41+2.2) +18% his 11 +58113) +37.1 i?15114) WV Male 27.2 (nfa) 3011+ 2. 9) 5.81 1.+11% nis Female 5.3 (Na) 551+ 0.1) 31 0.5) 7. 8 1+ 2. 3) 581+ 2. 2) 3.7 ?it: nis Both 13.1 1111a) 13.5.1+04) 1501+ 1.0) 15.31+0.3) 1551+ 1.2) 1.5 31: 1p<.01) 28 +3.4129) +258 ?it 130) WI Male 21.7 (We) 22. 2 1+ 0.5) .01+ 1.2) 24. 4 1+ 0 .4) 25.751+ 1.3) +1.1%1ps.01) Female 5.1 (nfa0.1) 1+ 1.0) 2.5 38113101) Both 20.7 1111a) 23.41.+27) 25.41+28) 28.91+3.5) 28.581- 01) +2.3 251p<.01) 3 +8.1 1 1) 9) WY Male 34.8 (We47. 1158) 44. 8 1 2. 4) 1.8 ?fa 1p<.05) Female (his) 521+ 0.5) 41+ {152) 1+ 1.4) 1251+ 1. 9) 3.2 1p<.01) Rates are age-adjusted to the U.S. year 2000 standard. Model-estimated average annual percentage change 1AAPC) based on all reporting periods; p?yalue indicates statistical signi?cance of trend; indicates trend not significant. Current state rank 150 states and the District of Columbia) is for the reporting period 2014 2018. Ranks are from highest rate 11) to lowest rate 151 Differences between ranks do not necessarily imply a statistically signi?cant difference. ll Overall rate change is between the first (1889 2001) and last (2014 2018) reporting periods. Ranks are from largest increase 11) to largest decrease (51). Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst and last periods. Rani-ts are from largest percentage increase 11) to largest percentage decrease 151). Differences between ranks do not necessarily imply a statistically significant difference. 0 Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. Figure 1. Percentage Changes in Annual Suicide Rates (per 100,000, Age-Adjusted) 2014-2016 Compared Against 1999-2001 I: Decrease 1.0% I:Ilncrease 18.3% - Increase 18.8% - 29.3% - Increase 31.9% - 37.4% - Increase 316% - 57.8% 'I'lHIIJihc?l . ?ram Hml?i Whit 2015 thud-HI: TDH Humid-Ila ?lr DH wwm' [mm Mun-1m spun {9:95:11 {mun Ilium-Io?! mum Mala aromas} mam a.2za[aa.a HELL Janus: Fumlla 3.: 2.93mi: 1.3105; [1:01 0.4 .1415 1024 2.3m[111 Lzulum 1.593qu p50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention Feb 20, 2018 MMWR DRAFT?Suicide Prevention [Title tbd] Structured abstract (247/250 words] Background: Suicide rates between 1999 and 2016 have increased significantly in the United States. Examining statedlevel trends and contributing circumstances of suicide can inform state prevention efforts. Methods: Trends in age-adjusted suicide rates, by sex and state, among people aged 10 and older were calculated based on data from the National Vital Statistics System (NVSS, 1999?2016). Changes in rates and state rankings were assessed across six consecutive th ree?year periods (1999?2001, 2002?2004, 2005?2001 2008?2010, 2011?2013, 2014?2016}. Data from the 2015 National Violent Death Reporting System across 27' states, were analyzed to assess differences between suicide decedents with and without known mental health problems. Results: Average annual percentage change in suicide rates increased significantly in x# states, ranging from x% in state to x% in state, with an average rate change of xx% across the period. People with and without known mental health problems experienced a range of contributing circumstances to their suicides, including substance use, relationship problems, and multiple stressful life events. Conclusions: Suicide rates have risen significantly across most states in the period 1999-2016. Numerous factors contribute to suicide among people with and without known mental health problems. Implications for Public Health Practice: To reverse trends in suicide across the nation, a population?based public health approach is needed. Specifically, comprehensive evidence?based strategies targeting all levels of society (individual, family, community), focused on preventing risk before it starts, identifying and supporting people already at risk, and caring for survivors, after a suicide is needed. Text (1800 words} INTRO In 2016, more than x# suicides took place across the United States with a rate of xx per 100,000. Rates of suicide have increased across the lifespan among males and females, across racialfethnic groups, and across urbanization levels.1 2 Rates of nonfatal attempts have also been on the rise, with emergency department visits for self-harm injury having increased more than 40% between 2001 and 2015.3 In 2015, the economic toll of suicides and selfuharm injuries totaled more than $69 billion in direct medical and work loss costs. These costs burden states and local communities as they struggle to take up the broad public health approach called for by the National Strategy for Suicide P?revention.?1 Such an approach entails preventing suicide risk before it occurs through evidence-based upstream prevention approaches such as strengthening economic supports and teaching coping and problem-solving skills, identifying and supporting people already at risk through training of gatekeepers and crisis intervention and effective treatment, and caring for survivors in the aftermath of a suicide. To date, no single state has been able to take up such a comprehensive approach. (194f?300 words} METHODS 1 NCHS Data brief 2 Kegler et al 2017 3 WISQARS Nonfatal injury reports 4 DHHS Feb 20, 2018 Suicide rate estimates and trend analyses exclude data for persons <10 years old. Age-specific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (international Ciossificotion of Diseases 10*? Revision underlying-cause-of death codes X60-X84, Y87.0, Age-specific population estimates were obtained from US. Census Bureau National Center for Health Statistics bridged-race population data releases. National and state-level suicide rate estimates were calculated for six consecutive three-year aggregate periods covering years 1999-2016. Rate estimates were age?adjusted to the U.S. year 2000 standard population and expressed per 100,000 persons per year. Age-adjusted suicide rate trends were modeled using the same three- year data aggregates, employing weighted least squares regression with inverse-variance weighting. Modeled rate trends are reported in terms of average annual percentage changes Data from the 2015 National Violent Death Reporting System from 27 states, were used to compare the characteristics, including precipitating circumstances, of suicide decedents with and without known mental health problems. compiles data from three primary data sources: death certificates, coroner/medical examiner reports (including toxicology), and law enforcement reports. RESULTS The most recent overall suicide rates (representing 2014-2016) ranged from 6.9 (District of Columbia] to 29.2 (Montana) per 100,000 persons per year, a four-fold difference (Table Across the entire study period, rates increased in all but one state (Nevada), with increases ranging from +0.2 (Delaware) to +8.1 (Wyoming). Percentage increases in rates ranged from +59% (Delaware) to +57.6% (North Dakota), with percentage increases of at least 25% observed in over half of all states (30} as well as nationally. Geographically, many states showing the largest percentage increases are in the upper Great Plains and the upper Intermountain West (Mapl- Modeled suicide rates trends were found to be significantly increasing for 44 states, as well as for the U.S. overall (Table 1). By sex, rate trends were found to be significantly increasing in 34 states for males and in 43 states for females. Nationally, the model?estimated AAPC for overall suicide rates was By sex, the national AAPC was +11% for males and +16% for females. Feb 20, 2013 IV Calendar June 5, 2018 Suicide Step Deliverable Begin at End by COB Workday: Dellverto Comments 08:00 AM. 1 DIRECTION AND ANALYSIS: TBD Initial Meeting 2 OD Planning DocumentISDHCOIDne Thing DONE RS, L5 3 CDCIDD review of Thing DONE 4 Program respond in writing to questions DONE BS from CDCIOD cwnnImwenmmv Din-Dwaam'; dunner ?167Apr? n5 MWRendvs ?din essentia- mummies-gamer . 43 Feb 20, 2018 8 FEM revises, cross-clears and submits MMWR 17?Apr 25-Apr 7 MMWR Max 1800 word text to Editors Submission 250 word abstract System, 15 references RS, LS Submit to MMWR by noon Please send VS team a comment] response matrix on how you addressed comments from Drs. Schuchat, Mac Kenzie, and Lyon-Daniel. Matrix only needed for comments from these 3 reviewers 9 MMWR edited and produced 26-Apr 53-May 10 MMWR Editors and Reviewers, PG M, RS 10 SCIENCE CLIPS: 21-May RS PGM provides citations for Science Clips 11 Rich reviews citations and sends to DDIOADS 22-May Bill Thomas and CDC librarian John lskander Gail Bang 12 FACTSHEETE i-Apr L5, RS Sand ES (nonvciaaredi in Word iormal: to V5 team 13 Roundtable 3-April LS, RS 1:30?4:30 15 CDCIOD (Dir, Principal Depuv Dir, DADS, 11-Apr Iii-Apr 4 CSELS (Rasmussen, Kent, Rovster, Martin}: CDCW review CID-cleared FSIIW) 44 Feb 20, 2018 Spanish] 45 16 revises from CDCIDD, CSELS, CDCW 1T?Apr 25-Apr Please send VS team a comments and submits revised to V5 comment/response matrix on team how you addressed comments from Drs. Schuchat, Mac Kenzie, and Lyon-Daniel. Matrix only needed for comments from these 3 reviewers 1? Complete internal graphic development Zia?Apr 41?May LS 18 [Principal Depuv Dir, DADS, 4?May Pre?brief RS, LS Principal Deputv Director, ADS, CSELS {Kent}; CDCW review full-color with ADC will provide comments on F5, Principal PR, telebriefing script?EAA at the Deputv ore-brief Director, ADS, ADC Kent, CDCW will receive courtesyr (week of 5- copies Feb) 19 Work days: Final edits to FSIG) Pre-brief 17-May with Principal Deputy Director, ADS, ADC (week of 7- Mari 20 HHSIASPA review and clear full-color LEE?I?ll?lavr 24?May L5 to NMB to Send FS with Press Release HHSIASPA through NMB 21 CDC Locks down full-color graphic FSIG) 24?May LS at 5:00pm 22 CDC final publication preparation [English and 25-May 4-Jun LS LS to send English F5 to Shannon Dmisore for Spanish translation Holidav 28?May Other Materials Produced Feb 20, 2013 23 Medical Outreach Program call while F5 is Brandv Peaker Program to discuss with VS being potential outreach strategies for reviewed clinicians by DD 24 TOWN HALL MEETING PREP: B-Mav PGM works independently with PGM ?nds 2 local demo Chelsea for this for Town Hall Payne, Tonya Jovner 35 Final Activities [12) SOCIAL and ELECTRONIC MEDIA: 24-Apr 26 revises PR Bil-Apr 4-Mav L5, DNEM 2? BABE reviews PR 7?Mav 11?May 23 revises PR from DADC review 14-May 17-May 29 receives and clears 18-May 24-May LS PR. 30 PGM OKs ASPA changes to 25-May LS social media materials and PR 31 Lynn, graphics, and PGM to work on "one 18-May 24-May L5 graphic? to go with PR LS, weeks prior to release; Meet with Kamelva Hinson and PGM to go over Social and Electronic Media UADC to provide PGM with a social media template 46 Feb 20, 2018 36 PGM to provide content to Kamelva Hinson; B?Mav PGM, Kamelva 4 weeks prior to release; PGM works with LaKia Bryant to provide Hinson, PGM to work directly:r with oaoc content on Digital Press Kit Arezoo on social and electronic media. Risman 50 sends to MLS for Spanish translation 3? (13} VS WEBSITE BUILT: 25?Mayr 31-May Spanish Website also built PGM provides its links and alt text to L5 DNEM.PGM Holiday 28-May 38 Rich creates CDC Announcement 29-Mav Rhonda Smith CDC Announcement released at 2pm on ?-Mar 39 (14) PRE-BRIEFING: 11-May: LS PGM to send all requested LS sends latest MMWR proof, material bv 10AM FSIG raphics version, PR, Telebriefing Script, Critical Contacts List and draft email 40 Pre~brief with Principal Deputy Director, ADS, week of In?person 21, 12th floor ADC May [unless DIV: Leadership, Comm, Policv, traveling] Science SMEs Call in number provided 41 Pre-brief with CDC Director week of 21? ln~person Dir Conf Rm, 21, 12th floor Mav [unless DIV: Leadership, Comm, Policy, traveling] Science SMEs Call in number provided d2 [15} NOTIFICATIONS: 31?May LS. DN EM, NPHIC call (PGM attends) PGM 43 lnternal--Final materials sent 4?Jun Done bv L5 to leadership and distributors 44 External - CDC Director sends out email to 5?Jun Email should include that "Critical Contacts" information is embargoed until 1pm on release date 45 External {cont} - PGM sends email to "Critical Email should include that Contacts" not otherwise contacted by CDCIDD information is embargoed until 1pm on release date 4? Feb 20, 2018 46 External (conti-?PGM and 5?Jun BRANCH: SME, Chief, Comm, notify all other partners of impending Policy,- Embargo in place until 1 release pm 4? (16) RELEASE 5-Jun RS, LS, DN EM Embargo in place until 1pm Press receives materials under embargo 48 CDC Director conducts telebrie?ng 5?Jun THF, LS, RS, Immediate Materials released to public at 1pm OADC, PGM Telebrief at NOON, Dir Conf Rm, 21, 12th floor DIV: Director, Comm, Policy BRANCH: Chief, SME, Comm, Policy 49 [17) MEDIA METRICS COLLECTED E?Jun LS, DNEM 24-hour media report due 50 30-day Media report due 30 days LS, DNEM after release 51 [18} TOWN HALL 12-Jun SME presents overview PGM participates 48 From: Dahlberg, Linda L. Sent: 13 Jul 2018 15:07:14 0400 To: Stone, Deborah Kristin Subject: For Review by COB 8f17: suicide approach summaries for the implementation guidance Attachments: SU _Peer Norm Programs - for SME review.docx, SU _Gatekeeper Training - for SME review.docx, SUI_Crisis Intervention - for SME review.docx Hello, We are in the home stretch of completing the implementation guidance for the One component of the guidance pertains to the specific approaches in the technical packages. We are down to the last 8 summaries 7 of them are specific to the suicide TP. We put these on hold until after the Vital Signs for obvious reasons! Attached are 3 short ones for your review. Lindsey is hoping to get this last batch into clearance ASAP we are up against a contract deadline with Banyan. If you could review and send any comments/suggestions on the three attached by Tuesday COB, I?ll incorporate your changes and get them ready for clearance. The other ones that we need to finalize include: - Postve ntion - Safer suicide care through system change 0 Treatment for people at risk of suicide - Treatment for victimsfsurvivors (which includes content across the technical packages} Please let me know if you have any questions. Thanks in advance for your help! Linda Norm Programs [Comment lalloy suggestions for ood, neral resources to include here? This approach seeks to make protective factors for suicide such as help seeking, reaching out and talking 59 to trusted adults, behaviors that are normal and acceptable. It also focuses on promoting connectedness ,i among peers, which can increase belonging, reduce isolation, build resiliency, and encourage adaptive coping behaviors. By leveraging the leadership qualities and social influence of peers, peer norm approaches are an important way to shift group-level beliefs and promote positive social and behavioral i i i i i i change. Strategy Promote Connectedness {Suicide} I Increase connectedness among peers and promote positive norms that protect against Kev Objectives a suicide Strengthen bonds to schools, peers, and adults Strengthen youth?s leadership and social influence skills Improve communication between youth and trusted adults implementation Programs are primarily delivered in school settings but may also be implemented in Considerations community settings Programs are designed to be developmentally appropriate for youth in middle, high? Programs are often delivered in groups and include social norm campaigns and active learning Experiences to reinforce program concepts Involving parents, school staff, or community members may also be important, 1 I I depending on the specific program model Implementers may need specialized education, training or certi?cation, depending on school, and college i i I the program i Key Stakeholders Public health 1 I Education ,1 I Community organizations Increases in i healthy coping attitudes and behaviors i referrals for youth in distress i help-seeking behaviors positive perceptions of adult support I Examnie Outcomes I 0 Additional Resources Exa mple Progra ms/ Practices] Policies: . Sources of Strength {Suicide} Example Programs Sources of Strength {Suicide} Description: Sources of Strength is a vouth suicide prevention project designed to use peer social networks to change unhealthy norms and culture. The mission of Sources of Strength is to prevent suicide by increasing help seeking behaviors and promoting connections between peers and caring adults. The program trains peer leaders, as well as adult advisers, to conduct messaging activities aimed at changing peer group norms around coping practices and problem behaviors. In addition, the program is designed to have a positive influence on the knowledge, attitudes and behaviors of the peer leaders. Specific PopulationsiSettings Kevr Partners Considerations I Populationlsi: Adolescents and I Public health agencies I Training and certification is required voung adults {ages 13?24 I School administrators and teachers to deliver the program I Community organizations 0 Training materials, videos, and other resources are available I School, community I Consultation and technical assistance are available - Additional Information I Sources of Strength Program Site - Gatekeeper Training This approach focuses on training individuals such as teachers, coaches, clergy, emergency responders, primary and urgent care providers, and others in the community to identify and respond effectively to people who may be at risk of suicide. By identifying people at risk of suicide and linking them to appropriate support and care, gatekeeper training can positively impact suicide and risk factors for suicide such as depression and feelings of hopelessness. Strategy Identify and Support People at Risk (Suicide) Key Objectives implementation Considerations Sector Engagement Example Outcomes Additional Rasources Improve ability of gatekeepers to identify and understand the warning signs of suicide Learn how to intervene appropriately and help people at risk of suicide Increase knowledge of available resources and support Programs may be implemented in a variety of settings schools, university/campus, healthcare, community, military) Many programs include specific guidance for the nature and sequencing of content to help gatekeepers feel comfortable with recognizing and inquiring about risk and facilitating access to support and care Programs are often delivered in groups and use a combination of methods leg, group discussion, audiovisual learning aids, presentations] to provide opportunities to engage participants and practice skills Training requirements vary depending on specific program model, ranging from a few hours to 2-5 days Evidence of effectiveness also varies for different programs so it is important to review the evidence supporting a speci?c program before selecting one to implement Public health Healthcare Education Government Community organizations Reductions in suicide deaths 0 suicide attempts depression 0 feelings of hopelessness Comparison Table of Suicide Prevention Gatekeeper Training Programs {Suicide Prevention Resource Center] Gatekeeper matrix Julzo 13update.pdf Example Programs/Practices/Policies: . Applied Suicide Intervention Skills Training {Suicide} 0 Garrett Lee Smith Suicide Prevention Program {Suicide} Example Programs Applied Suicide Intervention Skills Training (ASIST) (Suicide) Description: ASIST is a training program for hotline counselors, emergency workers, clergy, caregivers and others in the community. The ASIST model has three phases of caregiving: connecting, understanding and assisting. In the first phase [connecting], participants learn how to identify people who are having thoughts of suicide. In the second phase (understanding), participants learn how to recognize the caller?s invitation for help and how to listen to the caller?s reasons for dying and living. In the third phase (assisting), participants learn how to conduct a safety assessment, develop a safety plan for the person at risk, and connect the person at risk to community resources. The ASIST training program has been field tested in a variety of settings. Specific Populations/Settings Key Partners Considerations - Populationisl: Persons at risk of II Community organizations 0 2-day training workshops are suicide - Healthcare providers required to deliver the ASIST II Emergency medical services program . Settinglsi: School, community, - Faith?based organizations - Materials and consultation support T?I'Illiti??l?lif I Government (local, state, federal] are available - School administrators and staff - Program c051 available onlinc In Public health agencies Additional Information I ASIST Program Site - 0 Program Summary - skills-training asist Garrett Lee Smith IGLS) Suicide Prevention Program {Suicide} Description: Gatekeeper training is a core component of the Garrett Lee Smith [(3le Suicide Prevention Program which has been implemented in states, territories, tribal communities, and college campuses across the United States. The program is funded by the Substance Abuse and Mental Health Services Administration Individuals are trained to better recognize the risk for suicide, inquire about risk, intervene appropriately, and help the suicidal individual obtain assistance. Training from a few hours to a few days. Populations.l Settings Key Partners Considerations . opulationls]: Persons at risk of - Community organizations To find the state or local GL5 grantees in suicide - School/campus administrators Your community ViSit this WEb?ilE- and staff 0 Schoolfcollege campuses, - State mental health agencies community I Government (local, state, federal} I Tribal communities - Public health agencies Additional Information - Garrett Lee Smith Suicide Prevention Program Crisis Intervention This approach focuses on providing support and referral services, typically by connecting a person in crisis to trained volunteers and professional staff. Crisis intervention approaches are intended to impact key risk factors for suicide, including feelings of depression, hopelessness, and subsequent use of mental health care services. Crisis intervention can also put space and time between an individual who may be considering suicide and harmful behavior. Strategy I Identify and Support People at Risk (Suicide) KEY DPIEGIVES I Provide critical support and services to persons at risk of suicide I Reduce risk factors for suicide implementation I Crisis intervention services mav be accessed through a telephone hotline, online chat, Considerations text messaging, or in-person I Education and awareness about how to seek help mav also be made through public service announcements, billboards, brochures, and other materials in the offices of primary' care and other providers I Duration ofthe intervention support varies depending on type of service and the immediate and long~term needs of the client I Some crisis intervention programs use trained volunteers; others use licensed professional staff Sector I Public health Engagement 0 Social services I Communltv organizations Example Outcomes I Reductions in feelings of hopelessness pain 0 intent to die Additionai - Best Practices [Suicide Prevention Lifeline] - Resources I Crisis Center Accreditation Program - Example Programs}Practices/Policies: I National Suicide Prevention Lifeline [Suicide] Example Programs National Suicide Prevention Lifeline {Suicide} Description: The National Suicide Prevention Lifeline is a national network of local crisis centers that provides support to people in suicidal crisis or emotional distress. It also provides rosources to family members and friends and best practice resources for professionals. The hotline operates 24/? and is accessible bv phone or a web-based chat function. Trained counselors are on-hand to listen, offer free and confidential emotional support, and provide referrals for mental health services in the local area. Specific PopulationslSettings Kev Partners Considerations I Populationfsi: individuals in suicidal crisis or emotional distress I Settingisl: 1v'irtual setting via telephone and/or web-chat Community organizations Mental health providers Health care providers Public health agencies Lifeline Network Crisis Centers are accredited and follow written policies and guidelines addressing referral, training, and suicide risk assessment Manv centers offer other services, including training and educational rESources in suicide prevention and wellness for their local communities Crisis centers that are part of the National Lifeline Network also participate in Lifeline evaluation activities Additional Information I National Suicide Prevention Lifeline - From: Mercy, James Sent: 9 Jun 2018 22:59:39 -0400 To: Houry, Debra E. Deborah Thomas Joni Subject: Fwd: EMBARGDED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates Attachments: image002.emz Congrats again to you all and everyone else. I?ve been hearing really great things from many of our partners. Please pass on the the wonderful feedback we?ve been getting. I?m going to share another in a moment. From: Reed, Jerry Date: June 9, 2018 at 2:27:46 PM EDT To: Mercy, James Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates You all did a GREAT job on this. As a partner, I?m pleased we were able to spread the word. We got more media inquiry on this than anything I?ve seen in along time. Tragically, the deaths of Kate Spade and Anthony Bourdain contributed to the significance of the findings. A heartbreaking week but you and your team and the leadership of the Center and CDC really made a very significant contribution to our collective contribution. Many thanks. It?s always been a real pleasure working with you Jim. Best, Jerry Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide, Violence Er iniury Prevention Portfolio Lead National Action Alliance for Suicide Preyention Executiye Committee Member w?iLeMg 202?522?3771 {Ci} I 202294-3132 202?223-4059 Education Deyeio menl Center inc. Education DeveIOpment Center From: Mercy, James (CDCIONDIEHINCIPC) Sent: Thursday, June 07, 2018 3:52 AM To: Reed, Jerry Subject: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates Dear Jerry, i would like to personally let you know that our new Vitui Signs: Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, will be released later today. I believe that latest ir?itchl Signs will support our collective efforts to reduce suicide rates by 20% by 2025 and would appreciate if you could help disseminate this publication to your networks once the embargo lifts at 1:00 pm. I look forward to our continued partnership in support ofa comprehensive public health approach to suicide prevention. Jim The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortality Weekly Report article, "Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2013, at 1:00 pm following a media telebriefing at noon; all attached materials are EMBARGDED until 1pm EST. Key points in the Vital Signs report include: II in 2016, nearly 45,000 suicides occurred in the US among people 10 years and older II From 1999?2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each 0 Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition - A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health,job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the VitolSigns Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of media tools such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. James A. Mercy, Director Division of Violence Prevention National mate-r for Injury Presention and Control From: Mercy, James (CDCIONDIEHJNCIPCII Sent: 9 Jun 2018 23:02:06 -0400 To: Houry, Debra E. Deborah Thomas Joni Subject: Fwd: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Attachments: image004.png FYI - another congrats from the co-chair if the Action Alliance and Deputy Director of the Action Alliance. From: Clancy, Carolyn Date: June 9, 2018 at 4:39:59 PM EDT To: Mercy, James Subject: RE: BMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Belated congrats on fantastic rollout! brief our Acting Secretary later that day Thank you for your leadership Carolyn Carolyn Clancy MD Executive in Charge Veterans Health Administration 810 Vermont Ave, NW Washington, DC 20420 202-461-7000 From: Mercy, James Sent: Thursday, June 2018 9:18:02 AM To: Clancy, Caroiyn Cc: Bates, Alicia B. Subject: EMBARGOED Until [pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Dear Carolyn, I would like to personally let you know that new Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates, will he released later today. As eo?chair ofthe Action Alliance I thought you would be interested in this release, which includes state?level trends in suicide rates from 1999-2016, and looks at the circumstances of suicide among people with and without known mental health conditions, using data from National Violent Death Reporting System. i believe that our latest Vital Signs will support our collective efforts to reduce suicide rates by 20% by 2025. I would appreciate ifyou could help disseminate this publication to your networks and colleagues once the embargo lifts at :00 pm. Thank you for your commitment to creating safer communities for future generations. Jim The CDC Vital series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortality Weekly Report (MMWR) article. ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 2018. at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until EST. Key points in the Vital Signs report include: [n 2016, nearly 45,000 suicides occurred in the US among people 10 years and older - From 999?20l?, suicide rates increased in nearly every state. with 25 states experiencing increases of more than 30% each - Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition - A range offactors contributes to suicide beyond mental health conditions alone. including relationship. substance use, physical health, job, ?nancial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs inibnnation broadly with your colleagues and partners. Visit the Vital Signs Web to ?nd the MMWR article, fact sheet, and other materials. Take advantage ofCDC's social media such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to ioin us for the Vital Signs Town Hall on June 12 at 2:00 pm Vital Signs is about more than data, it is about action. We look forward to continuing our work. together to prevent suicides and promoting healthier communities. Thank you for your support. [James A. Mercy, Director Division of Violence Prevention National Center for injury Prevention and Control] James A. Mercy, Director Division of Violence Prevention National Center for 111ij Preventbn and Control James A Mercy, Director Division of Violeme Prevention National Center for Injmy Preventhn and Control From: Stone, Deborah Sent: 3 Jun 2018 13:29:02 +0000 To: Simon, Thomas Subject: FW: Is this a sufficient addition to the Suicide Prevention Hi Tom, Read from highlighted email {about halfway down} up. I think all is well. I'm just waiting for a reply from Rich to my last email. I thought Rich was going to send out an email to say, issue resolved. Anyway, read below. Deb From: Stone, Deborah Sent: Saturday, June 2, 2018 9:45 PM To: Schieber, Richard A. Subject: RE: Is this a sufficient addition to the Suicide Prevention Hi Rich, Is this what you have in mind? 1999 2016 suicides pop Incidence suicides pop Incidence %change rate rate 10-14 242 20213368 1.20 436 20618233 2.11 76.63 4564 7977 60355862 13.22 16196 84249823 19.22 45.45 rate ratio 11.02 9.11 {17.33 The rates of youth {10-14} suicide have increased more than the rates of middle aged (45-64) suicide rates between 1999 and 2016, but middle aged adult suicide rates still outpace rates of youth suicide by 9:1. Deb From: Schieber, Richard A. (CDCKOPHSSICSELSIDPHIDJ Sent: Saturday, June 2, 2018 8:12 PM To:Stone, Deborah Subject: RE: Is this a sufficient addition to the Suicide Prevention Good so far. 1 think the rate ratio of 9.1 is compelling. Now we need to think about how to express it clearly so the public will get it. HereCompare the rates per 100k pop' for the 2 groups at each of 2 points in time. This is the rate ratio of rates by group over time- The 9.1 ratio at one point in time is compelling and stands against any (wrong) perception that the change in youth should be the main focus. 2. What is the rate ratio at the second time, for each age group? 3. Using the incidence rates for each group at each of 2 times. what was the percent change in incidence over time in each of the 2 groups? I think Anne was saying that a large percent change in an age group over time above) could be misleading if the incidences were small at both times for such an age group. If I were providing this to none, I would likely develop a small table of these groups and its components. That is, for each of 2 age groups at each of 2 separate times, show counts, pop? size, incidence, change in incidence as a percent change, and rate ratios. State your conclusion. I would send this to her and also hand it to her at our Thurs. I think that would help her wrap her arms around the difference b/w the quikstats and your paper. tell me if missing something. This is my advice, but your decision whether to do this or not. Respectfully, Rich Rich Schieber, MD MPH CAPT, USPHS Director, CDC Vital Signs Program RBSd?cdc.goy 404 697 9666 From: Stone, Deborah (zaf9@cdc.goy> Date: June 2, 2018 at 7:33:00 PM EDT To: Schieber, Richard A. Subject: RE: Is this a sufficient addition to the Suicide Prevention Himcn Ok, thanks, glad no change is needed. In 2016, for every one suicide among the 10-14 yo (n:436] group there were 37 suicides among the 45- yo group In terms of rates. The rate of the 45?64 v.0. group in 2016 (Ell/100,000) was the rate of the 105 14 yo group However, since the 2016 population of people 45-64 (n=84,249,823) is so much larger than the population of 10-14 yo?s it would be more appropriate to compare the rate. Deb From: Schieber, Richard A. Sent: Saturday, June 2, 2018 7:12 PM To: Stone, Deborah (CDCXONDIEHINCIPQ <2an cdc. ov> Subject: RE: Is this a sufficient addition to the Suicide Prevention Yes, I can appreciate the confusion. It caught me off-guard as well. So just now I read the string again, and indeed she did find it satisfactory. So that? that, and no further change to the MMWR needed for this point. I would anticipate that she' 11 ask us in the meeting just before the telebriefing begins, and/or she? 11 be asked by the media, well, what about 10-14 yr olds? At that point, she should be able to refer to a q&a you have or will develop that shows the counts and their ratio for the 2 age groups. That is, for every 10-14 yr old who dies by suicide there? number of 45+ yr olds who die from suicide. and, per year of age, the older group is times more likely to die by suicide than the younger group. That way she wouldn? need to get into a protracted mathematical discussion about why percent changes in incidence over time for one group may spuriously make people think that the problem is greater in the young. What do you think? Rich Schieber, MD MPH CAPT, USPHS Director, CDC Vital Signs Program R884@cdc.goy 404 097 9666 From: Stone, Deborah <3af9?cdc.goy> Date: June 2, 2018 at 6:53:44 PM EDT To: Schieber, Richard A. Subject: RE: Is this a sufficient addition to the Suicide Prevention Hi Rich, I?m a little confused. Lastl knew on 5/15 Dr. Schuchat had approved this (email attached below): Suicide rates have also increased among persons in all age groups <75 years, with the largest percent increase from 13.2 per 100,000 persons [19991 to 19.2 per 100,000 1201611 and the greatest number of suicides (n=232,108 between 1999 and 2016) occurring among adults aged 45-64 years. Did something change that she wants the 10?14 yo group back in? Deb From: Schuchat, Anne MD Sent: Tuesday, MayI 15, 2013 2:13 PM To: Schieber, Richard A. Subject: RE: SUICIDE VS MMWR: Question about retaining the 45-64 yr olds with a percentage Thmis?nenow From: Schieber, Richard A. Sent: Tuesday, May 15, 2018 2:08 PM To: Schuchat, Anne MD Cc: Kent, Charlotte Kate lademarco, Michael Schieber, Richard A. Stone, Deborah Peaker, Brandy Solder, Omisore, Shannon L. Subject: SUICIDE VS MMWR: Question about retaining the 45-64 yr olds with a percentage Anne, Sorry to bother you again. All mention of the 10-14 yr olds has been removed. We weren?t sure if you wanted ALL percentages removed, including the 45% highlighted below. V5 and DVP think there?s value to retaining the 45% increase attached to the 45-64 yr olds, and they?ve added the counts to the text. What do you think? Current MMWR wording, after revision, is: Suicide rates have also increased among persons in all age groups s175 years, with the largest percent increase from 13.2 per 100.000 persons [19991 to l9.2 per 100,000 [20161) and the greatest number of suicides (n=232,108 between 1999 and 2016) occurring among adults aged 45-64 years. Thanks Richard Schieber, MD, MPH Director, CDC Vital Signs Program From: Schieber, Richard A. Sent: Saturday, June 2, 2018 4:29 PM To:5imon, Thomas (CDCKONDIEHXNCIPC) st 59 cdc. ov> Cc: Stone, Deborah Peaker, Brandy Sokler, (CDCIODIOADQ Omisore, Shannon L. Kent, Charlotte cc k3 cdc. ov> Subject: Re: Is this a sufficient addition to the Suicide Prevention Tom, Although ftnne said ?Thanks? last night, by which I assume the answer I sent was sufficient, ve had second thoughts. Here' what. I think will satisfy all and put this to rest. Please consider these 2 alternatives. 1. Modify the intro to specifically include national counts and rates, and percentage change over time, for youth 10-14 or whatever years NCHS has highlighted. Use the same dates y0u used for the overall national and 45*64 yr olds. Since it? in the Intro and not the Results, you could comment there that the 10 yr olds catch attn b/c of the high rates, but that? a mathematical artifact and not a true high-suicide group based on their low counts. 2. Alternatively, you could use your analysis to indicate the same thing in the Discussion. Either way, the issue is covered. What do you think? Rich Rich Schiober, MD MPH CAPT, USPHS Director, CDC Vital Signs Program RBS4?cdc.gov 404 697 9666 From: Simon, Thomas Date: June 2, 2018 at 8:46:52 AM EDT To: Schieber, Richard A. Cc: Stone, Deborah Subject: FW: Is this a sufficient addition to the Suicide Prevention Hi Rich, Thank you for sending the response to Dr. Schuchat last night. just wanted to remind you about this earlier exchange where she had approved inclusion in the introduction. Hopefully, that will still work for her. -Toni From: Schuchat, Anne MD Sent: Saturday, MayI 12, 2013 2:25 PM To: Schieber, Richard A. Cc: Simon, Thomas Stone, Deborah Peaker, Brandy Sorrells, Marjorie J. Kent, Charlotte Kate lademarco, Michael Subject: Re: Is this a sufficient addition to the Suicide Prevention Yes. Can you share what reference 3 is? The reader will be shocked about the 10 to 14 age group so I would look up the reference ifI were reading the article to see what the rates are. If it?s hard to ?nd in reference 3 we may want to mention what those absolute rates went from as i assume much begged absolute increase in the adult group. Ie 3Upercent increase from very low absolute rate not quite as alarming as when it?s from already big numbers. Sent from my iPhone On May 12, 2018, at 12:15 PM, Schieber, Richard A. wrote: Anne, The Suicide Prevention program is asking whether or not the boldfaced sentence at the bottom of this message, once added to the MMWR Introduction seen there, is suf?cient to answer your query about suicide rates by age and make its point. If not, please let us know what additional analyses would be needed, and the will see what they can do. Thanks. Rich Rich Schieber, MD (404) 697-9666 Schiebert?citcomcastnet BACKGROUND AND PURPOSE In 2016, nearly 451000 suicides (15.6f100,000 pepulation [age-adjusted]) occurred in the United States among persons aged 21.0 years (1). Between. 1999 and 2015, suicide rates increased among both sexes, all raciaL?ethnic groups, and all urbanization levels (23). Suicide rates have increased among all age groups younger than 75 years, with the highest percent increases among those aged 45- 64 and those aged 10-14 Suicide is the 1001 leading cause of death and is one of just three leading causes that are increasing Additionally, rates of emergency department visits for nonfatal self-harm, a key risk factor for suicide, increased 42% between 2001 and 2015 (1). Together. suicides and self?harm injuries cost the nation more than $69 billion in direct medical and work loss costs (1). From: Crosby, Alexander Sent: 4 Jun 2018 09:41:00 -0400 To: Stone, Deborah Subject: FW: 290988 - COMPLETED - Suicide Technical Package- Spanish translation Attachments: Suicide Technical Package_SPAN 5H_draft pending MLS approval.pdf Greetings: For your information. Alex From: Young, Joni Sent: Monday, June 4, 2018 8:52 AM To: Mercado-Crespo, Melissa lyey-Stephenson, Asha Z. Cc: Crosby, Alexander Geryin, Derrick Subject: FW: 290988 COMPLETED - Suicide Technical Package- Spanish translation Hi Melissa and Asha, Good Spanish translation of the Suicide Technical Package is almost complete! I asked if Sarah could share the latest version so that you both can start using it as a reference [see attached] The final version should be ready soon and will be posted on the internet. Please think about whether we need to order print versions. Thanks, Joni From: Roby, Sarah Sent: Monday, June 4, 2018 8:37 AM To: Young, Joni zc8 cdc. Subject: RE: 290988 COMPLETED Suicide Technical Package? Spanish translation Hi Joni, Attached is the PDF file with the Suicide Technical Package. I know this is in a hurry, so note that the final quality assurance check from MLS has not been completed yet? I sent it to them this morning. It will be posted to web pages as soon as MLS signs off. Thanks Sarah From: Young, Joni Sent: Friday, June 1, 2018 10:24 AM To: Roby, Sarah Date: June 1, 2018 at 10:23 :09 AM EDT To: Young, Joni (CDCHONDIEHXNCIPC) zc8 a?cdc. Joy} Subject: Re: 290988 - COMPLETED - Suicide Technical Package- Spanish translation Hi Joni, I emailed Alida. She will need to export the graphic design file to a PDF, but that shouldn't take too long. Keep you posted! Thanks, Sarah From: Young, Joni Sent: Thursday, May 31, 2018 5:08:28 PM To: Roby, Sarah Subject: RE: 290988 - COMPLETED - Suicide Technical Packagev Spanish translation Hi Sarah, I know that Alida is probably still working on the layout, but am wondering if the translation draft can be shared with Melissa Mercado?Crespo and Asha Ivey?Steyenson at this point. They are starting to look at providing TA to Puerto Rico and I think it would be helpful if they can start to look at that. Thanks Joni From: Roby, Sarah Sent: Wednesday, May 23, 2018 3:37 PM To: Young, Joni zc8 cdc. oy> Subject: FW: 290988 - COMPLETED - Suicide Technical Package- Spanish translation HiJoni! Great news! The Suicide TP is done with translation and I am sending on to Alida for layout. I will keep you posted on timeline from her. Talk soon, Sarah From: Robv, Sarah Sent: Wednesday, May 23, 2013 3:35 PM To: Gonzalez, Celina (CTR) ?:be9 cdc. ov> Cc: CDC Multilingual Translations Subject: RE: 290988 - COMPLETED - Suicide Technical Package- Spanish translation Hi Celina, Thank you so much for sending this along! It will be made available on our website as a PDF, so prior to launch I will be sure to send vou a copy for OA check. Best wishes, Sarah Sarah . Roby Health Education Specialist Office of the Director, Health Communication and Education Team Division of Violence Prevention National Centerfor Injury Prevention and Control Centers for Disease Control and Prevention Phone: {404) 4984375 Email: mgiG-dicgov From: Gonzalez, Celina (CTR) Sent: Wednesday, Mav 23, 2018 2:36 PM To: Roby, Sarah 4 cdc. 0v:- Cc: CDC Multilingual Translations Subject: RE: 290938 - COMPLETED Suicide Technical Package- Spanish translation Dear Sarah, Attached is the translation in .idml format as requested in order 290988. This order is now completed and closed. At the end of the file we added the following text as a stamp of approval and tracking record for the CDC Multilingual Services team: If you intend to do any desktop publishing to this translation or plan to make it available from the Internet or other media, please let us do a final QA check prior to its release to production to assure that the quality of the product has been kept. For web posting, please remember to add the MLS order number as meta tag of your page (refer to WCMS instructions), also add ?translated by CDC Multilingual Services" as part of the content source, for instance: Fuente del contenido: Centros Dara el Control la Prevencion de Enfermedades. traducido por CDC Multilingual Services #290988. Let us know how we are doing. Your feedback will help us improve the services we provide. Thank you for using the CDC Multilingual Services. We look forward to working with you again soon. Regards, Celina Gonzalez Posse Bilingual Publications Analyst ATA Certi?ed Translator Northrop Grumman Information Systems CDC Multilingual Services Email: xb59@cdc.gov Phone: 404?639-3?64 Mobile: 201?233~1422 Telework: Mondays, Wednesdays and Thursdays from 9:00 to 5:30 On site: Tuesdays and Fridays from ?:00 to 3:30 From: Hamilton, Maria {Natalia} Sent: Monday, May 21, 2018 9:13 AM To: Gonzalez, Celina (CTR) ?:xbsE} cdc. ov> Subject: FW: 290988 - CERTIFIED - Suicide Technical Package- Spanish translation Celina, This translation is certified. Regards, Natalia Hamilton Language Specialist CDC Multilingual Sewicesl?DCSf 0A DC Office :?ri?the Associate Director [hr [?nmmunicalion email: militia-edema? {tel} 404 639 3935:. {cell} 404 542 1443 I9 Cube ?AS-Cull 'l elework Days: 'l'uesday. Thursday 84 Friday From: Gonzalez, Celina (CTR) Sent: Wednesday, April 25, 2018 12:49 PM To: Hamilton, Maria (Natalia) (CDCIODIDADC) Subject: 290988 - TRANSLATED - Suicide Technical Package- Spanish translation Natalia, This has been translated and is ready to be certified. Thank you, Celina From: Communication Services Sent: Friday, April 06, 2018 1:06 PM To: Gonzalez, Celina Subject: Create-IT Email - Job Assignment Notice You have been assigned to job: 290988-A Prevenci?n del suicidio: Paquete t?cnico de politicas, programas pr?cticas Prevenci?n del suicidio: Paquete t?cnico de politicas, programas pra?cticas Antares: Deb Stone, MSW, MPH Kristin Holland, MPH Brad Bartholow, Alex Crosby, MD, MPH Shane Davis, Natalie Wilkins, 2017 Division de Prevenci?n de la Violencia Centro National para la Prevention 3; el Control de Lesiones Centros para el Control la Prevenci?n de Enfermedades Atlanta, Georgia Centros para el Control la Prevencion de Enfermedades Anne Schuchat, MD (RADM, USPHS), directora interina Centro National para la Prevention 3! e! Control de Lesiones Debra E. Houry. MD, MPH, directora Division cle Prevencion de la Violencia James A. Mercy, director Citation sugerida: Stone, D.M.. Holland. K.M., Bartholow. B., Crosby, A.E.. Davis, 5.. and Wilkins, N. (2017). Preventing Suicide: A Technicai Package ofPoiicies, Programs, and Practices. Atlanta, GA: Centro Nacional para la Prevention el Control de Lesiones, Centros para el Control la Prevention de Enfermedades. Prevena'?n del suiddio: Paquete t?mico de pnliticas, programs pricticas Contents Agradecimientos 5 Revisores externos . . 5 Rese?a 7 Fortalecimiento de los apoyos econom1c0515 Fortalecimiento del acceso a los cuidados relacionados con el suicidio de su prestaci?n 19 Creaci?n de ambientes protectores 23 Fomento de la conexi?n 27 Ense?anza de destrezas de superaci?n resoluci?n de problemas 31 Identi?caci?n de personas en riesgo provisi?n de apoyo 35 Reduccic?m de da?os prevenci?n de riesgos futures 41 Participaci?n de los sectores 43 Monitoreo evaluaci?n 45 Conclusi?n 47 Referenc1a549 Ap?ndice: Resumen de estrategias enfoques para la prevenci?n del suicidio 58 Prawn thin del snicidio: Paquete himico de paliticas, programs 3: [minim 2F Agradecimientos Deseamos agradecer a Ias siguientes personas, que contribuyeron de maneras especi?cas con la preparaci?n de este paquete te?cnico. Agradecemos en particulara Linda Dahlberg porsu vision, orientacion apoyo a lo largo de la creacion de este paquete. Asimismo, agradecemos a los directivos de la division, el centro Ios CDC por su cuidadosa revision las Utiles observaciones que nos brindaron en las versiones anteriores de este documento. Le agradecemos a Alida Knuth por su pericia en el formateo dise?o. por Ultimo, queremos dar Ias gracias expresar nuestra gratitud a todos los revisores externos por sus L'Itiles observaciones, el apoyo que nos mostraron el animo que nos dieron para la creacion de este recurso. Revisores externos Casey Castaldi Prevention Institute Carmen O?cina de Apoyo Estatal, Tribal, Local yTerritorial Centros para el Control la Prevencidn de Enfermedades Amalia Corby-Edwards Asociacion Estadounidense de Sicologia Rachel Davis Prevention Institute Pamela End of Horn Sede del Servicio de Salud para Indigenas Craig Fisher Asociacic?m Estadouniclense de Sicologia Keita Franklin Departamento de Defensa Jill M. Harkavy Friedman Fundacion Estadounidense para la Prevencion del Suicidio Jarrod Hindman Departamento de Salud Publica Medio Ambiente de Colorado Linda Langford Education Development Center, Inc. Richard McKeon Administracion de Salud Mental Abuso de Sustancias Doreen 5. Marshall Fundacion Estadouniclense para la Prevencion del Suicidio Christine Moutier Fundacion Estadounidense para la Prevenci?n del Suicidio Jason H. Padgett Education Development Center, Inc. Jerry Reed Education Development Center, Inc. Dan Reidenberg Suicide Awareness Voices for Education (SAVE) Christine Schuler Instituto Nacional para la Seguridad Salud Ocupacional, Centros para el Control la Prevencion de Enfermedades Morton Silverman Education Development Center, Inc. Ellyson Stout Education Development Center, Inc. Hope NLTiesman Instituto Nacional para la Seguridad Salud Ocupacional, Centros para el Control la Prevencion de Enfermedades 5e cite el nombre de los expertos anteriores con la o?iiocidn que tem'an oi memento de Io revision de este documen to. Mad? del middio: Paqmt?mim d; politic-Is. practices Rese?a Este paquete t?cnice presenta un grupe selecte de estrategias basadas en la mejer evidencia dispenible, para ayudar a las cemuniclacles [es estades a centrar su enfeque en las actividades de prevencien que tienen el mayor petencial para pretrenir el suicidie. Estas estrategias incluyen el fertalecimiente de les apeyes ecenemices; el fertalecimiente clel accese a les cuidacles relacienades con el suicidie de su prestacien; Ia creacien de ambientes pretecteres; el femente de la cenexic?in; Ia ense?anza de destrezas cle superacien reselucien de preblemas; identi?cacien de las persenas en riesge previsien de apeye; reduccien de les da?es prevencien del riesge future. En este paquete se incluyen estrategias que se enfecan en prevenir e1 riesge de suicidie en primer lugar, asi ceme enfeques cuye ebjetive es reducir les da?es inmecliates a large plaze del cempertamiente suicida en las persenas, las familiasr las cemunidades la seciedad. Las estrategias centenidas en este paquete tecnice apeyan las metas les ebjetives del inferme Estrategia Nacr'onalpare la Prevencicin delSuicidie? la prieridad de fertalecer Ia prevencien a nivel de cemunidad cenferida per la Alianza Nacienal de Accien para la Prevencien del Suicidie.2 La implementacien exitesa de este paquete se puede legrar mediante el compromise, Ia ceeperacien el liderazge de diverses secteres, entre elles les de salud pL?iinca, eclucacirfin,justiciar atencien m?dica, servicies seciales, cemercie, trabaje gebierne. gEn qu? consiste un paquete t?cnico? Un paquete tecnice es la recepilacien de un cenjunte basice de estrategias para reducir un factor de riesge resultacle especl?ce mantener esa reduccien.3 Les paquetes tecnices ayuclan a las cemunidades a les estades a clar prieridad a las actividades cle prevencien cen base en la mejer evidencia dispenible. Este paquete tecnice tiene tres cempenentes. El primer cempenente sen las estrategias [e la direccien medidas preventivas) para legrar la meta de prevenir el suicidie. segunde cempenente sen les enfeques. Les enfeques incluyen las fermas especi?cas de impulsar las estrategias. Este impulse se puede legrar a trav?s de pregramas, ceme tercer cempenente se incluye para cada enfeque Ia evidencia sebre Ia prevenci?n del suicidie les factores de riesge relacienades. Este paquete tiene el ebjetive de servir ceme recurse para erientary fundamentar Ia tema de decisienes relativas a la prevencien, tante en las cemunidades ceme en les estades. La prevention del suicidio es una prioridad El suicidie, cenferme Ia de?nicien de les Centres para el Centre! la Prevencien de Enfermedades (CDC), es parte de una clase mas amplia de cempertamientes deneminada violencia autein?igida. Se entiende per vielencia autein?igida un cempertamiente clirigide hacia une misme, cuye resultade deliberade es la lesien 0 el petenciel cle causar una lesic'in.4 Esta vielencia autein?igida puede ser cle caracter suicide no suicide. Para les ?nes de este decumente, n05 referimes selamente a aquelles cempertamientes que tienen per ebjetiue el suicidie: . Suicidio es la muerte causada per un cempertamiente perjuclicial dirigide hacia une misme, adeptade con la intencic?m de merir a causa de diche cempertamiente. - Intente de suicidie 5e de?ne come un cempertamiente no mortal, petencialmente perjudicial, dirigide hacia une misme, adeptade con la intencien cle merir a causa de cliche cempertamiente. Les intentes cle suicidie pueden no tener ceme resultade una lesien. La prevalencia del suicidie es alta. El suicidie presenta un desafie impertante para la salud publica en les Estades Unides en el munde. Centribuye a la muerte prematura, la merbilidad, Ia p?rdida de preductividad a cestes en t?rmines cle atencien m?dica. "5 En el 2015 (el a?e mas reciente para el cual 5e tienen dates de muertes}, el suicidie fue respensable de 44 193 muertes en las Estades Unides, le cual se traduce a apreximadamente 1 muerte cada 12 minutes.I5 Tambi?n en el 2015, el suicidie fue la 10.?1 causa principal de muerte ha estade entre las 12 principales desde 19?5 en las Estacles Unides? Las tasas de suicidie en general aumentaren el 28 ?if: entre el 2000 el 2015.?j El suiciclie es un problema que afecta a las persenas durante teda la Vida: es la tercera principal causa de muerte entre lesjevenes de 10 a 14 a?es, la segunda causa de muerte entre las personas de 15 a 24 anes las de 25 a 34, la cuarta entre las persenas de 35 44 a?es, la quinta entre las personas de 45 a 54 a?es la ectava entre las personas de 55 64 a?esf' Muld?n del mam mm I?mltodl polities. Las tasas do suicidio varian por raza origon ?tnico, odad otras caractoristicas poblacionalos. Entro los grupos poblacionalos con Ias tasas do suicidio mas altas duranto toda la Vida so oncuontran ol do indoamoricanos nativos do Alaska no hispanos ol do porsonas blancas no hispanas. Las tasas do suicidio para estos dos grupos on ol 2015fuoron 19.9 y16.9 por cada 100 000 porsonas rospoctiwamonte.?5 Otros grupos poblacionalos quo so vioron afoctados dosproporcionadamonto son ol do adultos do modiana odad (cuya tasa aumento ol 35 ontre ol 2000 3! ol 2015, con aumontos pronunciados tanto ontro los hombres [29 como entro las mujeres [voteranos otro personal militar (cuya tasa do suicidio casi so duplico ontre ol 2003 el 2008 y, por primora voz on docadas, suporo la do suicidio ontro ol do trabajadoros do ciortos grupos ocupacionalos;m'11 3; ol do jovonos soxualos do minorias quo, comparados con 105 no sexualos do los mismos grupos, mostraron mayor idoacion com portamionto suicida?l14 Las tasas do suicidio re?ojan solamento una porcion do] prolaloma.15 Hay una cantidad considorablomonto ma?s alta do porsonas quo torminan on ol hospital por comportamiontos suicidas no mortalos {o soa, intontos do suicidio) quo do personas con losionos mortalos, una cantidad aun mas alta quo rocibe tratamionto on on ontorno ambulatorio [por ojomplo, en la sala do omorgencias) que no rocibo ning?n tratarnionto.15 Por ojomplo, duranto ol 2014, ontro los adultos do 18 a?os mayoros, por cada uno que se suicido hobo 9 quo recibioron tratamiento en una sala do omorgencias por lesionos autoin?igidas, 2? que roportaron haber intontado suicidarso mas do 227 one roportaron haborlo considerado soriamonto.? ?5 El suicidio so asocia a varios factoros do riosgo do protocci?n. Al igual quo los otros comportamiontos humanos, ol suicidio no tiono una causa dotorminanto (mica. Ocurro como rospuosta a la intoracci?n do varias in?uencias biologicas, sicologicas, intorporsonalos, ambiontalos socialos, gonoralmonto, a lo largo dol tiornpo.?5 El modolo ocol?gico social, quo abarca varios nivelos do onfoquo ~individual, relational, comunitario 5ocia ??, o5 un marco 0til para ol analisis la compronsion dol riosgo do suicidio do los factoros do protoccion quo so han idonti?cado on la litoratura.? Existon factores do riosgo do protoccion on cada uno do ostos nivolos. Los factoros do riosgo incluyen, por ojomplo?-5 - En El nivol individual: antocodontos do doprosion do otras onformodados montalos, dososporanza, abuso do sustancias, ciortas afoccionos, intontos do suicidio antorioros, sor victima porpotrador do violoncia, doterminantos gon?ticos biologicos. - En El nivol relational: relaciones altamente conflictivas violentas, sensacion do aislamiento do falta do apoyo social, antecodontos do suicidio do unfamiliar sor quorido, ostr?s ?nancioro Iaboral. . En El nivol comunitario: inadocuada conoxion con la comunidad, barroras para la atoncion m?dica [por ojomplo, falta do accoso a provoedoros medicamentosi. - En El nivol social: disponibilidad do modios lotalos para comotor ol suicidio, ropresontacionos do] suicidio en los modios do manora no sogura, ostigma rolacionado con buscar ayuda con la onformodad mental. E5 importanto reconocor que la gran mayoria do las personas quo ostan doprimidas, quo intentan suicidarso quo tionon otros factoros do riosgo, no mueron por suicidio?a ?9 Asimismo, la relovancia do cada factor do riosgo puode variar por odad, raza, g?noro, orientacion sexual, lugar geogra?co do rosidoncia ostatus sociocultural - 8 Prevention dol middio: Paquote t?mico do politicos, programasy prinicas la expasiti?n ala vialencia se asocia a un mayor riesgo de depresi?n, trastornapar estr?'s ill". g?f Tambi?n 5e pueden encontrar factores de proteccion, 0 sea, influencias que amortiguan el riesgo de suicidio, en cada nivel clel modelo social ecologico. Entre Ios factores de proteccion que se han identi?cado en la literatura 5e incluyen Ias destrezas e?caces para la superacion resolucion de problemas, las objeciones morales al suicidio, una relacion fuerte de apoyo con la pareja, los amigos la familia; la conexion con la escuela, la comunidad otras instituciones sociales; la disponibilidacl de atencion medica fisica 5; mental de calidad continua; un acceso reducido a medios letales.? Estos factores de proteccion pueden, contrarrestar un factor de riesgo determinado actuar como amortiguadores contra on nL?Irnero de riesgos que se asocian al suicidio. El suicidio tiene relacic?m con otras formas de violencia. La exposicion a violencia (por ejernplo, a maltrato abandono infantil, acoso, violencia de semejantes, violencia en las relaciones sentimentales, violencia sexual violencia en la pareja intima} se asocia a un mayor riesgo de depresion. trastorno por estr?s postraurnatico ansiedad, suicidio intentos de suicidioFHE? Las mujeres expuestas a violencia en la pareja tienen 5 veces mas probabilidades cle intentar suicidarse que las no expuestas a esta illiolenciaF'5 La exposicion a experiencias adversas en la infancia, como al abandono maltrato fisico, sexual emocional, vivir en un hogar con problemas cle violencia, salud mental. abuso de sustancias otras formas ole inestabilidad, 5e asocian tambi?n a un mayor riesgo de suicidio intentos de suicidioFZ'F Los efectos sicosociales cle la violencia en la infancia la adolescencia pueden observarse d?cadas despu?s, incluyen problemas graves con las ?nanzas, la familia, el trabajo de estr?s, Ios cuales son factores que pueden aumentar el riesgo de suicidio. El suicidio frecuentemente tiene los mismos factores de riesgo individuales, relacionales, comunitarios sociales que otras formas de violencia, lo cual parece indicar que los esfuerzos para prevenir la violencia interpersonal podrian tambi?n ser Litiles para prevenir el soicidio??t30 Los CDC han creado paquetes t?cnicos para las distintas formas de violencia interpersonal a ?n de ayudar a que las comunidades identi?quen estrategias enfoques adicionales De la misma manera que el suicidio puede compartir factores de riesgo con la violencia interpersonal, los factores de proteccion tambi?n se pueden superponer. For ejemplo, para una persona, el hecho de estar conectada con su comuniolad,31 escuela,32 familia??3 adultos interesados por su laienestarF?L35 semejantes prosociales36 puede mejorar su resiliencia ayudar a reducir su riesgo de suicidio de otras formas de violencia. Preven chin del suicidlo: Paquete t?cnico d2 poll'tlcas. progra mas practices Las cansocuoncias dorivadas dol suicidio on la economia la salud son considerable-s. El suicidio 1; los intontos do suicidio tionon consocuoncias profundas en las personas, las familias las comunidadoSFM" En un estudio inicial, Crosby Sacks?1 ostimaron que ol 7 do la poblacion adulta do los Estados Unidos, sea, 13.2 millonos do adultos, conocia a alguion quo habia muorto por suicidio en los 12 mesos anterioros. Tambion ostimaron quo por cada suicidio, 425 adultos ostaban oxpuostos sabian do la muorto.? En un ostudio mas rocionto, en un ostado, Corol ot hallaron quo El 48 do la poblacion habia conocido a lo largo do su Vida a al monos una persona quo habia muorto por suicidio. Las invostigacionos indican que el ofocto do habor conocido a alguion que haya muorto por suicidio 0 do habor vivido la oxporioncia [o sea, habor intontado suicidarso, habor tonido ponsamiontos suicidas habor sido afoctado por la muorte do alguion a causa dol suicidio) va mucho mas alla do las losionos la muorto. Las porsonas quo han vivido la oxporiencia podrian sufrir consocuoncias a largo plazo, tanto fisicas como do salud mental. Estas varian dosdo onojo culpabilidad hasta impodimontos ?'sicosl sogL?In ol modio quo hayan usado la gravodad dol intontof3 Do manora similar las personas quo sobrovivon el suicidio do on sor quorido puodon padocor dolor sufrimionto continuo, como duolo ostigma, doprosion, ansiodad, trastorno por estr?s postraumatico mayor riosgo do idoacion suicida oxisten ofoctos ?nancieros ocupacionales para los sobrovivientos quo, aunquo so hablo monos do ostos, no tionon monor importancia.? El suicidio tambi?n causa un da?o economico inmonso en la sociodad. Sog?n ostimacionos modoradas, ol costo dol suicidio on ol 2013 fuo do 50 800 millonos do dolaros solamonte on concopto do costos m?dicos trabajo perdido do por Vida.?7Tras hacor ajustos por la posiblo cantidad do suicidios no roportados toniondo on cuonta los gastos do salud per capita, ol producto intorno bruto per capita la variabilidad do los gastos do salud ingrosos per capita do los ostados, otro ostudio ostimo quo los costos do por vida asociados a las lesionos no mortalos a las muortos causadas por la Violoncia autoin?igida oran do aproximadamento 93 500 millonos, tambion para ol 2013.48 La abrumadora carga do ostos costos provino do Ia p?rdida do productividad duranto ol curso do la Vida, con un costo promodio por suicidio do mains do 1.3 millonos do dolaros.? Es probable quo los costos economicos reales soan mas altos, ya quo ninguno do los ostudios incluyo cifras monotarias en relation con los otros costos sociales, como aquollos derivados dol dolor sufrimionto do los miombros do la familia, ni con otros do los ofoctos. El suicidio so puodo provonir. AI igual quo la mayoria do los problemas do salud p?blica, el suicidio os provoniblo?j Aunquo so soguir?n logrando avancos para ol futuro, en la actualidad oxiste ovidoncia que fundamenta numerosos programas, pra?cticas politicas, hay muchos programas ya listos para sor implomontados. De la misma manora ol suicidio no es causado por on factor unico, las invostigacionos parocon indicar quo tampoco so lograra una roduccion on ol suicidio modianto una ostratogia 0 un onfoquo mas bion, la mojor manora do lograr la prevention dol suicidio os modianto un onfoquo quo abarquo los nivelos individual, rolacional, familiar, comunitario 3! social, todos los soctorosr tanto privados como Evaluaci?n de la evidencia Esto paquoto t?cnico incluyo programas, practicas politicos quo han dado ovidoncia do toner un impacto on ol suicidio, 0 on los factoros do riosgo do suicidio 0 do protoccion contra ol suicidio. Para quo so consideraran para su inclusion on osto paquoto t?cnico, los programas, practicas politicos soloccionados dobian cumplir al monos uno do los siguiontos critorios: a] domostracion dol impacto on ol suicidio modianto motanalisis rovisionos sistom?ticas; b) ovidoncia do ofoctos provontivos signi?cantos on ol suicidio a partir do al monos un ostudio do ovaluacion riguroso {por ojomplo, un ostudio do diso?o aloatorizado controlado cuasioxporimontal]; c) domostracion dol ofocto en los factoros do riosgo do suicidio 0 do protoccion contra el suicidio modiante motanalisis rovisionos sistomaticas; d) ovidoncia - 10 would]! ml midrib: Paymemn mummy minim do ofocto on los factoros do riosgo do suicidio do protoccion contra ol suicidio do al monos un ostudio do ovaluaci?n riguroso (por ojomplo, un ostudio do diso?o aloatorizado controlado cuasioxporimontal]. Por Ultimo, otros factoros quo so tuvioron en cuonta fuoron la probabilidad do quo so lograran ofectos bone?ciosos sobro varias formas do violoncia; quo no hubiora ovidoncia do ofoctos da?inos sobro dotorminados rosultados ni con dotorrninados subgrupos; quo la implementation fuora viable on ol contexto do los Estados Unidos 5i ol programa, politica practica habia sido evaluado on otro pals. Algunos do los onfoquos incluidos on osto paquoto t?cnico todavia no cuontan con ovidoncia cionti?ca quo domuostro 5U ofocto en las tasas do suicidio, poro so sustontan on ovidoncia indicativa do su ofocto en los factoros do riesgo do suicidio 0 do protoccion contra ol suicidio {por ojomplo, bdsquoda do ayuda. roduccion dol ostigma, doprosion, conoxion). En t?rminos do la solidoz do la ovidoncia, los programas quo tionon ofoctos domostrados sobro los comportamiontos suicidas (por ojomplo, roduccion on la cantidad do muortos, intontos) proporcionan un mas alto nivol do ovidoncia; sin embargo, la base do ovidoncia no tiono igual solidoz on todas las areas. For ojomplo, ha habido una monor cantidad do ovaluacion on cuanto a la participacion do la comunidad los programas familiaros sobro los comportamiontos suicidas. Por lo tanto, los onfoquos quo so incluyon on osto paquoto quo tionon ofoctos sobro los factoros do riosgo 0 do protoccion roflojan la naturaloza ovoiutiva do la base do ovidoncia 3: ol uso do la mojor ovidoncia disponiblo on on momento dado. Asimismo, o5 importanto notar quo os comdn quo haya una signi?cativa hoterogonoidad ontro Ios programas, las politi? cas las practicas quo so oncuontran bajo una misma ostratogia enfoquo, on t?rminos do la naturaloza calidad do Ia ovidoncia disponiblo. No todos los programas, politicas pra?cticas quo usan ol mismo onfoquo tionon la misma o?cacia, incluso aquellos quo Sl son o?caces podrian no funcionar con todas las poblacionos. Para abordar los distintos grupos poblacionalos podrla sor nocosario adaptar los programas llovar a cabo mas evaluations-5. El objotivo do incluir ostos programas, practicas politicas basados on la ovidoncia on esto paquoto no es ol do proporcionar una lista integral para cada onfoquo, sino ol do proporcionar ejomplos quo han domostrado toner un impacto sobro ol suicidio, 0 un ofocto bono?cioso sobro los factoros do riosgo do suicidio los factoros do protoccion contra ol suicidio. A I Al igual que Ia mayon?a de los problemas de ?1 saludptiblita, el smtidr'o es prevenible. .. - - .. Proven thin del suicidio: Parquet: t?cnito do polities, pragra ma: '9 minim 1 2? ?k - Temas contextuales que afectan a muchas areas Una importante caracteristica de este paquete es el efecto complementario potencialmente sin?rgico que pueden tener las estrategias los enfoques incluidos. Estas estrategias enfoques abarcan distintos niveles de la ecologia social, incluyen esfuerzos que tienen el objetivo de influenciar tanto los niveles comunitario social como los niveles individual relacional, deben actuar de manera combinada como refuerzo uno del otro a ?n de prevenir el suicidio (ver el recuadro en la pagina 12). Las estrategias aparecen en determinado orden; se incluyeron primero los que se hipotetizo que tendran el mayor potencial de impacto en el suicidio en t?rrninos de salud pL?iblica general, seguidas de aquellas que podrian afectar a subgrupos poblacionales [por ejernplo, las personas que ya han teniclo un intento de suicidio}. Prevenci?n del suicidio Estrategia Enfoque Fortalecimiento de los apoyos - Fortalecimiento de la seguridad ?nanciera del hogar econ?micos - Politicas para la estabilidad de vivienda - Cobertura de afecciones mentales en las polizas de seguro m?dico - Reduccion de la escasez de proveeclores en las areas subatendidas - Cuidados mas seguros con relacion al suicidio mediante cambios a nivel cle sistema Fortalecimiento del acceso a los cuidados relacionados con el suicidio de su prestaci?n - Reduccion del acceso a medios letales entre las personas en riesgo de suicidio - Politicas cultura a nivel de organizacion - Politicas comunitarias para la reduccic'rn del consumo excesivo de alcohol Creation do ambientes protectores - Programas de normas cle semejantes Fomento de la cunexmn - Actividades de participation en la comunidad Ense?anza de destrezas do superaci?n resoluci?n de problemas - Programas de educacion socioeemocional - Programas de destrezas de crianza relaciones familiares - Capacitacion del personal de primera linea Identi?cation de las personas en - lntervencion en crisis riesgo provision the apoyo - Tratamiento para las personas en riesgo de suicidio - Tratamiento para la prevencion cle nuevos intentos Reducci?n de los da?os - lntervencion posterior prevention de riesgo futuro - lnforme mensajes seguros en relacion con el suicidio E5 importante notar que estas estrategias no son mutuamente excluyentes, sino que cada una tiene una area do concentracion inmediata. Por ejernplo, los programas de educacion socio-emocional, que son uno de los enfoques de la estrategia Ense?onzo de destrezas cie superocion resoiucfon de problemos, a veces incluyen componentes centrados en cambiar las normas de los semejantes el ambiente mas extenso. Sin embargo, la concentracion principal de estos programas es proporcionarles a los ni?os adolescentes las destrezas para resolver los problemas en las relaciones, la escuela con otros ni?os adolescentes, ayudarlos a abordar otras influencias negativas que se asocian con el suicidio (por ejernplo, el consumo de sustancias). - 12 Prevention del suia'dio: Paquete t?mica d2 politicas, prugramas pricticas El objetivo de este paquete es poner de relieve la importancia de los esfuerzos integrales para la prevencion proporcionar ejemplos de programas e?caces que abordan cada nivel de la ecologia social, con el conocimiento de que algunos programas, practicas pollticas pueden tener efectos en varios niveles. Asimismo, aquellos que implican varios sectores afectan varies niveles de la ecologia social, tienen mas probabilidades de tener un efecto mayor en la carga general del suicidio. La icleacionr Ios pensamientos, Ios intentos de suicidio las muertes varian por g?nero, raza origen r?tnicor edad, ocupacion otras caracterl?sticas poblacionales importantesF-SU Asimismo, ciertos periodos de transicion tambi?n se asocian a tasas mas altas de suicidio (por ejernplo, la transicion del trabajo a Iajubilacion, la transicion del servicio militar activo a la Vida De hecho, el riesgo de suicidio puede cambiarjunto a factores de riesgo dinamicos. Por ejemplo, la capacidad de superacion que tiene una persona puede cambiar en Ios periodos de crisis de mayor estres, limiter su capacidad normal para resolver problemas de modo e?caz de superar la situacion. Las investigaciones indican que la cantidad la intensidad de Ios factores de riesgo de proteccion clave que se experimenten causan cambios en el riesgo de suicidio.52 Idealmente, lo recomendable es que haya disponibles mLiItiples estrategias enfoques adaptados al contexto social, economico, cultural ambiental de Ias personas Ias comunidades, ya que podrl'an aumentar la probabilidad de eliminar Ias barreras que se interponen a una atencion e?caz de apoyo, proporcionan oportunidades para desarrollar la resiliencia de las personas las comunidades.? La identi?cacion de los programas, practicas politicas con evidencia de tener efecto sobre el suicidio intentos de suicidio, de tener efectos bene?ciosos sobre Ios factores de riesgo de suicidio de proteccion contra el suicidio es solamente el primer paso. En la practica, la e?cacia de los programas, practicas politicas identi?cados en este paquete dependera poderosamente de que? tan bien se implementen ytambi?n de Ias organizaciones aliadas Ias comunidades donde se implementen. Los profesionales en el campo podrian estar en la mejor posicion para evaluar Ias necesidades Ias fortalezas de sus comunidades de trabajar con los miembros de la comunidad para tomar decisiones sobre la combinacion de enfoques incluidos aqui que sean mas propicios para su contexto. Los procesos de plani?cacion estrat?gica guiada por datos pueden ayudar alas comunidades con este tralaajo.S355 Estos procesos motivan guian Ia participacion de Ias partes interesadas de la comunidad mediante un proceso de plani?cacion para la prevention dise?ado para abordar el per?l de Ios factores de riesgo de proteccion de la comunidad con programas, practices politicas basados en la evidencia. Estos procesos tambi?n se pueden usar para monitorear la implementacion de dichos programas, practicas politicos, hacer seguimiento de Ios resultados hacer ajustes segun indicado por Ios datos. El nivel de preparacion que tenga el programa para una amplia difusion implementacion {por ejemplo, disponibilidad de materiales del programa, capacitacion asistencia t?cnical tambi?n puede in?uir en su efecto. Las directrices para asistir a los m?dicos, Ias organizaciones Ias comunidades con la implementacion se elaboraran por separado. Este paquete incluye estrategias para Ios sitios donde Ias agencies de salud publica est?n bien posicionadas para hacer llegar liderazgo recursos a Ios esfuerzos de implementaci?nfambi?n incluye estrategias para Ios sitios donde la salud publica pueda actuar como una importante colaboradora [por ejemplo, estrategias que aborden los niveles de riesgo comunitarios sociales}, pero donde el Iiderazgo el compromiso de otros sectores (como el sector comercial, laboral de atencion medical sea critico para la implementacion de un programa politica en particular (por ejemplo, las politicas en el lugar de trabajo, el tratamiento para prevenir Ios nuevos intentos de suicidio}. La funcion de diversos sectores en la implementacion de una estrategia enfoque para la prevencion del suicidio 5e describe en mayor profundidacl en la seccion Participacr'cin de los sectores. En Ias secciones que siguen 5e describen las estrategias Ios enfoques que cuentan con la mejor evidencia disponible para prevenir el suicidio. mas? del middim' Pagan: titular d: po?tim. programs! Minions Fortalecimiento de los apoyos econ?micos Fundamento L05 estudios de los Estados Unidos que examinan Ias tendencias hist?ricas indican que las tasas de suicidio aumentan en los tiempos de recesi?n econdmica marcados por altas tasas de desempleo, p?rdida de trabajo inestabilidad econ?mica. que descienden en los tiempos de expansi?n econ?mica los periodos marcados por bajas tasas de desempleo, particularmente entre Ias persunas en edacl laboral de entre 25 64 a?os de edadF?j? Las presiones econ?micas ?nancieras?como 1a p?rdida del trabajo, periodos prolongados de desempleo, ingresos reducidos, di?cultad para cubrir gastos m?dicos, alimentarios de vivienda, incluso, la anticipacic?m de tales presiones ?nancieras?pueden aumentar el riesgo de suicidio de Ias personas, asi como tambi?n aurnentarlo de manera indirecta a! exacerbar los probiemas fisicos mentales El amartiguamiento de estos riesgos puede, por lo tanto, potencialmente protegerlas contra el suicidio. Por ejemplo, al fortalecer los sistemas de apoyo econ?mico 5e Ias puede ayudar a permanecer en su hogar conseguir vivienda asequible y, a la vez, pagar par Ias necesidades de la vida diaria, comp los alimentos, ia atenci?n m?dica, la capacitaci?n Iabora! el cuidado de ni?os. Este apoyp puede reducir el estr?s la ansiedad, el potential de una situaci?n de crisis y, por consiguiente, prevenir El suicidip. Aunque se necesita mucha mas investigacidn para comprender Ia forma en que los factores econ?micos interact?an con otrps factores para aumentar el riesgo cle suicidio, !a evidencia disponible sugiere que el fortalecimiento de los apoyos econ?micos puede ser una oportunidad de amortiguar el riesgo de suicidio. Enfoques Se pueden fortaiecer los apoyos econ?micos de Ias personas Ias familias al enfocarse en la seguridad ?nanciera del hogar asegurar 5U estabilidad de vivienda en los tiempos de estr?s econ?mico. Fortalecimiento de la seguridad ?nanciera del hogar. Este enfoque puede potentialmente amortiguar el riesgo de suicidiu al proporcionarles a las personas los medics ?nancieros para reducir la di?cultad econ?mica el estr?s relacionados con 1a p?rdida del trabajo 0 con otros problemas ?nancieros no anticipados. Proporcionar bene?cios por desempleo otras formas de asistencia temporaria, saiarios dignos, bene?cios m?dicos, yjubilacirim seguro por discapacidad para ayudar a cubrir el costo de Ias necesidades 0 para contrarrestar los costos en caso de discapacidad, son ejemplos de formas de fortalecer 1a seguridad ?nanciera del hogar. Politicas para la estabilidad de vivienda. Estas politicas tienen el objetivo de ayudar a Ias personas a permanecer en su hogar de proporcionarles opciones de vivienda a aquellas que lo necesiten en tiempos de inseguridad ?nanciera. Esto puede suceder por medic: de programas de vivienda asequible {por ejemplo, a trav?s de subsidios gubernamentales) 0 de otras opciones disponibles para quienes puedan comprar un hogar (comp programas de modi?caci?n de pr?stamns, servicios de plani?cacidn de mudanza 0 de asesoramiento ?nanciero), que ayuden a reducir al minimo el riesgo 0 el impacto de a5 ejecuciones hipotecarias los desalojos. Resultados potenciales . Reduccic?m en las tasas de ejecuciones hipotecarias - Reducci?n en las tasas de desalojos - Reducci?n en el sufrimiento emocional - Reducci?n en las tasas de suicidio Prawn chin del sulcidio: Paquete himico do politicas, programs 3' pra'cticas Evidencia Hay evidencia que sugiere que el fortalecimiento de la seguridad ?nanciera del hogar la estabilidad de vivienda pueden reducir el riesgo do suicidio. Fortalecimiento de la seguridad ?nanciera del hogar. El Programo de Seguro por Desampleo Federal Estotal permite que- Ios estados de?nan Ia cantidad la duraci?n maxima de Ios bene?cios por desempleo que Ios trabajadores tienen derecho de percibir tras la p?rdida del trabajo.59Un analisis de las variaciones existentes an Ios progromos do bene?cios por desarnpleo de todos Ios estados demostro que en los estados que proportionaban bene?cios por desempleo mayores al promedio (mediana: 7990 dolares por persona en dolares estadounidenses ajustados por in?ation) se habl?a contrarrestado el impacto del desempleo en Ias tasas de suicidio. Los efectos de los. progromos de bene?cr'os par desempleo tambi?n fueron uniformes on t?rminos de sexo grupo etario.59En otro estudio en Ios Estados Unidos se examino el vinculo existente entre el desempleo Ias tasas de suicidio usando datos mensuales sobre el suicidio, Ia duration del desempleo (menos de 5 semanas, 5-14 semanas, 15-26 semanas mas de 26 semanas) la p?rdida de trabajo, se hallo que la duration del desempleo, en contraste con solamente Ia p?rdida ole-I trabajo, predecia el riesgo de suicidio??grupados, estos resultados parecen lndicar qua Ios programas de bene?cios por desempleo estatales deban ser generosos no solo an cuanto a sus asignaciones ?nancieras sino tambi?n a su duration. Otras medidas que fortalecen Ia seguridad ?nanciera del hogar [por ejemplo, Ias asignaciones relativas a la jubilacic?m al seguro por discapacidad, la compensaci?n de seguro por desempleo. Ios bene?cios m?dicos otras formas de asistencia para las familias} tambi?n han demostrado in?uir en Ias tasas de suicidio. En un estudio realizado por Flavin Radcliff?l 5e examino el efecto que tuvieron los gastos per capita de los estados para tales asignaciones, bene?cios m?dicos asistencia a Ias familias (Asistencia Temporal para Familias Necesitadas por sus siglas en ingl?s] sus gastos totales sobre las tasas ole suicidio durante El periodo 1999?2000, haciendo ajustes por la cantidad de factores do riesgo de suicidio {por ejemplo, movilidad residencial, tasas de divorcio, tasas de desempleo) a nivel de estado. A medida que aumentaron Ios gastos per capita totales por asignaciones, bene?cios m?dicos asistencia para Ias familias hubo un descenso asociado en Ias tasas de suicidio de Ios estados. En t?rminos de Vidas salvadas, Flavin Radcli?? calcularon el costo de reducir Prevenci?n :lel middio: Paquete t?mim de polititas, programs y'prictitas 1a evidentia- system-cues! LI fortaledmient'oide?lg . seguridad?nqncierd . hogar?ai?stah?id?d~ ?2 de vivienda pueden reducir el riesgo de suicidio. . Ias tasas de suicidio de un estado por un punto entero para Ios a?os estudiados.?r A nivel national, estimaron que ocurririan 3000 suicidios menos al a?o si cada estado aumentara 45 dolares al a?o e1 gasto per capita para estos tipos de asignaciones asistenciales.61 Aunque este fue un estudio correlational, Ios resuitados demuestran Ios potenciales bene?cios de Ias politicas que llegan particularmente a Ias personas mas vulnerables en Ios momentos de mocha necesidad. Se necesita hacer mas estudios de evaluacion para entender en mayor profundidad el efecto que estos tipos do programas tienen en Ios resultados. Politicas para la estabilidad de vivienda. El Programa de Estabifizacion Vecr'nai' {Neighborhood Stobr'iizotion Program)? fue dise?ado para ayudar a Ios vecindarios que estuvieran sufriendo altas tasas de ejecucion hipotecaria abandono, al desacelerar ei deterioro de Ios vecindarios proporcionarles opciones de Vivienda asequibles a aquellas personas con ingresos bajos. moderados medios clue fueran a comprar. Este programa tambi?n ofrece asistencia ?nanciera para la compra de casa nueva a las personas eiegibles. Aunque este programa no se ha evaluado rigurosamente en t?rminos de su efecto en Ios resuitados reiacionados con el suicidio, aborda Ias ejecuciones hipotecarias Ios desalojos, que son factores de riesgo de suicidio. Un analisis longitudinal sobre los datos anuales relacionados con el suicidio Ias ejecuciones hipotecarias mostro que a medida que aumentaba Ia proportion de propiedades sujetas a ejecucion hipotecaria en Ios Estados Unidos, tambi?n aumentaba Ia tasa de suicidio, particuiarmente entre los adultos de edad iaborai?30tro estudio realizado a partir de los datos provenientes de 16 estados de los Estados Unidos que participan en el Sistemo Nacionai de- Notr'?mcion de- Muerres Viola-mas hallo que la cantidad de suicidios precipitados por ejecuciones hipotecarias desalojos aumento mas del 100 entre el 2005 (antes de que comenzara Ia crisis de vivienda] el 2010 (despu?s de su punto maximo).5? La mayoria de estos suicidios ocurrio antes de que la persona muerta perdiera efectivamente la casa. Estos hallazgos parecen indicar que si se integran recursos, mensajes remisiones para la prevention del suicidio a Ios servicios de plani?cacion asesoramiento ?nancieros, hipotecarios de mudanza, esto podria ayudar a prevenir suicidios. Preven chin del suicidio: Paquete t?mico de politicas. pragra mas pt?dicas 3F Fortalecimiento del acceso a los cuidados relacionados con el suicidio de su prestaci?n Fundamento Si bien la mayoria de Ias persenas cen preblemas de salud mental ne intentan suicidarse ni mueren per suirzidiolfr1g el nivel de riesge cenferide per distintes tipos de enfermedad mental en investigacienes anteriores se indica que la enfermedad mental es un factor de riesge impertante de suicidieF'W Tambien se ha hallade que Ias tasas de suicidio a nivel estatal se cerrelacienan con medidas de salud mental generales, come la depresien?a? 59 Les hallazges derivades de la Encuesta Necionol'sobre Comorbilidad indican que una cantidad relativamente baja de persenas en los Estades Unidos con trasternes de enfermedad mental recibe tratamiente para tales La falta de accese a la atencidn de salud mental es uno de los factores contribuyentes relacionados con el use insu?ciente de servicies de salud mental?1 Une de los cempenentes esenciales de la prevention es identi?car las maneras de mejerar el accese de Ias personas que lo necesitan a la atencion de salud mental a cuidades relatives al suicidie epertunes, asequibles de calidad.5 Ademas, Ias investigationes parecen indicar Lin maxime aprevechamiente de los servicies previstes cuande les sistemas de atencien m?dica de salud mental estan organizades de manera tal, que la atencien se presta efectiva e?cazmenteflAparte de les bene?cios del tratamiente, estes enfoques tambi?n pueden normalizar el compertamiento de basqueda de ayuda aumentar el use de estes servicies. Enfoques Hay varies enfeques que se pueden usar para fertalecer el accese a los cuidades relacienades con el suicidie la prestacion de estes, incluides; Cobertura de afecciones mentales en ias pelizas de seguro m?dico. Las leyes federales estatales incluyen dispesicienes que establecen igual cebertura para los servicies de salud mental en los planes de segure m?dice que para las demas preecupacienes de salud (es decir, paridad en la salud mental)? Les bene?cios servicies cubiertes incluyen ciertas caracteristicas, come cantidad de visitas, cepages, deducibles, servicies ambulateries hespitalaries, medicamentes recetades hespitalizacienes. Si un estade tiene una ley cle paridad de salud mental mas fuerte que la federal, entences los planes de segure regulades por el estade deben seguir la ley de paridad del estade. Si un estade tiene una de paridad menes fuerte que la federal (per ejemple, incluye cebertura para algunas afeccienes mentales pere no para etras], entonces la de paridad federal prevalecera sobre la del estade. Ofrecer igual cobertura no necesariamente implica efrecer buena cobertura, ya que la extension de los servicios bene?cios que ofrecen los planes de seguro medico para aberdar distintas afecciones varia. Sin embargo, ayuda a asegurar que los servicies de salud mental est?n cubiertes a la par de etras preecupacienes de salud. Reduccien de la escasez de proveedores en las areas subatendidas. El accese a atencien m?diea de salud mental e?caz de avanzada depende en gran parte de la capacitacien el tama?e de su fuerza laberal. M?s de 85 millenes de persenas en los Estados Unides viven en areas en Ias que no hay su?cientes preveedores de salud mental; esta escasez es particularmente marcada en Ias cemunidades urbanas de bajes ingreses Ias comunidades ruralesi'4 Hay varias fermas de aumentar Ia cantidad la distribution de los proveedores de salud mental que ejercen en Ias areas subatendidas. Estas incluyen efrecerles incentives ?nancieros a trav?s de les programas estatales federales existentes {per ejemplo, pregramas de amortization de pr?stamos) ampliar el aleance de les servicies de salud a trav?s del use de tecnelegl'as de telefenia, video internet. Tales enfeques aurnentarian Ia prebabilidad de que Ias personas que la necesiten puedan acceder a atencien medica asequible de calidad para los preblemas de salud mental, Io cual puede reducir el riesge de suicidie. Pmand?n del sultidin: Paquete timid: do politicas, programs If prinicas 1F Cuidados mas seguros cur- relacion al suicidio mediante cambios a nivel de sistema El acceso a servicios de atencion m?dica de salud mental es esencial para las personas en riesgo de suicidio; sin embargo, es solamente uno de Ios componentes de la prevencion. La atencion debe tambien ser prestada de manera e?ciente e?caz. M?s especi?camente, debe prestarse dentro de un sistema que apoye la prevencion del suicidio la seguridad del paciente a trav?s de un solido Iiderazgo, la capacitacion de la fuerza laboral, Ia identi?cacion evaluacion sistematica del riesgo de suicidio, Ia implementacion de tratamientos basados en la evidencia [ver identi?cocion de las personas en riesgo yprovision o'e opoyo}, la continuidad de la atencion el mejoramiento continuo de la calidad. El cuidado que este centrado en el paciente que promueva Ia equidad para todos los pacientes es, ademas, cle critica importanciaf5 Resultados potenciales - Mayor uso de los servicios de salud mental - Menores tasas de abandono del tratamiento - Reduccion de Ios sintomas depresivos . Reduccion en las tasas de intento de suicidio - Reduccion en las tasas de suicidio Evidencia Hay evidencia que sugiere que la cobertura de las afecciones de salud mental en las polizas de seguro me'dico mejorar el acceso a Ios servicios la prestacion de estos puede reducir Ios factores asociados al suicidio tener un efecto directo en las tasas de suicidio. Cobertura de afecciones mentales en las palizas de seguro m?dico. La Encuesto Nacionalsobre el Consume de Drogasylo Saiud (NSDUH) es una encuesta representativa a nivel nacional de la poblacion de los Estados Unidos que proporciona datos sobre el consume de sustancias, afecciones de salud mental utilizacion de servicios?? Con Ios datos de esta encuesta, Harris, Carpentery Baoi'? encontraron que 12 meses despu?s de que los estados promulgaran las ieyes o'e poridad de salud menroi, aumento signi?cativamente el uso autorreportado de servicios de salud mental. Mas aim, Ia investigacion subsiguiente realizada por Lang?g examino la relacic'm entre las leyes estatales de salud mental las tasas de suicidio desde 1990 hasta el 2004, encontro que las leyes de paridad de salud mental se asociaron, especi?camente, a una reduccion aproxirnada del 5 en las tasas de suicidio. Esta reduccion se tradujo, en los 29 estados con leyes de paridad, en la prevencion de 592 suicidios al a?o.59 Reduccion de la escasez de prove-adores en las areas subatendidas. Un ejemplo cle un programa para mejorar el acceso a proveedores de saluol mental es el Cuerpo Nacional de Salud porsus sigias en ingl?s), que ofrece incentivos ?nancieros para atraer a m?clicos de salud mental 0 del comportamiento hacia las areas subatendidas.? Los programas como este animan a las personas a trabajar en profesiones de salud mental en sitios designados como ?areas de escasez de profesionales de salud" por sus siglas en ingl?s] a cambio de la amortizacion de sus pr?stamos estudiantiles. Una encuesta sobre la retencion de estos profesionales realizada por la Administracion de Recursos Servicios de Salud (HRSA, por sus siglas en ingl?s] hallo que el 61 cle ellos seguia trabajando en areas de escasez designadas despu?s de su compromiso de 4 a?os con el pesar de que este programa no ha sido evaluado en terminus clel efecto que tiene sobre el suicidio, aborda el acceso a la atencion m?dica, el coal es un componente esencial de la prevencion del suicidio. Los servicios de teiesol'ud mental (TMH, por sus sigl'os en ingl?s) son servicios de atencion sicologica siquiatrica a distancia que se prestan mediante el uso de tecnologias de telefonia, video Internet}? Este tipo de servicio se puede usar en una variedad de entornos [por ejemplo, centros medicos ambulatorios, hospitales, establecimientos de tratamiento militares) para tratar una amplia variedad de afecciones mentales.Tambi?n puede mejorar e! acceso de los pacientes que est?n en areas aisladas su satisfaccion con la interaccion con el sistema de salud mental, reducir tanto sus gastos tiempo de transporte como las demoras para la prestacion de la atencion m?dica. Una revision sistematica de Ios servicios de - 10 Prevond?n Ilel middle: Paquetet?mim do militias, program minim El acceso a servicios de atena'?n me?dica salad mental es critico para las persona: en riesgo de sulcidia. TMH hallo que los que fuean cali?cados como servicios de alta buena calidad fueron e?caces para el tratamiento de afecciones mentales como la depresion, la esquizofrenia, el abuso de sustancias, el suicidio la ideacion suicida.m Ademas, Mohr colegas80 hicieron un metanalisis para examinar el efecto de la sicoterapia telefonica, en particular, 1; hallaron que este tipo de terapia redujo signi?cativamente Ios sintomas depresivos en comparacion con la terapia cara a cara.Tambi?n hallaron que Ias tasas de abandono del tratamiento fueron signi?cativamente mas bajas entre Ios pacientes que recibian la sicoterapia administrada telef?nicamente que entre aquellos que la recibian care a care.? Por Io tanto, Ios servicios de TMH quizas no solo ofrezcan mejor acceso a atencion de salud mental sino que tambi?n podrian asegurar continuidad en el tratamiento y, por consiguiente, una mayor reduccion en el riesgo de suicidio. Cuidados mas seguros con relacion al suicidio mediante cambios a nivel de sistema. El Sistema de Salud Henry Ford, que es una organizacion cle mantenimiento de la salud (HMO, por sus siglas en ingl?s} en el estado de Michigan, lidero la iniciativa Atencr'on Perfecta de la Depresidn (Perfect Depression Cored,? que es la precursora de lo que ahora se llama Cero Suicidios (Zero Suicide). La meta general de Atencion Perfecta de la Depresidn era eliminar el suicidio entre Ios miembros de la HMO. En t?rrninos mas amplios, Ia meta del programa era redise?ar Ia forma en que se prestaba la atencion m?dica para la depresion enfocarse en que fuera e?caz, segura, centrada en el paciente, oportuna, e?ciente equitativa entre los pacientes a ?n de lograr una ?mejora notable"en su calidad seguridad. El programa evaluaba determinaba el riesgo de suicidio de cada paciente implementaba atencion de seguimiento coordinada continua a nivel de aistema.81 AI examinar el efecto del programa 5e hallo que hubo un descenso drastico estadisticamente signi?cativo en Ias tasas de suicidio entre el inicio (1999 el 2000) el periodo de intervention (2002-2009]. Durante ese tiempo, las tasas de suicidio descendieron un 82 96.3"? Asimismo, entre Ios miembros de la HMO que recibieron los servicios de especialidad de salud mental, la tasa de suicidio 5e redujo signi?cativamente a lo largo del tiempo, desde 1999 al 2010 (de 110.3 a 4?.6 per cada 100 000 personas; con una mediana de 36.2 per cada 100 000 personas durante ese periodo?Mdem?s, para 105 miembros de la HMO que habian accedido solamente a servicios m?dicos en general, 3; no a servicios de especialidad de salud mental, la tasa de suicidio aumento de a 5.6 por cada 100 000 personas De manera similar, en el estado de Michigan, Ias tasas de suicidio de la poblaci?n general aumentaron de 9.8 a 12.5 per cada 100 000 personas durante ese periodo.a3 Preven chin del suicldio: Paquete t?mico da polititas, programs 1: pt?ditas 3F Creaci?n de ambientes protectores Fundamento Los esfuerzos de prevencion que no solo 5e enfocan en los cambios de comportamiento individuales {por ejemplo, buscar ayuda, intervenciones de tratamiento) sino tambi?n en cambios en el ambiente pueden aumentar Ia probabilidad de que se consigan resultados positivos de salud comportamiento.M La creacion de ambientes que aborden los factores ole riesgo de proteccion en los lugares donde las personas viven, trabajan se entretienen puede ayudar a prevenir el suicidio.? 17Por ejemplo, las tasas de suicidio son altas entre los adultos de mediana edacl que forman parte del 42.6 de la fuerza lalzloralfa5 ciertos grupos ocupacionales?nr? las personas que esta?n en centros de detencion (por ejemplo, prision, ca?rcellf? entre otros. Por lo tanto, los entornos donde residen trabajan estas poblaciones son ideales para implementar programas, practicas politicas que actL'Jen como amortiguadores contra el suicidio. Si 5e hacen cambios en la cultura de una organizacion mediante, por ejemplo, la implementacion cle pollticas cle apoyo, se pueden cambiar Ias normas sociales, se puede animar a las personas a buscar ayuda se puede demostrar que se valora la buena salud la buena saiud mental, no el estigma ni los demas factores de riesgo de suicidiolii?Elii De manera similar, si para prevenir los comportamientos da?inos se modi?can las caracteristicas del ambiente fisico como, por ejempio, el acceso a medios letales, se pueden reducir las tasas de suicidio. particularmente en tiempos de crisis transicion.39'9" Enfoques SegL'ln la evidencia actual, 5e proponen tres posibles enfoques para la creacion de ambientes que protejan contra el suicidio. Reduccion del acceso a medics Ietales entre las personas en riesgo de suicidio. L05 medios cle suicidio como El USO de armas de fuego, colgarse sofocarse, saltar de un lugar alto, no proporcionan mucha oportunidad de rescate y, por lo tanto, tienen como resultado tasas altas de muerte {por ejemplo, aproximadamente el 85 de las personas que usan una arma de fuego en un intento cle suicidio mueren por la lesion}?5 Las investigaciones, ademas, parecen indicar que: 1) el intervalo de tiempo entre el momento de la decision de actuar el intento de suicidio puede ser tan corto como 5?1 0 minutos??lg" 2) las personas tienden a no sustituir los m?todos altamente letales por otros, cuando estos no estan disponibles 0 son de dificil acceso?grgg Por lo tanto. aumentar el intervalo de tiempo entre la decision de actuar el intento de suicidio {por ejemplo, al hacer que sea mas dificil acceder a medios letales) puede salvar vidas. Los siguientes son ejemplos de enfoques que reducen el acceso a medios letales de las personas en riesgo de suicidio: - lntervencr'ones en l'ugares propicios para el suicidio. Los lugares propicios para el suicidio, lugares doncle pueden materializarse los suicidios con relativa faciliclad, incluyen los lugares altos {por ejernplo, precipicios, balcones techos), las vias del tren los lugares aislados, como los parques. Los esfuerzos para prevenir el suicidio en estos lugares incluyen colocar barreras limitar el acceso a ellos para evitar que las personas salten, instalar carteles tel?fonos para animar a las que est?n considerando suicidarse a solicitar ayudalo?? - Practices de almocenamiento seguro. Tener Ios medica mentos, Ias armas de fuego otros prod uctos dome?sticos guardados en un lugar seguro puede reducir el riesgo de suicidio al crear una separacion entre las personas vulnerables el facil acceso a medios letales. Dichas practicas podrian incluir educacion consejeria en torno al almacenamiento de las armas de fuego bajo llave en un lugar seguro (por ejemplo, en una caja fuerte una caja de seguridad para armas), no cargadas por separado de las municiones; a! mantenimiento de los medicamentos en un armario bajo Have 0 en otro lugar seguro alejado de las personas que podrian estar en riesgo que hayan intentado suicidarse Politicas cultura a nlvel de organizaci?n. Se podrian implementar pollticas una cultura que fomenten un ambiente de proteccion en los lugares de trabajol los centros de detencion otros entornos seguros {por ejemplo. los entornos residenciales). Dichas politicas valores culturales animan a! liderazgo de arriba hacia abajo podrian promover compartamientos prosociales [por ejemplo, pedir ayuda), el desarrollo de destrezas. normas sociales positivas, evaluaciones, remisiones acceso a servicios de asistencia (por ejemplo, salud mental. tratamiento de abuso de sustancias, consejeria ?nanciera). asi como tambi?n la creacion de planes de respuesta ante crisis. intervenciones posteriores otras medidas para fomentar un ambiente fisico seguro. Estos ajustes en las poiiticas la cultura pueden tener un impacto positivo en el clima la moral de la organizacion, ayudar a prevenir el suicidio los factores de riesgo relacionados (por ejernplo, la depresic?m, el aislamiento sociall?sv ?32 Premldtin del marlin: Paqm timim dc polities. pmgramasy Mattias 3? Politicas comunitarias para la roducci?n dol consumo excesivo do alcohol. So he hallado on ostudios do invostigacion on los Estados Unidos quo hay una asociacion fohacionto ontro la mayor disponibilidad do alcohol los suicidios en los que media el Las politicas para roducir oxtensamente ol consumo oxcosivo do alcohol incluyen limitar la ubicacion do los lugares quo voodoo alcohol su donsidad googra??ca, imponor impuostos sobro ol alcohol 3; prohibir la do venta do alcohol a Ias personas quo no tongan Ia odad legal para consomirloJ?5 Estas politicas son importantos porquo so ha hallado quo ol consumo oxcesivo rapido do alcohol so asocia a mas do una torcora parto do los suicidios a aproximadarnente ol 40 0/0 do los intontos do suicidio.m? Resultados potenciales - Mayor almacenamiento seguro de medios letales - Reduccidn en las tasas do suicidio . Roduccion do los intontos do suicidio - Aumonto en la bdsqueda do ayuda . Roduccion on Ias muortos por suicidio rolacionadas con ol alcohol Evidencia La ovidoncia sugioro quo croar ambientos protoctoros puodo roducir Ias tasas do suicido do intontos do suicidio aumontar la cantidad do comportamiontos protoctoros. Roduccion dol acceso a modios letales ontro las personas on riesgo do suicidio. En un motanalisis on El quo so examino ol ofocto do las lntervenclones en lugores proplcios poro ya soon implomontadas do manora combinada aislada, tanto en los Estados Unidos como on otros paisos, so hallo quo ostas intorvoncionos so asociaban a monoros tasas do suicidio.100w Por ojomplo, dospu?s do orguir una barrora on ol puento Jacques?Cartier on Canada, las tasas do suicidio por saitar do osto puonto so rodujoron do aproximadamonto 10 a 3 muortos por suicidio al a?o.mg Asimismo. so mantuvo osta roduccion en la cantidad do suicidios por saltar desdo lugares altos incluso cuando so tuvioron on cuonta todos los puontos lugaros corcanos quo so podian usar para osto proposito, lo cual paroco indicar quo los suicidios no so trans?rioron a otros lugaros altos.mfg La o?cacia dol uso do barroras en los puontos quodo domostrada, ado-mas, en un estudio en el quo so examino ol impacto quo tuvo el rotlro las barroras do seguridad dol puento Grafton Bridge on Auckland, Nuova Zolanda. Luogo do rotirar Ias barroras so quintuplicaron tanto la cantidad como Ias tasas do suicidioF3- ?09 Dtra forma on quo so puodon roducir los modios para ol suicidio implica ol uso do proctlcos o?o olmocenomlonto seguro. En un estudio do casos controlos do ovontos rolacionados con oi uso do armas do fuogo idonti?cados on 3? condados on Washington, Oregon Misuri. 5 centros do trauma, los invostigadoros hallaron quo guardar Ias armas do fuogo doscargadas, soparadas do Ias municionos, on on lugar bajo llavo 0 con dispositivos do soguridad era una modida protoctora contra los intontos do suicidio ontro los adolescentos.?? Adomas, una revision sistomatica rocionto do Ias intorvoncionos do oducacion consojoria, tanto clinicas como comunitarias, paroco indicar quo ol hocho do proporcionarlos a las personas los dispositivos do soguridad para las armas do fuogo aumonto signi?cativamonto la practica do almaconarlas do manora segura on comparacion con proporcionarles los incontivos ocondmicos para que los compraran por su cuenta.?01 Otro programa, llamado Consejeno en Solo do Emorgencios sobre elAcceso Medias Loroles (Emergency Department Counseling on Access to Lethal Moons, ED CALM), instruyo a los m?dicos do omergoncias siquiatricas do on hospital do ni?os grando a proporcionarlos consojeria sobre los modios Iotalos Ias cajas do soguridad para armas a los padres do los monoros do 18 a?os que ostuvioran rocibiondo atoncion m?dica por un comportamionto suicida. En un proyocto do mojora do la calidad provio posterior a la consojoria, Runyan ot all?i hallaron quo al momento dol onsayo posterior ol 76 do los padres (dol 55 do aquollos a los one so los hizo soguimionto, n=l 14} roportaron quo todos los modicamontos - 14 Prevention dol suiddio: Paquoto t?mico do politicos, prugramasy practicas que habian en su casa estaban bajo llave, comparado con menos del 10 al momento de la visita inicial a la sala cle emergencies. Entre los padres que indicaron la presencia de armas en el hogar en el ensayo previo to sea, e115?' todos tel 100 reportaron en el ensayo posterior que Ias armas estaban actualmente guardadas loajo llave.?g Politicas cultura a nivel de org anizacionJuntos poria Vida (Together fortife) es un programa de la fuerza policial de Montreal que se implemento para abordar el suicidio entre los o?ciales de policia. Las politicas los componentes del programa tenian e! objetivo de fornentar una cultura dentro de la organizacion que promoviera la solidaridad el apoyo mutuo entre todos los miembros de la fuerza policial. El programa incluyo la capacitacic?rn de supervisores, gerentes todas las unidades para mejorar sus competencias para identi?car el riesgo cle suicidio aurnentar la conciencia el uso de los recursos existentes. Tambi?n incluyo una campa?a educativa para mejorar Ia conciencia la bosqueda de ayuda.?' Se him on seguimiento de los suicidios entre los policias a lo largo de 12 a?os se compararon esas tasas con las de Quebec, que fue la cuidad de control. Las tasas de suicidio descendieron signi?cativamente en el grupo de intervencion (1'39 a una tasa cle 6.4 suicidios por cada 100 000 personas al a?o, en comparacion con un aumento del 11 en la ciuclad cle control (29.0 por cada 100 Otro ejemplo de este enfoque es el Programo de Prevencion dei Suicidio de lo Fuerzo A?reo de ios Estados Unidos {United States AirForce Suicide Prevention Program). El programa incluyo 1 1 politicas iniciativas educativas que tenian el objetivo de cambiar la culture de la Fuerza A?rea en torno al suicidio. Este programa use a lideres corno ejemplos a seguir agentes de cambio, establece expectativas de comportamiento en cuanto a tener conciencia sob-re el riesgo de suicidio, desarrolla Ias destrezas los conocimientos de esta poblacion (o sea, mediante educacion capacitacion} investiga cada caso de suicidio (0 sea, medicion cle los resultaclos). Asimismo, representa un cambio fundamental que implica ver al suicidio a la enferrnedad mental no solo como problemas me'dicos sino tambien Como problemas mas abarcadores cle todas Ias fuerzas armadas, que afectan a toda la Mediante el uso de un dise?o de estudio de series temporales para examinar el efecto del programa en varios criterios de valoracion relacionados con la violencia, los investigadores hallaron que el programa 5e asocio con una reduccion del 33 en el riesgo relativo del suicidio)? El programa tambi?n se asocio con reducciones en el riesgo relativo de los criterios de valoracion relacionados, incluidos la violencia moderada grave en la familia (30 54 respectivamente), el homicidio (51 la muerte accidental (18 En un analisis longitudinal del programa para el periodo desde 1981 hasta el 2008 {16 a?os antes de que se lanzara el programa en 1997, 1 1 a?os despu?s) se hallo que las tasas de suicidio fueron signi?cativamente mas bajas despues del lanzamiento del programa que antes de este?? Estos efectos fueron constantes a lo largo del tiempo, excepto en el 2004, a?o que los autores hallaron 5e asoci? a una implementaci?n menos rigurosa de los componentes del programa en comparaci?n con los otros a?os.? Por Ultimo, mientras todavia 5e esta formando la evidencia para la prevencion del suicidio en las instalaciones correccionales, la evidencia preliminar parece indicar que se pueden potencialmente reducir Ias tasas de suicidio mediante politicas practicas a nivel de organizacion que incluyan capacitacion rutinaria en la prevencion del suicidio para todo el personal; evaluaciones de ingreso de riesgo estandarizadas; la provision de informacion compartida entre los miembros del personal [especialmente en las transiciones los traslados de los reclusos); diversos niveles de observacion; ambientes fisicos seguros; protocolos de respuesta ante emergencias; la noti?cacic?m de comportamientos suicidasi suicidios en toda la cadena de mando, el uso de la tecnica de intervencion de apoyo tras incidentes criticos analisis de muertes (critical debrie?ng and death Cuando 5e implementaron estas politicas practices en 1 1 prisiones de Luisiana, Ias tasas de suicidio 5e redujeron en un 46 ?fa (de una tasa de 23.1 por cada 100 000 personas antes de la intervencion a una de 12.4 por cada 100 000 personas al a?o siguiente}.I13 Otros programas similares han mostrado reducciones en las tasas de suicidio, tanto en los Estados Unidos como en otros paises Politicas comunitarias para la reducci?n del consume excesivo de alcohol. Si bien existen varias politicas para limitar el consumo de alcohol en exceso, hay varios estudios sobre la reiacion entre la densidad geogra?ca de lugares de venta de alcohol los factores de riesgo cle suicidio (como violencia interpersonal conexion social), que sugieren que las medidas para reducir la densidad geogra?ca de lugares de venta de alcohol podrian potencialmente reducir Ia cantidad de suicidios en los que medie el alcohol. Asimisrno, un analisis longitudinal sobre la densidad geogra?ca de lugares de venta de alcohol, la mortalidad por suicidio las hospitalizaciones por intento de suicidio en un periodo de 6 a?os en el area de 581 codigos postales de California indico que Ias densidades mayores de bares, especi?camente, se relacionaron con mayores cantidades de suicidios intentos de suicidio, en especial en las areas rurales.?9 mean del suicidio: Paqm I?mlm d: polities. programs! minim 3F . .m 1.. I. 9 Fomento de la conexi?n Fundamento La sociologa Emile Durkheim plante? Ia teoria en 189? cle que una de las causas principales del riesgo de suicidio era tener vinculos sociales debiles; 0 sea, falta de La conexi?n es el grado al que una persona grupo de personas tienen cercania social, se interrelacionan comparten recursos con Ios clemas.?21 Las conexiones sociales 5e pueden formar dentro Ios distintos niveles de la ecologia social 3! entre estos niveles;? por ejemplo, entre personas lsemejantes, vecinos, compa?eros de trabajo), familias, escuelas, vecindarios, lugares de trabajo, comunidades religiosas. grupos culturales la sociedad en su totalidad. Dentro del contexto de esta conexion, el t?rmino capital social se re?ere al sentido de con?anza que una persona tiene en su comunidad vecindario, su integracion social 3! tambi?n a la disponibilidad de organizaciones sociales a su participaci?n en ellas.? '23 En muchos estudios ecologicos transversales longitudinales se ha examinado el efecto que tienen Ios aspectos del capital social en Ios sintomas de la depresion, el trastorno depresivo, la salud mental en general 3: el suicidio. Si bien la evidencia es limitada, Ios estudios existentes parecen indicar que hay una asociaci?n positiva entre el capital social (medido a partir de la con?anza social la participacion comunitaria vecinal) tener mejor salud mentalli?l'125 Juntos la conexion el capital social pueden proteger contra Ios comportamientos suicidas a1 reducir el aislamiento, animar la adopcion de comportamientos de superacic?un adaptativos al aurnentar el grado de pertenencia, valor personal 3; valoracion, para ayudar a desarrollar resiliencia ante la adversidad. El grado de conexion puede tambi?n proporcionar a las personas un mejor acceso a recursos apoyos formales, movilizar a las comunidades a satisfacer las necesidades de sus integrantes proporcionar actividades colectivas de prevencion primaria a la comunidad en su totalidadJ? Enfoques AI modelar las normas de los semejantes mejorar Ia participacion comunitaria para fomentar la conexion entre las personas dentro cle las comunidades puede proteger contra el suicidio. Programas de normas de semejantes. Estos programas tienen el objetivo de normalizar Ios factores de proteccion contra el suicidio, como buscar ayuda, acercarse hablar con un adulto de con?anza promover la conexion con semejantes. AI aprovechar las cualidades de liderazgo la influencia social de Ios semejantes, estos enfoques se pueden usar para modi?car las creencias a nivel de grupo promover un cambio positive a nivel social comportamental. Estos enfoques generalmente estan dirigidos a Iosjovenes se implementan en entornos escolares, pero tambi?n se pueden implementar en entornos comunitarios.??5 Actividades de participacion en la comunidad. La participation en la comunidad es uno de los aspectos del capital social.m Los enfoques para la participacic'rn en la comunidad pueden implicar la participacion de las personas en una variedad de actividades, incluidas las actividades religiosas, las actividades de Iimpieza enverdecimiento (greening) las actividades grupales de ejercicio fisico. Estas actividades les proporcionan Ia oportunidad de tener mayor participacion en la comunidad de conectarse con otros integrantes de la comunidad, organizaciones recursos, lo cual lleva a una mejor salud fisica general, menos estres menos sintomas depresivos que, a su vez, reducen el riesgo de suicidio. del suicidio: Pique? timion dc polities. pmgramasy minim 27 Resultados potenciales Aumento en las attitudes Ins comportamientos saludables de superaci?n Aumento en Ias remisiones dej?venes que est?n sufriendo Aumento en la basqueda de ayuda Aumento en la percepci?n sobre el apoyo de los adultos Promover Ia conexi?n entre las personas [as comunidades puede proteger contra el suicidio. . .. . (he: . - 28 Prevend?n del suiddin: Paquet ?cni a de politicas, programs pricticas {4:21 . "ll. . ll. I 3.21235 Evidencia La evidencia actual sugiere que las actividacles de normas cle semejantes )1 la participacion en la comunidad presentan un nLimero ole bene?cios positivos. aunque 5e necesitan hacer mas investigaciones de evaluacion para examinar 5i estas mejoras respecto de los factores de proteccion contra Ios comportamientos suicidas 5e traducen en una canticlad menor de intentos de suicidio muertes por suicidio. Programas de normas de semejantes. Las evaluaciones muestran que los programas como Fuentes de Fortaleza {Sources of Strength) pueden mejorar Ias normas las creencias que Ios estudiantes crean difunden sobre el suicidio en las escuelas. En un estudio controlado aleatorizado sobre el progra ma Fuentes de Fortaleza que se realizo con 18 escuelas secunclarias superiores [6 metropolitanas, 12 rurales], Ios investigadores hallaron que el programa mejoro las normas adaptativas relativas al suicidio, la conexion con los adultos la participacion escolar?? Los lideres semejantes tambi?n tuvieron mayor propension a remitir a sus amigos suicidas a un adulto que los del grupo de control. El resultado del programa para los estudiantes fue una mayor percepcion de apoyo de los adultos a los jovenes suicidas, particularmente entre aquellos que tenian antecedentes cle icleacion suicida, la aceptabilidacl de los comportamientos cle bdsquecla de ayuda. Por Ultimo, Ios lideres semejantes capacitados tambi?n reportaron una mayor reduccion en las actitudes de inadaptacion respecto de la superacion, en comparacion con los no capacitaclos.36 Actividades de pa rticipacion en la comunidad. En Filadel?a 5e realizo una iniciativa de enverdecimiento de lotes vacantes entre 1999 e! 2008. Los residentes locales miembros de la comunidad trabajaronjuntos para Iimpiar, enverdecer mantener 4436 lotes (o 7.8 millones de pies cuadrados) en cuatro a?reas ole la ciudad. Los investigadores hallaron reducciones signi?cativas en los niveles de estr?s autorreportados de los residentes, que es uno ole Ios factores de riesgo cle suicidio, mayor actividad fisica, que es uno de los factores de proteccion contra el suicidio, que en los residentes de las areas ole Iotes vacantes de control. Hay algo de evidencia de bene?cios en otras areasr como reducciones en la cantidad de asaltos a mano armada vandalismo?zgr ?9 Prevend?n del suicidin: Paqum t?mim dc polities, magnum pr?dicas 5F Ense?anza de destrezas de superaci?n resoluci?n de problemas Fundamento El desarrelle de destrezas de la Vida diaria, prepara a Ias persenas para afrontar exitesamente les desafies de la Vida diaria para adaptarse al estr?s la adversidad. El cencepte general de destrezas de la Vida diaria abarca a varies cenceptos, pere suele incluir destrezas de superacien reselucien de problemas, regulacien emecienal, reselucien de conflictos pensamiento critico. Las destrezas de la Vida diaria son impertantes para preteger a las personas contra les compertamientes suicidas.?25 Les pregrarnas de prevencien del suicidie que se centran en Ias destrezas de la Vida diaria las destrezas sociales se derivan de las teerias cegnitivas sociales,?? que sostienen que el comportamiente suicida se atribuye, ya sea al aprendizaje directe a medeies, a caracteristicas ambientales individuales (per ejempie. desesperanza). La incapacidad de emplear estrategias adecuadas para superar les factores estresantes inmediatos para identi?car encentrar Ia selucien a les problemas ha side caracterizada entre Ias personas que intentan suicidarse.?3* Ense?arles preporcienarles a lesjevenes ias destrezas para afrentar les desafies factores estresantes de tedes les dias es, per le tante, un importante cempenente de la prevencien del suicide. Enfoques Les pregramas de educacien secie?emecienal de destrezas de crianza relacienes familiares sen dos enfeques para ense?ar destrezas de superacic'm de reselucien de problemas. Programas de educacien socie-emecienal. Estes pregramas se centran en el desarrelle el fertalecimiente de las destrezas de cemunicacien resolucien de problemas, Ia regulacion emocienal. Ia reselucien de cenflictes, Ia busqueda de ayuda las destrezas de superacion. Aberdan una 1.rariedad de factores de riesgo de suicidio de proteccien contra el cempertamiente suicida. Les propercienan a les ni?os a lesjevenes Ias destrezas para resolver problemas en las relacienes, la escuela con etres ni?os jevenes, ayudan a lesjevenes a manejar Ias etras in?uencias negativas asociadas al suicidie (come el consume de Estes enfeques generalmente se imparten a tedes les estudiantes de un grade escuela en particular, aunque algunes pregramas se centran tambi?n en grupes de estudiantes censiderades en alto riesge de suicidie. Las eportunidades para practicar referzar Ias destrezas sen una impertante parte de les pregramas e?caces.132 Programas de destrezas de crianza relaciones familiares. Estes programas les propercienan apoye alas personas que est?n a cargo cle ni?es, ytienen e] objetive de referzar Ias destrezas de crianza, mejorar Ias interaccienes padre-hije positivas mejerar Ias destrezas habilidades cempertamentales emecienales de les ni?es.132 Este tipe de pregrarna, per lo general, se dise?a para les padres personas a cargo de les ni?es de un range de edad especi?ce puede ser autedirigide impartide a families de manera individual en grupes de familias. Algunes de les pregramas tienen sesienes principalmente con les padres persenas a cargo de ni?es mientras que etres incluyen sesienes para los padres persenas a cargo de ni?es, lesjevenes la familia. El centenide especi?ce de les pregramas nermalmente varia segun Ia edad del nine. pere frecuentemente coincide en que incluye temas de desarrelle infantil, cemunicacion relacien padre?hije. de destrezas interpersonales reselucien de problemas del jeven. Pmand?n del suicidin: Paquete timid: d: polities, programasy pra?cticas Resultados potenciales - Reduccion en la ideacic'm suicida - Reduccion en los intentos de suicidio - Reduccion en los comportamientos de riesgo de suicidio (por ejemplo, depresion, ansiedad, problemas conductuales, abuso de sustancias} - Mejoras en los comportamientos de busqueda de ayuda - Mejoras en la competencia social 3; las destrezas de regulacion emocional - Mejoras en las destrezas de resolucion de problem-as manejo de conflictos Evidencia Hay varios programas de education socio-emocional de crianza relaciones familiares que demostraron en las evaluaciones rigurosas mejorar la resiliencia reducir los comportamientos problematicos los factores de riesgo de varios comportamientos, incluidos aquellos estrechamente relacionados con el suicidio, como la depresion, los comportarnientos de internalizacion el abuso ucacion socio?emocional. El Programa de Jdvenes Conscientes de la Salud Mental Youth Aware ofMenral Health Program, YAM) fue desarrollado para adolescentes de 14 a 16 a?os usa e] dialogo interactivo representaciones de roles para ense?arles sobre los factores de riesgo de proteccion asociados con el suicidio [incluidos el conocimiento acerca de la depresion la ansiedad) mejorar sus destrezas de resolucion de problemas para afrontar los eventos adversos de la Iirida, el estr?s, la escuela otros problemas.? En un estudio controlado aleatorizado, por grupos, realizado en 10 paises de la Unidn Europea 168 escuelas, los alumnos de las escuelas asignadas aleatoriamente al grupo del programa YAM tuvieron probabilidades signi?cativamente menores de intentar suicidarse 0 de tener ideaciones suicidas graves en el seguimiento de los 12 meses en comparacion con los de las escuelas de control que- recibieron materiales educativos la atencion habitual. En t?rminos generales, el riesgo relativo de intentos de suicidio juvenil entre los que estaban en el grupo de YAM se redujo en mas del 50 al indicar que de 1000 alumnos, cinco del grupo YAM intentaron suicidarse en comparacion con 11 del grupo de control. Ademas, en cuanto a la ideacic?in grave de suicidio, el riesgo relativo en el grupo YAM 5e redujo en 49.6 Otro ejemplo es el Juego del' Buen Comportamiento (Good Behavior Game, 636), que es un programa para ni?os de 6 a 10 a?os que se imparte en la clase. El programa usa una estrategia de manejo del comportamiento en equipos, que promueve el buen comportamiento al establecer una expectativa Clara de buen comportamiento consecuencias para el comportamiento de inadaptacion. El objetivo del programa 636 as crear un sistema social integrado en la clase que apoye la capacidad de aprender cle todos los ni?os, con pocas manifestaciones de comportamiento agresivo disrupti?ro.135 En el programa participaron dos cohortes de ni?os durante los a?os escolares 1985-86 1986-87 cuando estos asistian a primer 5; segundo grado. Se analizaron un numero de resultados proximales distales entre las dos cohortes a lo largo del tiempo. Con respecto a los resultados distales relacionados con el suicidio, un analisis de los resultados del programa GBG indico que las personas de la primera cohorte que fuean asignadas a participar en el programa GBG cuando estaban en primer grado, reportaron la mitad de las probabilidades ajustadas de ideacion suicida de intentos de suicidio a! momento de la evaluacion aproximadamente 15 a?os despue?s [cuando tenian entre 19 21 a?os}, en comparacion con aquellas que habian estado en el entorno escolar estandar. El efecto bene?cioso del programa se mantuvo en cuanto a la ideaci?n suicida independientemente de que se hubieran incluido covariables de rei?erencia.135 El efecto del programa (386 en los intentos de suicidio fue menos robusto en algunos modelos ajustados, que incluyeron a cuidadores de salud mental. En la segunda cohorte de estudiantes qua estaban en el programa GBG, ni sus resultados de ideacion suicida ni sus intentos de suicidio fueron signi?cativamente distintos a los del grupo de control.?35 Segun los investigadores, esto pudo deberse a una posible falta de ?delidad en la implementacidn del programa, corno menor mentoria monitoreo a los maestros.Tambi?n se hallo que el programa GBG se asocio a un menor riesgo de abuso de sustancias posterior de otros factores de riesgo en los estudiantes de la primera cohorte. Los resultados de la segunda cohorte fueron, en general, menores; pero apuntaban hacia la direccion deseada.?36 and?ndel sulddlo: Paquetet?mim do palitlcn. program? af?nities Programas de destrezas de crianza relaciones familiares. Los enfoques de capacitacion en destrezas de crianza familiares han demostrado tener un efecto prometedor en la prevencion de factores de riesgo claves asociados al suicidio. Por ejemplo, el programa A?os increibies {incredible Years, iY) es un programa de capacitacion integral en grupo para padres, maestros ni?os que tiene el objetivo de reducir Ios problemas de conducta de abuso de sustancias [dos importantes factores de riesgo de suicidio en Ios jovenes} al mejorar los factores de protection como, por ejemplo, las interacciones relaciones padre-maestro-ni?o positivas receptivas, la autorregulacion emotional la competencia social (todos, factores de proteccion contra el suicidioll.132 El programa consta de entre 9 20 sesiones que se ofrecen en un entorno comunitario {por ejemplo, en centros religiosos, de recreation, de tratamiento de salud mental hospitales). Varios estudios han demostrado el efecto del programa iY en la reduccion de los sintornas de internalization, como la ansiedad la depresion, de Ios problemas de conducta en Ios ni?os?? ?33 Este programa tambi?n se asocio a un mejoramiento en la capacidad de resolver problemas de manejar con?ictos; estas destrezas se mantuvieron en el seguimiento de 1 El programa, adema?s, demostro producir mayores bene?cios con relacion a los sintomas de internalization en Ios ni?os, segL?in evaluaron las madres, en comparacion con el grupo de control de aquellos en lista de espera, cuando se incluyeron los componentes de padre, ni?o maestro.?32 Asimismo, el programa Fortoiecimienro de ios 10-1-4 {Strengthening Families 10?14) implica sesiones para Ios padres, Iosjovenes las familias con la meta de mejorar las destrezas de Ios padres para disciplinar a sus hijos, manejar las emociones Ios con?ictos, comunicarse con sus hijos; promover las destrezas interpersonales de resolucion de problemas de Iosjovenes; crear actividades familiares que forjen cohesion interacciones positivas entre padres hijos. La premisa del programa es que el desarrollo de estas destrezas, tanto en los padres como en Ios hijos, reducira Ios comportamientos de internalizacion el abuso de sustancias en la adolescencia, Ios cuales son dos importantes factores de riesgo de suitidio.142 El programa Fortoiecimiento deios ha demostrado reducir signi?cativamente Ios comportamientos de externalizacion, como la agresion el consumo de alcohol drogas entre Ios participantes jovenes, tambi?n Ia depresion el consume de alcohol 3: drOgas entre las familias 3 [.05 en foques de capacitaci?n en des trezas de crianza familiares han mos trado ten er efectos prometedores para la prevention de las factores de riesgo clave asaciados a! suicidia. Preventl?n?al suicidio: Parquet: t?cnim dc programs pr?dicas 3F - Li Identi?caci?n de las personas en riesgo provisi?n de apoyo Fundamento Para poder reducir Ios suicidios, es necesario poner atencion brindar cuidados a las poblaciones vulnerable-s, ya que las tasas de comportamientos suicidas en estos grupos tienden a ser mas alias que las tasas promedio. Estas poblaciones vulnerables incluyen, entre otras, a las personas con un nivel socioecon?mico mas bajo afectadas por un problema de salud mental; las personas que hayan intentado suicidarse anteriormente; Ios veteranos el personal militar en servicio activo; las personas que est?n internadas en una institucion, hayan sido victimas de violencia no tengan hogar; las personas que tengan un estatus de minoria sexual; Ios miembros de ciertos grupos raciales ?tnicos minoritarios.ML 12- ?3'143 El apoyo a las personas en riesgo requiere de la identi?cacion proactiva de los casos la respuesta e?caz, programas de intervencion en crisis tratamientos basados en la evidencia. Encontrar formas optimas de identi?car las personas en riesgo, adaptar Ios servicios para que sean mas accesibles lpor ejemplo, por Internet cuando sea lo apropiado} motivar a las personas para que reciban atencion m?dica basada en la evidencia {por ejemplo, por medios de tratamiento colaborativo} siguen siendo desafios clave?irm- ?5 Si Ios servicios simplemente se mejoran amplian, esto no garantiza que seran utilizados por las personas que mas Io necesitan, ni que aumentara necesariamente Ia cantidad de personas que hagan seguimiento de las remisiones tratamientos recomendados. Por ejemplo, algunas personas que viven en comunidades desfavorecidas podrian tener problemas sociales economicos que pueden afectar adversamente su capacidad de acceder a Ios servicios de apoyo.? Enfoques Los siguientes enfoques se centran en la identi?cacion el apoyo a las personas que est?n en mayor riesgo de suicidio. Capacitaci?n de personal de primera linea. Esta capacitacic?m tiene el objetivo de instruir a maestros, entrenadores, clerigos, personal de respuesta a emergencias, proveedores de atencion m?dica primaria urgente, a otras personas de la comunidad en identi?car a las personas que podn?an estar en riesgo de suicidio a responder de manera e?caz, incluso facilitarles servicios de bdsqueda de tratamiento de apoyo. Esta capacitacion de] personal de primera linea puede ser implementada en una variedad de entornos a ?n de identi?car brindar apoyo a las personas en riesgo.?6 lntervencion en crisis. Estos enfoques brindan servicios de apoyo remision, que generalmente consisten en conectar a la persona que esta en crisis (0 a un amigo familiar de la persona que est? en riesgo) con un voluntario capacitado 0 personal profesional mediante Lina linea telefonica de ayuda, chat en linea, mensajes de texto 0 en persona. Los enfoques de las intervenciones en crisis tienen el objetivo de impactar Ios factores de riesgo de suicidio claves, que incluyen depresion, el sentimiento de desesperanza la utilizacion subsiguiente de servicios de salud mental.?? De manera similar a la reduccion de Ios medios para el suicidio, las intervenciones en crisis pueden aumentar la distancia el tiempo entre la persona que est? considerando suicidarse el comportamiento da?ino. Tratamiento para las personas en riesgo de suicidio. Puede incluirvarias formas de sicoterapia administrada por proveedores con licencia para ayudar a las personas con problemas de salud mental otros factores de riesgo de suicidio, mediante Ia resolucion de problemas la regulation emotional. El tratamiento generalmente se hace en un formato individual grupal entre pacientes m?dicos, puede ser de varias semanas de duracion continua, segLin 5e necesite. Los tratamientos clue emplean Ia terapia colaborativa (o sea, entre el paciente el terapeuta administrador de atencion) la terapia integrada (0 sea, con vinculacion entre la atencion m?dica primaria la de salud del comportamiento) pueden ayudar a animar a Ios pacientes motivar su participacion en la terapia y, por lo tanto, aumentar su retencion reducir su riesgo de soicidioma'150 Prev-add? del suiddia: Paquete mimic: dc polities. programs, pr?aicas Tratamiento para prevenir los noevos intentos. Estos enfoques generalmente incluyen hacer contacto de seguimiento el uso de diversas modalidades (por ejemplo, con visitas domiciliarias, por correo, tel?fono, correo electronico] para motivar Ia participacion de los sobrevivientes de un intento de suicidio reciente en un tratamiento continuo para prevenir los nuevos intentos de suicidio?? El tratamiento puede centrase en mejorar Ias destrezas de superacion, Ia conciencia plena otras destrezas de regulacidn emocional, puede incluir tanto visitas domiciliarias de administracion de casos para mejorar la adherencia al tratamiento la continuidad de la atencion m?dica, como terapia interpersonal individual 0 en grupo. Los enfoques que motivan Ia participacion de las personas que han intentado suicidarse Ias conectan con otras que lo han intentado con proveedores son especialmente importantes porque muchas de ellas no se presentan a los servicios de atencion m?dica posterior; entre el 12 el 25 volveran a intentarlo dentro del a?o, entre el 3 el 9 de aquelias que sobreviven el intento mueren por suicidio entre a?os despu?s del intento inicial.151 Resultados potenciales - Reduccion en la ideacion suicida - Reduccion en los intentos de suicidio - Reduccion en Ias tasas de suicidio - Reduccion en la depresion los sentimientos de desesperanza - Reduccion en los nuevos intentos de suicidio - Mejora en Ias destrezas de superacion -Aumento en la participacion en el tratamiento el cumplimiento con la torna de los medicamentos Evidencia La actual evidencia parece indicar que identi?car alas personas que est?n en riesgo de suicidio proporcionarles tratamiento apoyo de manera continua puecle impactar positivamente Ias tasas de suicidio los factores de riesgo relacionados. Capacitacion dei personal de prime-m iinea Copacitocion en Destrezos Apiicodos de lntervencion contra ei Suicidio {Appiieo' Suicide intervention Skills Training, ASST) es un programa de capacitacion de amplia implementacion que ayuda a los consejeros que atienden Ias lineas de ayuda, los trabajadores de emergencias otro personal de primera linea a identi?car a Ias personas suicidas crear una conexic?in con ellas, comprender sus razones para vivir morir, ayudar a conectar a [as que lo necesitan con los recursos disponibles, de manera segura. En un estudio en el que se used on ensayo aleatorizado controlado, Gould, Cross, Pisani, Munfakh Kleinman?? evaluaron Ia capacitacion en toda la red de lineas de ayuda de la Red Nocionoide Prevencion deiSuicidio durante eI periodo 2008?2009. Mediante el uso de los datos de 1410 personas suicidas que llamaron a 1? centros de esta red, los investigadores hallaron que Ias que habian hablado con consejeros que contaban con la capacitacion del programa ASISTtenian probabilidades signi?cativamente mayores de sentirse menos deprimidas, menos suicidas, menos abrumadas mas esperanzadas al ?nal de la llamada que aquellas que habian hablado con consejeros que no contaban con esa capacitacion. Los consejeros con la capacitacion del programa ASiSTfueron, ademas, m?s capaces de mantener a las personas en el tel?fono por mas tiempo de establecer una conexion con eltas. Sin embargo, Ia capacitacion en no produjo mas evaluaciones de riesgo de suicidio integrales que la capacitacion en cuidados habitual.I52 - 7m Wu?diwiddio: Paqu'ete?uicodepnli?m La capacitacion en la atencion de primera linea tambi?n ha sido uno de Ios componentes principales del Programa Garret Lee Smith para la Prevencion alei Suicidio, (Garret Lee Smith Suicide Prevention Program), que se ha implementado en 50 estados en 50 tribus. En una evaluacion de m?ltiples sitios se analizo el lmpacto que tuvo la capacitacion del personal de primera llnea en los intentos cle suicidio las muertes. Para ello se compararon los cambios en las tasas de suicldio comportamientos suicidas no mortales entre personasjovenes de 10 a 24 anos en condados qua implementaron Ia capacitacion del programa GL5 con la trayectorla observada en condados similares que no la implementaron. Los condados que implementaron esta capacitacion tuvieron tasas de suicidlojuvenil signi?cativamente menores al a?o de su implementacion.153 Estos hallazgos representan una reduccion de 1 muerte por suicidio por cada 100 de 10 a 24 a?os, la prevencion de aproximadamente 237 muertes en ese grupo de edad. entre el 2007 el 2010. Los condados que implementaron Ias actividades del programa GL5 tambi?n tuvieron tasas de intentos de suicidio signi?cativamente menores entre losjovenes de 16 a 23 a?os al a?o siguiente de la implementation que otros condados similares que no implementaron estas actividades (4.9 menos intentos por cada Mas de 7?9 000 intentos de suicidio podrian haberse prevenido durante el periodo de analisis. lntervencir?m en crisis. Las lineas de ayuda para la prevencion del suicidio son una forma de brindar intervenciones en crisis. En una evaluacion sobre la e?cacia de la Red Nacionai ole Prevencidn deiSuicia?io en prevenir suicldios. 1085 personas suicidas que llamaron a esta linea completaron una evaluacion estandar de riesgo de suicidio 380 de ellas completaron una evaluacion de. seguimiento entre 1 52 dies despu?s de la evaluaci?n inicial (mediana =13.5 dias}. Los investigadores hallaron que mas de la mitad de Ias personas de la muestra inlcial estaban seriamente considerando suicidarse cuando llamaron que tenian on plan para llevarlo a cabo. Los investigadores tambi?n hallaron que entre los participantes del seguimiento, hubo una reduccion signi?cativa del dolor sicologico, Ia desesperanza la intencion de morir entre el inicio de la llamada (momento 1) el seguimiento (momento Entre el momento 2 (e1 ?nal de la llamada) el momento 3, el efecto 5e sostuvo en cuanto al dolor sicologico la desesperanza, pero no fue signi?cativo en cuanto a la intention de morir, lo cual parece indicar que se necesita un mayor esfuerzo de acercamiento durante despu?s de la llamada en el caso de las personas con altos niveles de intento de soiucidio.155 Tratamlento para las personas en riesgo de suicidio El programa Mejora del Estado cie AnimoyPrornocion deiAcceso ai Tratamiento Coiaborativo (improving Mood~Promoting Access to Collaborative Treatment, tiene el objetivo de- prevenir el suicidio entre los pacientes mayores de atencion m?dica primaria al reducir Ia ideacion suicida la depresion. El programa iMPACTfacilita Ia formacion de una alianza terap?utica, que es on plan personalizado de tratamiento que incluye Ias preferencias del paciente un seguimiento proactivo (bisemanal durante la fase aguda mensual durante la fase de continuacion) por parte de un administrador de cuidados para la El programa ha demostrado mejorar signi?cativamente la calidad de Vida reducir la de?ciencia funcional, la depresic'm la ideacion suicida de los pacientes durante los 24 meses de seguimiento?s?l-m en comparacion con Ios que recibieron Ios cuidados habituales. El enfoque Evaluacion Manejo Coiaborativos del Riesgo de Suicidio (Collaborative Assessment and Management of Suicidaiity, CAMS) es un enfoque terap?utico para la evaluacion el tratamiento especi?cos del suicidio. El enfoque ?exible del programa se puede usar en todos Ios entornos de tratamiento independientemente de la orientacion teorica del m?dico implica que este el paciente trabajanjuntos en un proceso de evaluacion interactivo a ?n de crear on plan de tratamiento particular para paciente. Las sesiones son colaborativas involucran una contribucion constante por parte del paciente sobre lo que le esta funcionando lo que no, con el objetivo ?nal de mejorar Ia alianza terap?utica aumentar la motivacion del paciente suicida para recibir tratamiento. El programa CAMS ha sido probado respaldado en 6 estudios correlacionales.W1 en una variedad de entornos ambulatorios de internacion, en un estudio aleatorizado controlado otros adicionales que est?n en curso. Un estudio de viabllidad realizado con una muestra comunitaria de pacientes suicidas asignados aleatoriamente a1 programa CAMS a un cuidado habitual mejorado [ingreso con un siquiatra una enfermera especializada en siquiatrica seguido de 1-11 visitas con un administrador de casos medicamentos, sengn sea necesario) se hallo una mejor retencion del tratamiento entre los del grupo CAMS mejoras signi?cativas en cuanto a la ideacion suicida, Ios slntomas generales de sufrimiento emocional el sentimiento de desesperanza en el seguimiento de los 12 meses.153 main del middle: Paqm I?mlm d! polities. programs! pristine Otros ejemplos incluyen la terapia dial?ctica conductuai por sus sigias en ingl?s) la terapia familiar basada en ei apego porsus sigias en ingl?s). La terapia dial?ctica conductual es una terapia multicomponente para personas que est?n en alto riesgo de suicidio que podrian tener di?cultades con la impulsividad con la regulacion emotional. Los componentes de esta terapia incluyen terapia individual, capacitacion en destrezas grupal, instruccion telefonica entre sesiones un equipo ole terapeutas para la consulta. En un estudio controlado aleatorizado de mujeres que habian tenido recientemente un comportamiento suicida de autoda?o, aquellas que recibieron terapia diai?ctica conductuai tuvieron Ia mitad de Ias probabilidades de tener un intento de suicidio en El seguimiento de los dos a?os que aquellas que recibieron el tratamiento comunitario (23 comparado con 46 requirieron menos hospitalization por ideacion suicida tuvieron menor riesgo m?dico respecto de todos los intentos de suicidio actos de autoda?o combinados.'59 La terapia familiar basada en el apego es un programa para adolescentes de 12 a TB a?os que tiene el objetivo de tratar el trastorno depresivo mayor clinicamente diagnosticado, eliminar la ideacion suicida reducir Ia ansiedad dispositional?m En un estudio controlado aleatorizado sobre la terapia familiar basada en el apego 5e hallo que los adolescentes suicidas asignados a esta terapia tuvieron una mejora signi?cativamente mas alta en cuanto a la ideacion suicida en Ias 24 semanas de seguimiento que aquellos asignados a una terapia habitual mejorada. Asimismo, un porcentaje signi?cativamente mas alto de participantes que recibia Ia terapia familiar basaa'a en er' apego reporto no haber tenido ideacion suicida la semana anterior a la evaluation de Ias 12 semanas en comparacion con los adolescentes que recibieron un cuidado habitual mejorado (69.2 ?xi: comparado con 34.6 3! a Ias 24 semanas (82.1 comparado con 46.2 El proyecto Traduccion de initiativas para ia Depresiari en Solucianes E?caces (Transiating initiatives for Depression into Effective Solutions, usa un enlace de cuidados para la depresion para vincular la atencion m?dica primaria con los servicios de salud mental. Este enlace de cuidados para la depresi?n evalt?ra educa a los pacientes, hace seguimiento tanto con los pacientes como con los proveedores entre las visitas de atencion m?dica primaria a ?n de optimizar el tratamiento. Estos cuidados colaborativos aumentan Ia e?cacia de la forma de proportionar Ios servicios de salud mental al insertarlos en el entorno de atencion m?dica primaria, donde se detectan originalmente muchas afecciones mentales luego se tratan, en el caso de la mayoria de los pacientes. En una evaluation del proyecto se hallo una reduccion signi?cativa en los puntajes de gravedad de la depresion en el 70 de los pacientes de atencion m?dica prirnaria.1E1 L05 paclentes tratados con el enfoque tambi?n demostraron cumplirniento con la toma de los medicamentos Ias visitas de seguimiento en un 85 95 respectivamente.?5' Tratamiento para prevenir I05 nuevos intentos. Hay varias estrategias que apuntan a prevenir los nuevos intentos, que han demostrado tener un impacto en la reduccion de las muertes por suicidio. Por ejemplo, el programa intervention Brave en Sal'a ale Emergencia con Visitas ale Segaimiento {Emergency Department Brief intervention with Foiiow?up Visits) implica una sesion informativa de una hora al momento del alta hospitalaria, que aborda la ideacion suicida intentos de suicidio, el sufrimiento emotional, Ios factores de riesgo de suicidio de proteccion contra ei suicidio, alternativas al autoda?o opciones de remisiones combinada con contactos de seguimiento a lo largo de 18 meses [en las semanas 1, 2, 4, 2' 11, los meses 4, 6, 12 18). Los contactos de seguimiento 5e hacen por tel?fono mediante visitas domiciliarias, seg?n el esquema especi?co, por hasta 18 meses. En un estudio controlado aleatorizado que inscribio a personas que habian intentado suicidarse, en ocho salas de emergencia hospitalarias, en cinco paises (Brasil, India, Sri Lanka, Iran China) se hallo que proportionar una breve intervencion, seguida de nueve visitas de seguimiento a lo largo de 18 meses, se asocio a una cantidad signi?cativamente menor de muertes por suicidio en comparacion con e1 grupo del tratamiento habitual (0.2 We comparado con 2.2 Otro ejemplo de tratamiento para la prevencion de nuevos intentos implica enfoques ale contactas a?e seguimiento activos como enviartarjetas postales cartas hacer llamadastelefonicas a ?n de incrementar Ia sensacion de conexion del paciente con los proveedores de atencion medica reducir su aislamiento.151 Estos enfoques induyen Ia expresion cle apoyo inter?s por el bienestar de la persona generalmente invitan a los pacientes a reconectarse con su proveedor. Los contactos se hacen de rnanera periodica (par ejemplo, mensualmente cada tantos meses en los primeros 12 meses posteriores al alta; algunos de los programas continuan Ios contactos durante dos a?os mas). En los metanalisis realizados por Inagaki et all? 5e hallo que las intervenciones para la prevention de los nuevos intentos de suicidio en los pacientes admitidos a una sala de emergencias por intento de suicidio redujeron los nuevos intentos en aproximadamente el 17 durante hasta los 12 meses posteriores al alta; sin embargo, Ios efectos de estos enfoques en midrib: Paquexet?mm do pnlitlm. progrmasy prinitas los nuevos intentos mas alla de los 12 moses no han sido evaluados Ade-mas, debido a que tanto la cantidad do ensayos incluidos en este metanalisis como el tama?o de las muestras relationadas fueron reducidos, no fue posible determinar el efecto que tuvieron sobre el suicidio Ios enfoques de contacto seguimiento activos. En un estudio controlado aleatorizado sobre el enfoque de contactos seguimiento a largo plazo para la prevention poscrisis del suicidio, Motto and Bostrom??i" hallaron qua Ios pacientes que no aceptaron cuidados continuos, pero que fueron aleatorizados para ser contactados por carta cuatro veces al a?o mostraron tasas de suicidio menores durante Ios dos a?os de seguimiento qua aquellos del grupo de control que no recibieron estos contactos adicionales. Otros estudios tambi?n han mostrado que Ias cartas poscrisis Ias tarjetas de superacion tie-nan un efecto de proteccion contra Ia ideacion suicida Ios intentos de suicidio.?54' ?55 Por ultimo, el enfoque de terapio cognitive conductuol para la prevencidn o'el suicidio por sus sigl'as en ingl?s) es un ejemplo de enfoque terap?utico para la prevention de nuevos intentos. Usa un enfoque de reduccion del riesgo do prevencion de recaidas que incluye el analisis de Ios factores ole riesgo proximales los factores estresantes (por ejemplo, Ios problemas en las relaciones, Ias di?cultades relacionadas con la escuela 0 el trabajol anteriores posteriores al intento de suicidio: la creacion de on plan de seguridad; desarrollo de destrezas education sicologica. La terapia asimismo contiene modulos de destrezas familiares que se centran en el apoyo Ios patrones de comunicacion familiar, en mejorar las destrezas de resolucion de problemas de la familia. En un estudio controlado aleatorizado sobre este enfoque se hallo que. en comparacion con el tratamiento habitual, Ia terapia cognitiva de 10 sesiones ambulatorias dise?ada para prevenir la repeticion de I05 intentos de suicidio mostro una reduccion del 50 0/0 en la probabilidad de- nuevos intentos de suicidio entre los adultos que habian sido admitidos a una sala de emergencias por un intento de suicidioff?? . Hay varias A estrategias que 5 . - apuntan a prevenir [as a nuevosintentos, que han if demostmdo tener an impacto en la reducci?n 1' delas muertes 3.. ?l . par suicidiaPmen??n del suicidio: Parquet: t?mim do pray man pr?dicas 39 A ,1 Reducir Ios da?os prevenir el riesgo futuro Fundamento En Ios Estados Unidos 3: on El rosto dol mundo, cada a?o millonos do porsonas sufron ol duolo causado por un soicidio.5 So ha mostrado que ol riesgo los factoros do riesgo do suicidio aumontan ontro Ias porsonas quo han sufrido Ia p?rdida do un amigo persona do so grupo, familiar, compa?oro do trabajo otro contacto corcano a causa do! suicidio.?5? Por lo tanto. es muy importanto brindarlos cuidado atoncion a ostas porsonas quo ostan on duolo. A posar do las buonas intoncionos, frocuontomonto la rospuosta do Ios modios do otros puodo aumontar osto riosgo. Por ojemplo, las invostigacionos muostran quo Ia exposition al informo sonsacionalizado dosinformado do on suicidio puodo aumontar ol riesgo do suicidio ontro Ias porsonas vulnorablos puodo contribuir involuntariamonte a lo quo so donomina suicidio por imitacion contagio??gw '59 Enfoques Algunos do 105 onfoquos one so puodon usar para roducir ol dar'ro 3; ol futuro riesgo do suicidio incluyon Ia intorvoncion posterior ol informo difusion do monsajos soguros tras ol suicidio. lntorvoncionos posterioros. Son onfoquos quo so implomontan despu?s do quo haya ocurrido un suicidio puodon incluir sosionos do comontario, consojoria on grupo do apoyo para ol dLJiolor para Ios amigos, familiaros otros contactos corcanos sobroviviontos. Por Io general, no so ha ovaluado ol impacto do ostos programas sobro ol suicidio, Ios intontos do suicidio ni Ia idoacion suicida, poro puodon roducir Ia culpa dol sobrovivionto, Ios sontimiontos do doprosion 3! ol duolo complicado.1m lnformo monsajes soguros on relation can ol suicidio. La forma on quo so comunica information sobro un suicidio rocionto al p?blico [por ojomplo, on una asambloa oscolar, Ios modios do comunicacion on masa, Ios modios socialos} puodo incrementar o1 riesgo do suicidio ontro Ias porsonas vulnerablos contribuir involuntariamento al suicidio por imitation. Los informos quo incluyen monsajes do prevention dol suicidio, historias do osporanza rosiliencia. factoros do riesgo protoccion, onlacos a rocursos do ayuda (por ojomplo, linoas do ayuda), quo ovitan sonsacionalizar ol ovonto roducir su causa a un solo factor, poodon ayudar a roducir Ia probabilidad do suicidio por imitativfm.?1 Resultados potenciales - Roduccion on Ia idoacion suicida - Roduccion on Ios intontos do suicidio - Roduccion on Ias tasas do suicidio - Roduccion on ol sufrimionto sicologico - Mojoras on ol informo tras ol suicidio Roduccion on ol ofocto do imitation rolacionado con ol suicidio Evidencia La evidencia actual sugiere que las interventiones posteriores el informe mensajes seguros pueden afectar Ios factores cle riesgo de suicidio de proteccion contra el suicidio. lntervencion posterior. Un ejemplo de programa de intervencion posterior con evidencia de efecto sobre Ios factores de riesgo de suicidio cle proteccion contra el suicidio es el Servicio de Respuesta StandBy {o solo StondB? segtin su obrew'ocion). StandBy brinda apoyo de acercamiento telefonico presencial a los clientes mediante un equipo profesional de respuesta a crisis. Los coordinadores del sitio crean planes personalizados de administracion de casos, en Ios que se remite a Ios clientes a otros servicios existentes de la comunidad segt?rn sus necesidades?n En un estudio realizado por Visser, Comans Scu??ham,W2 Ios clientes que estaban en el grupo de StondBy tuvieron probabilidades signi?cativamente menores cle estar en alto riesgo de suicidio [ideacion suicida intentos de suicidio) tuvieron menos sufrimiento sicologico que los que estaban en el grupo de duelo ole control, que no habian tenido contacto con el programa Stond??y (48 64 respectivamente}. Asimismo, las investigaciones parecen indicar que los enfoques de intervention posterior activa, en Ios que el acercamiento a los sobrevivientes del suicidio ocurre en el Iugar del suceso, se asocian aI inicio mas pronto clel tratamiento, mayor asistencia a reuniones de grupos de apoyo asistencia a mas reuniones, en comparacion con la intervention posterior pasiva (0 sea, Ios enfoques en Ios que los sobrevivientes se autorremiten para recibir Informe mensajes seguros en relaciOn con ei suicidio. Una forma de asegurar que se informe de manera segura se difundan mensajes seguros sobre el suicidio es animar a los medios noticiosos a adherirse a Ias Recomendaciones para reporter el La evidencia mas persuasive que respalda estas recomendaciones para el informe de suicidios proviene de AustriaTras un marcado aurnento en la cantidad de suicidios en el tren subterraneo de Viena, se incorporaron pautas para los medios se use on dise?o de series temporales interrumpidas para evaluar el efecto de Ias pautas a nivel nacional en Ios suicidios subsiguientes. Debido a Ios cambios en la calidad la cantidad de Ios informes noticiosos hubo una reduccion signi?cativa de 81 suicidios al a?o a nivel Por Ultimo. Ias investigaciones parecen indicar no solo que informar sobre Ios suicidios de una manera negativa (por ejemplo, informar sobre Ios mitos relativos al suicidio la repeticion) tiene efectos negatives respecto al suicidio, sino tambi?n que informar sobre Ias destrezas de superaci?n ante la adversidad puede rnostrar efectos protectores contra el suicidio.?4 Informar sobre la ideacion suicida sola {sin informar sobre un suicidio intento de suicidio) conjuntamente con la descripcion def "dominio"que se tuvo sobre one situation de crisis en la que se superaron Ias adversidades se asocio a una reduccion signi?cativa en las tasas de suicidio durante eI periodo inmediatamente posterior a tal la: intervenciones posteriores, e! informe ylos mensajes a - seguros pueden in?uir en Ios factore?s de riesgo de suicidio de proteco'?n contra el suicidio. a Prevend?n delrsuiddio: Paquate?mimdepulf??as Pms?wt'nridiw Participaci?n de los sectores El sector de salud pL'iblica puede cumplir una funcion importante {mica para abordar el suicidio. Las agencias de salud plilblica, que generalmente colocan la prevencion al frente de sus esfuerzos trabajan para lograr un amplio efecto a nivel poblacional, pueden aportar liderazgo recursos criticos para abordar este problema. Estas agencias pueden, por ejemplo, actuar como medios para la convocacic'in reunion de las organizaciones socias las partes interesadas a ?n de plani?car, priorizar coordinar los esfuerzos de prevencion del suicidio. Asimismo, Ias agencias de salud p?blica se encuentran bien posicionadas para recoger difundir datos, implementar medidas preventivas, evaluar programas hacer seguimiento del progreso. Si bien el sector de salud p?blica puede cumplir una funcion de liderazgo en la prevencion del suicidio, Ias estrategias enfoques descritos en este paquete t?cnico no se pueden lograr a trav?s de este sector solo. Seg?n se menciona en la Estrategr?o Nacional para fa Prevencicin delSuicidr'o,? Ia integracion coordinacion de las actividades de prevencion en todos los sectores entornos son esenciales para ampliar el alcance el efecto de los esfuerzos de prevencion del suicidio. Otros sectores que son vitales para la implementation de este paquete incluyen, entre otros, a los sectores de educacion, gobiemo (local, estatal federal), servicios sociales, servicios de salud, comercio, trabajo,justicia, vivienda, medios de comunicacion a las organizaciones que conforman al sector de la sociedad civil, como Ias organizaciones religiosas, Ias organizacionesjuveniles, las fundaciones otras organizaciones no gubernamentaies. De forma colectiva, estas organizaciones pueden lograr una diferencia en la prevencion del suicidio al afectar los diversos contextos riesgos subvacentes que contribuyen al suicidio. Las estrategias enfoques descritos en este paquete t?cnico se resume-n en el Ap?ndicejunto con los sectores relevantes que se encuentran bien posicionados para liderar los esfuerzos de implementacion. Por ejemplo, ei sector comercio trabajo. el cle salud [incluidas las compa?ias aseguradoras, los proveedores los sistemas de salud), asi como Ias entidades gubernamentales estan en la mejor posicic'in para implementar los programas las politicas que sirven para el Fortoiecimr'ento de los opoyos econdmicos el Fortalecimfen to dei acceso a los cuidados relocr'onodos con el suicidr'o de su prestocidn. Estos tipos de apoyos van mas alla del cambio de comportamiento individual requieren del compromise apoyo de aquellos sectores que pueden abordar directamente algunos de los riesgos subyacentes contextos ambientales que aumentan el riesgo de suicidio. Las entidades de salud pL?iblica pueden cumplir un papal importante al reunir sintetizar informacion que sirve para conformar politicas, crear conciencia evaluar la e?cacia de diversas politicas. Mas aL?m, la alianza con organizaciones no gubernamentales comunitarias puede ser instrumental para conseguir respaldo para las politicas que afectan a las personas las familias crear conciencia sobre estas politicas. El sector de salud p?blica ha estado a la vanguardia de muchos esfuerzos de prevencion basados en la comunidad ha estado trabajando colaborativamente con organizaciones escolares comunitarias para cambiar Ias normas sociales in?uir en el comportamiento relacionado con la salud de manera positiva. El sector de salud priblica es muy adecuado para tomar un rol de liderazgo similar para Promoveria conexr'dn a trav?s de actividades que favorecen el cambio en Ias normas de los semejantes motivan la participacion en la comunidad, para apoyar el desarrollo, la evaluacion la adopcion de programas e?caces para la Ense?onza de destrezos de superacidn resolucion de problemas a ?n de prevenir el ries?go de suicidio en primer lugar. Estos programas generalmente 5e imparten en entornos escolares comunitarios, lo cual hace que las organizaciones educativas no gubernamentales sean socios vitales para la prevention. Por otro Iado, Ias empresas, los lugares de trabajo las entidades locales estatales son quienes estan en mejor posicic?m para establecer politicas respaldar Ias practicas que sirven para Crearambienres protectores en los lugares donde las personas viven, trabajan se entretienen. Las entidades de salud pUinca pueden cumplir una funcion importante al reunir sintetizar informacion, trabajar con otras agencias gubernamentales [por ejemplo,justicia penal, defensa) agencias dentro del poder ejecutivo de su gobierno estatal 0 local para apoyar politicas otros enfoques, evaluar la e?cacia de las medidas tomadas. De manera similar, Ias enticlades de salud p?blica pueden aliarse con escuelas, lugares de trabajo organizaciones comunitarias para implementar evaluar los programas, practices politicas de prevenci?n que apuntan a crear ambientes de apoyo seguros saludables. mean del middle: Paqm I?mlm d: polities. pngranusy martin; ?3 Por L?rltimo, en este paquete 5e incluye un mimero de intervenciones que se pueden impartir en entornos hospitalarios, de atenci?n m?dica primaria, de cuidado de la salud mental comunitarios para la ldenti?cacr?dn de las personas en riesgo yprovr?sicin de apoyo. Las actividades intensidad de muchas cie estas intervenciones requieren la experiencia de profesionales que cuenten con licencia est?n capacitados para administrar apoyo critico de intervenci?n. L05 sectores de salud, servicios sociales yjusticia pueden trabajar colaborativamente para apoyar a las personas que est?n en alto riesgo de suicidio a sus familias. Estas actividades requieren, asimismo, que se coordinen los appyos entre varios proveedores de servicios prganizaciones comunitarias. lndependientemente de la estrategia que se use, 5e necesitara la acci?n de muchos sectores para que se logre la implementaci?n exitosa de este paquete t?cnico. En este sentido, todos los sectores pueden cumplir un papel importante in?uyente para prevenir el suicidio en primer lugar reducir el da?p inmediato a largo plaza de los comportamientos suicidas al ayudar a aqua-H05 que est?n pasandp por un momenta de crisis a recibir los servicios el apoyo que necesitan. Todos Ios sectares pueden tener un papal importan te in?uyente en la pre vencio?n del suicidio. Monitoreo evaluaci?n El monitoreo la evaluation son componentes necesarios del enfoque de salud pl?Jblica para la prevencion. E5 importante tener datos oportunos con?ables para monitorear el alcance del problema evaluar el efecto de los esfuerzos de prevention. Estos datos tambien son necesarios para la plani?cacion implementation de Ios esfuerzos de prevention, 3; es importante que se re?nan de manera continua sistematica. Sin embargo, tambi?n es importante que se re?nan datos que sean uniformes coherentes entre todos Ios sistemas. Tener datos coherentes les permite a la salud pL'Jblica a otras entidades poder medir mejor el alcance del problema, identi?car a Ios grupos en alto riesgo monitorear los efectos de los programas las politicas de prevencion. En este momento es com?n que Ios distintos sectores, agendas organizaciones empleen diferentes de?nitiones de ideacionn suicida, comportamiento suicida muerte por suicidio, lo cual puede hacer que sea diflcil monitorear uniformemente determinados criterios de valoracion a lo largo del tiempo en los distintos sectores. Por ejemplo, la forma en que se clasi?can las muertes puede cambiar de una jurisdiccion a la otra, puede cambiar seg?n estandares rn?dicos m?dico-legales locales.4 Al ofrecer de?niciones uniformes recomendaciones en cuanto a los datos sobre la violencia autoin?igida que se deben recoger, Ios CDC proportionan un marco que ayuda a garantizar que los datos se recojan de manera uniforme en todos los sistemas de Existen sistemas de vigilancia a nivel federal, estatal local. Es importante evaluar la disponibilidad de datos de vigilancia de sistemas de datos en todos estos niveles para identi?car abordar las brechas que haya en estos sistemas. El Sistema National de Estadr'str'cos Vitoles (NVSS, porsus sigr'os en ingl?s)? de Ios CDC el Sistema National de Noti?cation de Muertes Violentas son ejernplos de sistemas de Vigilancia que proportionan datos sobre las muertes por suicidio. NVSS es un sistema de vigilancia en todo el pals que recoge datos demogra?cos, geogra?cos sobre las causas de muerte que aparecen en Ios certi?cados de defunci?n? es un sistema de vigilancia a nivel estatal (actualmente en 40 estados, el Distrito de Columbia Puerto Rico) que combina los datos de Ios certi?cados de defuncion. informes policiales informes de funclonarios m?dicos forenses a ?n ole proveer information detallada sobre las circunstancias de las muertes violentas. incluido el suicidio, que pueden ayudar a las comunidades a guiar Ios enfoques para la prevencic?nrn.?5 Los datos del Equipo de Revision de Muertes lnfantiles??5 3; del Equipo de Revision de Muertes por Suicidio (que hay en varios estados) ofrecen otro recurso para identi?car las muertes obtener conocimientos acerca de los vacu?os en los servicios, los sistemas Ios factores de riesgo de suicidio modi?cables. Frauen thin del snicidio: Paquete t?cnico do politicas. programs If prinicas El Pregromo de Seguimiento de Tedos los Lesiones del Sistemo Electr?nico Nocienal de Vigilancie de Lesiones porsus siglas en ingl?s) proporciena dates representatives 3 nivel nacienal sebre todes los tipos 3: causes de lesienes no mortales tretadas en sales de emergencia en hospitales estadeunidenses, puede userse para evaluar Ias tasas tendencies a nivel nacional de lesienes autein?ingidas, por causa (per ejemplo, caidas, envenenamiento, etc), edad, raza erigen ?tnice, sexe, dispesicien (deride VB la persona lesionada cuando se le da el alta de la sale de Adema?s de infermacien sebre Ias muertes Ias lesienes no mortales, algunes sistemas de vigilancia tambie?n preporcionan estimados nacionales, estatales algunos locales sobre el comportamiento suicide. El Sistemo de ngloncia de los Comportomientos de Riesgo en los Jovenes recoge infermacien sobre una muestra representative a nivel nacienal de estudiantes de a 1.2.0 grade es un recurso clave para el monitoree de cempertamientes de riesge para la salud entre lesjevenes, incluse de si han censiderade seriamente suicidarse, si han intentade suicidarse, hecho planes para suicidarse necesitede el tretamiente de un rn?dico enfermera por un intente de suicidie cuye resultade haya side one lesion, envenenamiente sebredesis.?" Les dates del se ebtienen a partir de une encuesta nacienel esceler realizada per los CDC de encuestes realizadas per agencies de salud educacienales nivel estetal, territorial tribal, en distrites escelares urbanes LaEncuesto Noci'enel sobre el Consume de Dregas la Salad (NSDUHJW es una encuesta anual de la poblacien civil no internada en una institucien, de 12 a?es mayor. La NSDUH preporciona estimationes tante a nivel nacienal come estatal sobre el consume de sustancias (alcohol, tabace, dregas ilegales use no m?dico de medicamentos recetades); la salud mental (enfermedad mental en el a?e anterior, enferrnedades concomitantes); la utilizacien de servicios,junto con ideacion suicide, planes de suicidarse intentes de suicidie. Esta encuesta es un recurso clave para hacer seguirniente de las tendencies de les factores de riesgo relecienades con el suicidie en la poblecion ayudar a identi?cer los grupos que est?n en mayor riesge?? Tambi?n es impertante a tedes les niveles (local, estatal federal) para aberdar Ias brechas en la respuesta, hacer seguimiente del progrese de los esfuerzes de prevencien evaluar el efecto de estes esfuerzes, incluse de este paquete t?cnice. Les dates de Ias eveluacienes, que resulten de la implementacien el monitoree de los pregramas, sen esenciales pare informer sebre lo que funciona lo que no funciena para la reduccion de las tasas de suicidio respecte de les factores de riesge de preteccien relecienades. Las teorias del cambie los medeles legicos que identi?can resultados a certo, mediano 3; large plazo sen une parte importante de la evaluacien de les pregramas. La base de evidencie para la prevencien del suicidio he avanzede sustancialmente en Ias ?ltimas decades. Sin embargo, 5e necesita hacer investigacien adicienal para entender el efecte que tienen los pregramas, practices 3; peliticas sobre el suicidie (y los intentos de suicidio, come minime} en contraposicien con meramente examiner la e?cacia que tienen respecte de los factores de riesge.Tambi?n se necesiten mas investigacienes para examiner Ia e?cacia de las estrategias de prevencitjn primaria {antes de que ecurra el riesgel de las estrategias a nivel cemunitario para la prevencien del suicidie a nivel peblacienal. Sera importante que los investigedores estudien la e?cacia de distintas combinacienes de las estrategias enfoques incluides en este paquete. La mayeria de las evaluecienes existentes se centran en enfeques que han side implementades de manere aislade, pere existe el petencial de entender los efectes sin?rgices que tienen dentre de un enfeque de prevencien integral. Per Liltime, tembi?n hey muchas eportunidades petenciales para construir fortalecer la celaberacien entre las distintas areas progrematices (per ejemple, prevencien de la uielencia, prevencien del abuse de sustancias) a ?n de evaluar el efecto que tienen los distintes enfeques sebre diverses criteries de 1iraloracir?n. Pumdlin-Ilel middle: Paquexet?mlm do politics. program-15y prit?cas Conclusi?n El suicidie es un preblema de salud pL?iblica grave. Las tasas de suicide han estade aumentande per mas de una d?cada Ies cestes alcanzan facilmente les miles de millenes de delares cada a?e. Si bien el suicidie es un resultade estadisticamente rare, tiene un impacte humane cen un efecte demine de prefunde alcance. Es probable que cada une de nesetres interact?e cen sebrevivientes de suicidie ?persenas que han pasade per la experiencia persenas que piensan a diarie en el suicidie?, ya sea en nuestre hegar, lugar de trabaje cemunidad. El suicidie Ies intentes de suicidie sen preblemas de salud publica que preecupan a la seciedad. Hay un numere de barreras que han impedide e pregrese. Estas incluyen, per ejemple, el estigma relacienade cen la bL?Isqueda de ayuda, Ia enfermedad mental el heche de ser sebreviviente; tambien incluyen el temer relacienade cen preguntarle a alguien sebre les pensamientes suicidas. Afertunadamente, al igual que muches preblemas de salud piliblica, el suicidie es prevenible?-E? se esta haciende mas al respecte ahera que nunca, segdn queda evidenciade per el trabaje de la Alianza National de Accien para la Prevencien del la publicacien del primer inferme mundial sobre el suicidie5 la ebtencien de dates de vigilancia ma?s epertunes, entre etres. En un esfuerze per seguir impulsande el campe de trabaje la seciedad mas hacia la prevencien, este paquete t?cnice incluye estrategias enfeques que se usarian idealmente de manera integral, multisecterial en niveles meltiples. Incluye estrategias enfeques que previenen eI riesge de suicidie en primer Iugar, asl? ceme estrategias centradas en reducir les da?es inmediates a large plaze del cempertamiente suicida.Tambie?n incluye estrategias que varian, desde enfeques que abarcan a la peblacien entera independientemente de su nivel de riesge. a estrategias cuye ebjetive es apeyar a Ias personas que tienen el mayer riesge. Este paquete t?cnice fundamentalmente extiende les limites de Ias estrategias tipicas de prevencien tiene en cuenta les enfeques que van mas alla del cambie del cempertamiente individual, a ?n de aberdar mejer les facteres de riesge que afectan a Ias cemunidades peblacienes de manera mas generalizada {per ejemple, peliticas ecenemicas para fertalecer Ia seguridad de vivienda ?nanciera). Mientras la base de evidencias sigue a?erande, Ia celeccien de pregramas, peliticas practicas que se delinean aqui estan dispenibles en este memente para ser implementadas. Cenferme cen Ia buena practica de salud publica, el ebjetive es que el meniteree la evaluacien cumplan un papel impertante en esa implementacien. Asimisme, a medida que haya mas evidencia dispenible, este paquete te?cnice pedra re?narse para que refleje el estade cerriente de la ciencia. Para terminar. de acuerde con el mensaje cle resiliencia expresade per aquelles que han vivide esta experiencia, "la esperanza, Ia ayuda la sanacien sen pesibles". ?la esperanza, Ia ayuda la sanaa'a?n son posibles": . .1 I I Preventi?n del marlin: Parquet: t?aiigo da politic-15,. pang rallies ?radius Referencias 11. 12. 13. 14. 15. 16. 18. 19. 20. U.S. Of?ce of the Surgeon General, National Action Alliance for Suicide Prevention. 2012 Nationalstrategy lorsuicicle prevention: goals and objectives for action. Washington, D.C.: 2012. National Action Alliance for Suicide Prevention. Action Alliance priorities. 201?; Frieden TR. Six components necessary for effective public health program implementation. 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Otrasfactures Enfoque a programa, de suicidio rig-ago ?19 Sectores Practica a politica Suicidio ideaci?n Side prindpales? 5:0be Bi pro aruon . . . contra el suicidio Estrategia Fortalacimiento de la sag uridad ?nanciera del hngar Dbierno {local Programas da bene?cr'os por desempreo astatal, fade-ran Comercio?trabajo Fortalecimiento de 105 econ?micns Otros apoyos (ingresos) v" Polititas para la astabilidad de vivienda Gobierno (local; Programa de Estabr'h?zacicin Vecinau? I v" estatal, federal} Cobartura de afecciones mentales en las p?lizas de seguro m?dico Fortalerimiento Leyes de parr'dad de Ia safud manta!l I v/ de acreso a Reducir Ia falta de proveedares en Ias iiraas subatandidas Egg?gf?g?gii? '05 ?mad? Cuerpo Nacr'ona! de Salud ., . relationadas con Atencmn medlca el suitidio 3' de 5? Teresaiud manta! (TMH) prestaci?n Cuidadas mas seguros con rela cic'rn al suicidio mediante camhius a nivel de sistema SEMCIOS Arencidn Perfecm de la Depresi?n Henry Ford {precursora de Caro Suicidios} 1/ 1/ Reducd?n del acceso a medias letales entre las personas en riesgo de suicidio Gobierno (local, Interyanaion es en {05 Iugares propr'cr'os para v, estatal, federal} e! de afm acenamr'ento seguro Salud pdblica Consqien?a en Sara de Em ergencr'as sabre e! Atenci?n ?di ca Acceso a Medias Leral'es 1? ED CALM) {reaci?n de . - - - ambientes PolitIcas cultura a nwel de Organization Comercioltrabajo Junta; par la Vida Prutect?res .. . Justicia Program-:2 de Pre vencron def de fr: Fuarza Aerea {re-?05 EE. UU. Gobierno (local, Prevencron def en tantra; estatal, federai} correccionafes Politicas basadas en la comunidad para redutir el consume excesivo de alcohol GDbiernO Regufacr'?n de la densidad de has Fug ares de v, estatal] venfa de (1:50:10; Comerclor'trabajo Prograrnas de normas de semeja rites Salud public-a Fomento de la ?fem? Fortaleza u/ Educacic?m cunexi?n Actividades da participaci?n en la comunidad Salud p?blica Enverdecr?mr'enro de dram urbane: vacantes Gobierno {Local} ?Esta columna hate referencia a los sectores principales que se encuentran bier: posicionados para traer liderazgo recursos a Ios esfuerzos de implementaci?n. Para cada estrategia, hay muchos otros sect-ares, como el de organizaciones no gubernamentales, que son asenciales para la plani?cacic?m de la prevenci?n Ia implementaci?n de actividades programaticas especi?cas. Pravend?n del suiu'dio: Paquete t?mim de pulitiras, y'prictitas Mejor evidencia disponihle Intentas OJror. farm?" . Enfoque program-a. de suicidio Sectures strategla . - - . . . . ., smadm 0 de - - 1 tact-ca ope Itlca Suladle eldeaaon .. pnnopa as to emun sabre ei . . . contra el suladm suicidie Programas ele educaci?n soda-emulanal - Salud publlca Ensenanza (IE Jdvenes Conscientes data Safad Manta! Educaci?n de Jaego def Buea Compartamienta superman . . . [admit-m d8 Enfnques de destrezas de crlanza relacmnes famrlrares Salad publica problemas Ari-05 tncrer'btes Educacian Fortatecrmrenta as tas Fammas. Til?34 Capacitaci?n del personal de primera Iinea Capacitacr?c?m en Destrezas Apttcadas Salad p?blica de tntervencr?an contra at .. . . Pragrama Garret Lee Smith Mention medlca para ta Preven cr'c'ln def lntenrenci?n en crisis Salud pablica Red National de Prevencian a?e! Suicidr?o v? r/ Servicios sociales Tratamienta para las personas en riesgo de suicidio . Mejara def Estada de Ammo Pramacfan afarr v, Identi?cation d9 Accesa a! Ratamr'enta Cafabarativa (EMPALTJ . . las personas en - . . . Ate-anon medlca . . Evatuacron yManep Cataboratrvas def "?590 3! Riesgo d6 Sui-{Mic Servicing sociales ?15 3905'? Terapia dfat?ctfca canductuat v? Justicia Terapia famifr'ar basada an e! apega (ASH) Traducci?n de r'nr?ciativas para J'a Deprasfdn .r en Sotucr'ones E?caces Tratamientu para prevanir Ios nuevos intentus a In ergeacran reve en :30 a mergenaa I Atencian m?dica can de Sagurmrenta Enfoques de contacts; desegaimfenro actives v? Servicios sociales Terapr'a cagnr?tfva canductua! para ta v? prevencian def sufcidia Intervenci?n posterior . Atencian m?dica Red uclr I05 danos de Resp uesta StandBy el "2590 Informe mensajes segurns en relaci?n eon el suicldio Salud P?blica . . . Medias de para to: medias v" camuni ca ci?n ?Esta columna hace referencia a los sectores principales que se encuentran bier: posictanados para traer liderazgo recursos a los esfuerzos de implementacian. Para cada estrategia, hay muchos otrus sect-ares. como el de urganizaciones no gubernamentales, que son esenciales para la plani?cacian de ia prevenci?n Ia imple mentacian de actividades programaticas especi? cas. Pmend?n del suicidin: Paquete t?mim de polities. programs 1! pridicas 3F Para obtener m?s information Para informarse mas sobre la prevention del suicidio, Ilame al 1-800-CDC-INFO visite ias p?ginas web de los CDC sobre la prevention de violencia en National Center for Iniury Prevention and Control Division of Violence Prevention From: Stone, Deborah Sent: 14 May 2018 02:47:29 +0000 To: Peaker, Brandy Subject: FW: CDC Commentary for a June Vital Signs on Suicide Hi Brandy, I wanted to share this email chain with you in case the VS office wants to work with AJPH in the future. Dr. Morabia was very receptive to a commentary to the VS even though ours didn?t get accepted. Thanks Deb From: American Journal of Public Health Editor Sent: Wednesday, April 25, 2018 6:57 PM To: Stone, Deborah (CDCIONDIEHXNCIPQ Subject: Re: CDC Commentary for a June Vital Signs on Suicide Dear Deb Stone, I am just as disappointed as you are that this did not work out. I will consider other pieces in the future. We may want to prepare them in advance in such a way that they do not fail. Sincerely, Alfredo Morabia, MD, Editor?in-Chief, AJPH ?mitt?er MPH Podcast From: Stone, Deborah (CDCKONDIEHJNCIPC) <2an cdc. ov> Sent: Monday, April 23, 2018 11:43 AM To: American Journal of Public Health Editor Subject: RE: CDC Commentary for a June Vital Signs on Suicide Dear Dr. Morabia, I thank you for your time and consideration. My regrets that the piece was not up to standards. lpian to work with the authors to consider next steps for highlighting the Vital Signs more effectively. Again, I appreciate your consideration and support of the intended outcome. I hope you may consider another commentary linked to a Vital Signs in the future. Sincerely, Deb Stone From: American Journal of Public Health Editor Sent: Sunday, April 22, 2018 6:42 PM To: Stone, Deborah <2an cdc. ov> Subject: Re: CDC Commentary for a June Vital Signs on Suicide Dear Deb Stone, I have discussed the editorial with another editor because I was not convinced it was publishable and the assessment was not positive either. I am very sorry to disappoint you this time. Sincerely, Alfredo Morabia, MD, Editor?in-Chief, AJPH Twitter AJPH Podcast From: Stone, Deborah <2af9@cdc.gov> Sent: Thursday, April 19, 2018 4:41 PM To: American Journal of Public Health Editor Subject: RE: CDC Commentary for a June Vital Signs on Suicide Dear Dr. Morabia, Thank you for your support of our CDC Vital Signs. My colleague, Dr. Eric Caine from the University of Rochester, NY submitted the editorial on April 5th as you requested but to date he has not heard anything back about the status of his submission. I'm attaching the submission here for your convenience. Any guidance you can provide to keep this on release would be so appreciated. track for a June Sincerely, Deb Stone From: American Journal of Public Health Editor Sent: Monday, February 19, 2018 2:56 PM To: Stone, Deborah (CDCIONDIEHXNCIPQ Sent: Thursday, February 15, 2018 11:41 PM To: American Journal of Public Health Editor Subject: Fw: CDC Commentary for a June Vital Signs on Suicide From: Stone, Deborah <2an cdc. ova- Sent: Thursday, February 15, 2018 5:57 PM To: am52@columbia.edu Cc: PreventiveMedicine@qc.cuny.edu Subject: CDC Commentary for a June Vital Signs on Suicide Dear Dr. Morabia, My name is Deb Stone. I?m a behavioral scientist at CDC in the Division ofViolence Prevention. i am leading the publication of a CDC Vital Signs focused on suicide to be released June 5, 2018. Vital Signs, as you may know, began in 2010 and is a high profile CDC publication widely distributed to highlight important public health threats and what can be done to prevent them. The release always includes a web page, an MMWR article, a translation piece fact sheet), science clips, and a telebriefing by the CDC Director with the media. It also often includes a companion commentary piece in a top tier journal, linked on our CDC Vital Signs web site and referenced in the other materials. lam writing to inquire whether AJPH may be interested in collaborating with us to publish such a commentary. The commentary intends to integrate our study findings and the work of one state that is pioneering the first-ever comprehensive community-based public health approach to suicide prevention. I believe that both the Vital Signs article and the journal companion piece will attract a great deal of attention. This is the debut feature on suicide in a Vital Signs and the results are highly compelling and relevant to a wide public health audience {see description below} including states, prevention practitioners, and providers. In addition, the U.S. Surgeon General has also expressed interest in conducting a town hall meeting as part of the wider release. BRIEF DESCRIPTION: Suicide rates have increased nearly 30% between 1999 and 2016. To address this serious and growing problem, the proposed Vital Signs will use data from the National Vital Statistics System 1999-2016) and National Violent Death Reporting System 2015). The trends in suicide rates in the U.S. overall and by state and sex, will be reported for the first time. Changes in state rankings overtime will also be included. To help the reader fully understand and appreciate the multiple factors influencing suicide risk, the report will also compare the many social and environmental circumstances preceding suicide among people with and without known mental health problems. Preventive solutions will be offered that focus on a comprehensive population-based approach using the best available evidence as described in the Suicide Prevention Technical Package. We have selected AJPH as ourjournal of choice for this commentary as we believe its reputation for high quality science and public health prevention most closely aligns with our message and our target audience. We hope that you will partner with us as we forge this exciting territory. For your convenience, here is an example of a relatively recent Vital Signs {on opioidsl and the companion commentary. I look forward to your reply and the opportunity to provide additional information. Sincerely, Deb Stone Deb Stone. Scl}. MPH Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research a Evaluation Branch 4TH) Buford Hig hway. F-E4 Atlanta. GA 30341 detone3@cdc.gov From: Lenard, Courtney Sent: 7 Jun 2018 10:14:12 -0400 To: Houry, Debra E. Amy B. James Thomas Alexander Deborah Kristin Asha Z. Brad Erin Marie R. Valerie M. Malia Elizabeth Jacqueline Arlethia Elizabeth Melissa R. Cc: CDC DNDIEH NCIPC 0C Subject: FW: CDC Press Release: Suicide rates rising across the U.S. *Embargoed Until 1 PM. EDT, Thursday, June 2, 2018* Attachments: Importance: High Signs press release went out this morning. From: Media@cdc.gov (CDC) Sent: Thursday, June 7, 2018 9:02 AM To: Media@cdc.gov (CDC) Subject: CDC Press Release: Suicide rates rising across the U.S. *Embargoed Until 1 HM. EDT, Thursday, June 7, 2018* Importance: High Press Release Embargoed until 1:00 pm ET Thursday. June 7, 2018 Contact: CDC Media Relations 404-639-3286 Suicide rates rising across the US. Comprehensive prevention goes b?v??d ofocos on mental health concerns Suicide rates have been rising in nearly every state, according to the latest Vim! Signs report by the Centers for Disease Control and Prevention (CDC). in 20'l 6, nearly 45,000 Americans age 10 or older died by suicide. Suicide is the .10th leading cause of death and is one of just three leading causes that are on the rise. Suicide is rarely caused by a single factor. Although suicide prevention efforts largely focus on identifying and providing treatment for people with mental health conditions, there are many additional opportunities for prevention. ?Suicide is a leading cause of death for Americans and it's a tragedy for families and communities across the country," said CDC Principal Deputy Director Anne MD. ?From individuals and communities to employers and healthcare professionals, everyone can play a role- in efforts to help save lives and reverse this troubling rise in suicide." Many factors contribute to suicide For this Vital Signs report. CDC researchers examined state-level trends in suicide rates from 1999-2016. In addition, they used 2015 data from National Violent Death Reporting which covered 27 states, to look at the circumstances of suicide among people with and without known mental health conditions. Researchers found that more than half of people who died by suicide did not have a known diagnosed mental health condition at the time of death. Relationship problems or loss, substance miSuse; physical health problems; and job, money, legal or hensing stress often contributed to risk for suicide. Firearms were the most common method of suicide used by those with and without a known diagnosed mental health. condition. State suicide rates vary widely The most recent overall suicide rates (2014-2016) varied four-fold; from 6.9 per 100,000 residents per year in Washington, DC. to 29.2 per 100,000 residents in Montana. Across the study period, rates increased in nearly all states. Percentage increases in suicide rates ranged from just under 6 percent in Delaware to over 57 percent in North Dakota. Twenty-five states had suicide rate increases of more than 30 percent. Wide range of prevention activities needed The report recommends that states take a comprehensive public health approach to suicide prevention and address the range of factors contributing to suicide. This requires coordination and cooperation from every sector of society: govemment, public health, healthcare, employers, education, media and community organizations. To help states with this important work, in. 20] 7' CBC released a technical aekage on suicide prevention that describes strategies and approaches based on the best available evidence. This can help inform states and communities as they make decisions about prevention activities and priorities. Everyone can help prevent suicide: I Learn the warning signs of suicide to identify and appropriately respond to people at risk. Find out how this can save a life by visiting: Reduce access to lethal means such as medications and ?rearms among people at risk of suicide. 0 Contact the National Suicide Prevention Lifeline for help: (8255). ht! ps:s?s?suicidcpreventionl i felineoru The media can avoid increasing risk when reporting on suicide by: I Following and sharing recommendations available at (for example, avoiding dramatic headlines or explicit details on suicide methods); I Providing information on suicide warning signs and suicide prevention resources; and I Sharing stories of hope and healing. Vital Sirrns is a CDC report that typically appears on the ?rst Tuesday of the month as pan of the CDC journal Morbiditv and Mortalitv I-t-"eelth: Report. The report provides the latest data and information on key health indicators, and what can be done to drive down these health threats. are US. Department of Health and Human Services CDC works protecting America ?3 health. safety, and security. Whether diseases start at home or abroad, are curable or preventable. chronic or acute, or from human activity or deliberate attack. CDC responds to America ?s most pressing health threats. CDC is headquartered in Atlanta and has experts located throughout the United States and the world. To unsubscribejrom this CDC media listserv. please reply to roll with the email address you would like removed. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Weekly/Vol. 67 i No. 22 June 8, 2018 Vital Signs: Trends in State Suicide Rates United States, 1999?201 6 and Circumstances Contributing to Suicide 27 States, 2015 Deborah M. Stone. 5:th 'l?homas R. Simon l?hDi; Katherine A. Fowler, l?th; Scott R. Kegler, Pth; Keniing Yuan, Kristin M. Holland, Asha Z. hey-Stephenson, I?th; Alex E. Crosby, Abstract Introduction: Suicide rates in the United States have risen nearly 30% since 1999., and mental health conditions are one of several factors contributing to suicide. Examining stateelevel trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. Methods: Trends in age-adjusted suicide rates among persons aged :10 years, by state and sex, across six consecutive 3-year periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data From the National Violent Death Reporting System, covering 27 states in 20! 5, were used to examine contributing circumstances among decedents with and without known mental health conditions. Results: During 1999?20 16, suicide rates moreased signi?cantly in 44 states, with 25 states experiencing mcreases Rates increased significantly among males and females in 34 and 43 states, rmpectively. Fifty-four percent ofdecedents in 27 states in 201 5 did not have a known mental health condition. Among decedents with available information, several circumstances were signi?cantly more likely among those without known mental health conditions than INSIDE among those with mental health conditions, including 625 Invasive Methicillin-Resistant Staphylococcus oureus relationship problemsi'loss (45.1% versus life Infections Among Persons Who Inject Drugs Six Sites, 2005?201 6 629 Tobacco Product Use Among Middle and High School Students United States, 2011?2017 634 Update: Influenza Activity in the United States During stressors (50.5% versus and recent! impending crises (32.9% versus but these circumstances were common across groups. Conclusions: Suicide rates increased significantly the 201??18 Season and Composition ofthe 2018?19 across most states during 1999?2016. Various Influenza Vaccine circumstances contributed to suicides among persons 643 Update: ACIP Recommendations for the Use of With and without known mental health conditions. Quadrivalent Live Attenuated Influenza Vaccine Implications for Public Health Practice: States United Sis??95: 2018?19 Influenza 59350" can use a comprehensivg evidence?based public 646 Notes from the Hemorrhagic health approach to prevent suicide risk before it Fever Outbreak?Central Uganda, August?September occurs, identify and support persons at risk, prevent 201? reattempts, and help friends and family members in 6?48 QuickStats the aftermath of a suicide. Continuing Education examination available at infolitmliiweekly. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Introduction in 2016. nearly 45,000 suicides population [age-adjusted? occurred in the United States among persons aged :10 years From 1999 to 2015. suicide rates increased among both sexes, ail racial/ ethnic groups, and all urbanization levels (2.3). Suicide rates have also increased among persons in all age groups <75 years, with adults aged 45?64 having the largest absolute rate increase (from 13.2 per 100,000 persons [1999] to 19.2 per 100,000 [2016]) and the greatesr number ofsuicides (232,108) during the same period (1.3). Suicide is the tenth leading cause ofdeath and is one ofjust three leading causes that are increasing in addition, rates ofemergency department visits for nonfatal self-harm, a main risk factor for suicide, increased 42% from 2001 to 2016 (1). Together, suicides and self-harm injuries cost the nation approximately $730 billion per year in direct medical and work loss costs if}. The National Strategy for Suicide Prevention calls for a public health approach to suicide prevention with efforts span? ning multiple levels (individual, famiiyfrelationship, community, and societal]. Such a comprehensive approach underscores that suicide is rarely caused by any single factor. but rather, is deter? mined by multiple factors. Despite this call to action, suicide prevention largely focuses on identifying and tefEtring suicidal persons to mental health treatment and preventing reattempts (6). in addition to mental health conditions and prior suicide attempts, other contributing circumstances include social and economic problems, access to lethal means (eg, substances, firearms) among persons at risk, and poor coping and problem- solving skills Expanded awareness of these additional circum- stances contributing to suicide risk and action to address them can be] reach the national goal, established by the National Action Alliance of Suicide Prevention and the American Foundation for Suicide Prevention, of reducing the annual suicide rate 20% by 2025 To assist states in achieving this goal, CDC analyzed state?specific trends in suicide rates and assessed the multiple contributing factors to suicide; this report presents options for strategies to include in comprehensive suicide prevention efi'orts that are based on the best available evidence. Methods Suicide rates were analyzed for persons aged :10 years because determining suicidal intent in younger children can be difficult (8). Ageaspecific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (International Class?imrion ofDireiases, Fitme- Revision, underlying?cause?ofdeath codes ?37.0. Age? specific population estimates were obtained from U.S. Census Bureau/National Center for Health Statistics bridged?race population data releases. National and staterlevel suicide rate estimates were calculated for six consecutive 3?year aggregate periods spanning i999? 2016 (1999?2001; 2002?2004; 2005?2007; 2003?2010; 2011?2013; and 2014-2016). Rate estimates were age- adjusted to the U.S. 2000 standard population and expressed The of publications is published by the Center for Surveillance. Epidemiology, and Laboratory Services. Centers For Disease Control and Prevention US. Department DE Health and Human Services, Atlanta, GA 30329-4027. Suggc?ed citation: [nudist tomes; first three. then ct .1L. if more than steel [Report title]. MMWR Morb Mortal Wkly Rep 2018;67:linc1usive page numbers]. Centers for Disease Control and Prevention Robert R. Redfield, MD, Dir-retal- Annc Schucllat. MD. Principe! Depend Dirmor Leslie Dauphin. Acting Arterial? Diremar?r .S'rz?mcr Joanne Conn. MD. 542M, Dir-emu [wire 43am.- Quality Chesiey L. Richards, MD. MPH. Deputy Public Health Erin-tri?e 5mm: Michael F. ladetnaico. MD. MPH. Din-am: Center?rr Epidemiology mm'LdiEremmq Service: MMWR Editorial and Produetion Staff [Weaklyl Charlotte K. Kent. MPH. Acting Edimn'n Chief: Executive Editor- Jacqueline Gladier. MD. Editor Mary Dotr, MD. MPH, (Julius Editor Temsa F. Rutledge. Managing fairer Douglas W. Weathuwax. Lead Tat?nimi? Wtr??f?ar Glenn Damon. Soumya Dunworth, Teresa M. Hood. MS. manual Writer-a?oat: Martha F. Boyd. Lew} Visual Specialise Maureen A. Lei-ally. Julie C. Mnrtinroe. SmphenR. Spriggs. Tong Yang. Vitae! In?rmetfm Sammie: 'Quang M. Dean. MBA. H. King. Terraye M. Starr, Mona Yang, In?ramim spa-area MMWR Editorial Boon! Timothy F. Jones. MD. Matthew L. Buuitoo. MD. MPH Virginia A. Cains. MD Katherine Daniel. PM) Jonathan E. Fielding, IulD. MPH, NIBA David Fleming. MD eta MMWR Jun88,2018 r' Vol.6? No.22 William E. Helper-in. MD. DIPH. MPH King K. Holmes. MD. Robin Ikrda. MD. MPH Rim-.1 F. Khabbaz. MD Meadows. MSN. RN Jewel Mullen. MD. MPH. MFA Patricia Quinlislt. MD. MPH Patrick L. Remington. MD. MPH Carlos R'oig. M5. MA Wait-.1.? L. Roper. MD. MPH William Seha?iter. MD US Department of Health and Human ServicesiCemers for Disease Control and Prevention Morbidity and Mortality Weekly Report per 100,000 persons per?year. Age-adjusted suicide rate trends were modeled using the same 3-year data aggregates, employ- ing weighted least-squares regression with inverse-variance weighting. Modeled rate trends are reported in terms oF average annual percentage changes. Characteristics oF persons aged 1:10 years who died by suicide, with and without known mental health conditions, and the circumstances surrounding the suicides were compared in the 27 states? with complete data participating in CDC's National Violent Death Reporting System in 2015. defines mental health conditions as disorders and listed in the Diagnostic and Statistical Manual Disorders, Farr; Edition (9), with the exception oF problematic alcohol use and other subsranee use that are captured separately in VDRS aggregates data From three primary data sources: death certi?cates, coroneri'medical examiner reports (including toxi? cologyl, and law en Forcement reports. A range oF circumstances (relationship problems, life stressors, and recent or impending crises)I have been identi?ed as potential risk Factors For suicide in Circumstances captured are those identi?ed as con? tributing to suicide in coronerfmeclical examiner or law en Force? ment reports, which re?ect inForntation provided by Family and Friends at the time oF death. Decedents could have experienced multiple circumstances. Decedents with and without known mental health conditions were compared using chi-square tests. Logistic regression analyses were used to estimate adjusted odds ratios (aORsl with 95% confidence intervals (Cls), controlling For sex, age group, and tacoll ethnicity. Results The most recent overall suicide rates (representing 2014? 2016} varied FourFold, From 6.9 (District oF Columbia]I to 29.2 (Montana) per [00,000 persons per year (Supplementary Table; Across the study period, rates increased in all states except Nevada (where the rate was consistently high throughout the study period}, with absolute increases ranging From 0.8 per 100,000 (Delaware) to (Wyoming). Percentage increases in rates ranged From 5.9% (Delaware) to 57.6% (North Dakota), with increases >50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Media Advisory Embargocd Until 1 pm. EDT Thursday, June 7, 2018 Contact: CDC Media Relations (404) 639-3286 CDC Telebrie?ng: New Vital Signs Report Nearly 45 .000 deaths by suicide in 2016: What can be done to prevent suicides? What According to the latest Vital Signs report. suicide increased in nearly every US. state from 1999 through 2016. In addition, suicide rates increased more than 30%] in half of states. Mental health conditions are often seen as the cause of suicide, but suicide is rarely caused by any single factor. In fact. many people who die by suicide are not known to have a diagnosed mental health condition at the time of death. Who CDC Principal Deputy Director Anne Schuchat. MD. RADM, USPHS When Thursday, June 7. at 12:00 p.111. ET Dial-In Media: Non-Media: 800-369-1605 INTERNATIONAL: 1-630-395-0331 PASSCODE: CDC Media Important Instructions If you would like to ask a question during the call, press *1 on your touchtone phone. Press *2 to withdraw your question. You may queue up at any time. You will hear a tone to indicate your question is pending. TRANSCRIPT A transcript of this media availability will be available following the brie?ng at web site: that US. Department of Health and Human Sewices CDC 1-1 -o t'lx'Jf 24/? protecting America is health, safety, and security. Wiether diseases start at home or abroad, are curable or preventable, chronic or acute, or from human activity or deliberate attack. CDC responds to America ?s most pressing health threats. CDC is headquartered in Atlanta and has experts located throughout the United States and the world. Press Release Embargoed until 1:00 pm ET Thursday. June 7, 2018 Contact: CDC Media Relations 404-639-3286 Suicide rates rising across the U.S. Comprehensive prevention goes beyond n?acns on mental' health concerns Suicide rates have been rising in nearly every state, according to the latest Vito! Sign report by the Centers for Disease Control and Prevention (CDC). In 2016, nearly 45,000 Americans age 10 or older died by suicide. Suicide is the 10th leading cause of death and is one ofjust three leading causes that are on the rise. Suicide is rarely caused by a single factor. Although suicide prevention efforts largely focus on identifying and providing treatment for people with mental health conditions, there are many additional opportunities for prevention. ?Suicide is a leading cause ofdeath for Americans and it?s a tragedy for families and communities across the country." said CDC Principal Deputy Director Anne Schuchat, MD. ?From individuals and communities to employers and healthcare professionals. everyone can play a role in efforts to help save lives and reverse this troubling rise in suicide." Many factors contribute to suicide For this Vital Signs report, CDC researchers examined state-level trends in suicide rates from 1999- 2016. In addition, they used 2015 data from National Violent Death Repolting System, which covered 27 states, to look at the circumstances of suicide among people with and without known mental health conditions. Researchers found that more than half of people who died by suicide did not have a known diagnosed mental health condition at the time of death. Relationship problems or loss, substance misuse; physical health problems; and job, money. legal or housing stress often contributed to risk for suicide. Firearms were the most common method of suicide used by those with and without a known diagnosed mental health condition. State suicide rates vary widely The most recent overall suicide rates (2014-2016) varied four-fold; from 6.9 per 100.000 residents per year in Washington. DC. to 29.2 per 100.000 residents in Montana. Across the study period. rates increased in nearly all states. Percentage increases in suicide rates ranged from just under 6 percent in Delaware to over 57 percent in North Dakota. Twenty-five states had suicide rate increases of more than 30 percent. Wide range of prevention activities needed The report recommends that states take a comprehensive public health approach to suicide prevention and address the range of factors contn'buting to suicide. This requires coordination and cooperation from every sector of society: government, public health, healthcare, employers, education, media and community organizations. To help states with this important work, in 2017 CDC released a technical package on suicide prevention that describes strategies and approaches based on the best available evidence. This can help inform states and communities as they make decisions about prevention activities and priorities. Everyone can help prevent suicide: I Learn the waming signs of suicide to identify and appropriately respond to people at risk. Find out how this can save a life by visiting: wwaeThel to.com I Reduce access to lethal means such as medications and firearms among people at risk of suicide. I Contact the National Suicide Prevention Lifeline for help: (8255). The media can avoid increasing risk when reporting on suicide by: I Following and sharing recommendations available at for example, avoiding dramatic headlines or explicit details on suicide methods); I Providing information on suicide warning signs and suicide prevention resources; and I Sharing stories of hope and healing. Vita! Si gig is a CDC report that typically appears on the ?rst Tuesday of the month as part of the CDC journal Morhidin' and Mortaiin' l?Veekiv Report. The report provides the latest data and information on key health indicators, and what can be done to drive down these health threats. LLS. Department of Health and Human Services CDC works protecting America ?s heaith, safem and security. Whether diseases start at home or abroad, are curable or pre veritabie, chronic or acute, or from human activity or deliberate attack, CDC responds to America 's most pressing heaith threats. CDC is headquartered in. Atlanta and has experts located throughout the United States and the worid. Suicide rates ruse across the US from 1999 to 2016. SOURCE: Nationa! Vita! Statistics SystemFrom: Richmond-Crum, Malia (CDCIDNDIEHINCIPC) Sent: 7 Jun 2018 09:36:28 -0400 To: cmaxwell@suicidology.org Cc: Stone, Deborah Subject: FW: CDC Report Attachments: Signs_ Suicide_6.7.2018_article.pdf, MMWR Supplemental tab e_VS Suicide_ 6.7.2018_final.pdf, FACT Chris, Thank you very much for reaching out. Deb shared your email with me as I?m helping with outreach related to the Vital Signs launch. Embargoed copies of the report and associated materials are attached. Please do not share this information with your networks until the embargo lifts at 1pm today. Some additional information is below on events - telebriefing for media, social media tools and Town Hall teleconference next week. I'm so sorry we weren?t able to share these materials with you sooner so that it would have helped with media inquiries. We were under a strict embargo and are only allowed to share even embargoed copies beginning at this morning. Please let me know if I can answer any questions or help in anyway moving forward. Best, Malia The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and DC, examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e?mail contains advance copies of several Vita! Signs materials, including the Moi?oidin? and Mortality Week?y Report (MWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four?page consumer fact sheet. This latest edition of CDC Vital Signs will he released today, Thursday, June 2018, at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older DFrom 1999?2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 20] 5 indicate that more than half of people who died by suicide did not have a known mental health condition I A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, ?nancial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webpageto ?nd the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vita! Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vitoi Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vitni Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Malia Richmond-Grunt, MPH Team Lead, Policy and Partnerships Division of Violence Prevention National Center for Injury Control and Prevention Centers for Disease Control and Prevention Office: 770-488-0526 accent-6135 mrichmondcrum?i?cdcgov f. at. Preventing Injuries and Violence Through Science and Action ?an ?oi-i From: Chris Maxwell Sent: Thursday, June 7, 2018 9:27 AM To: Stone, Deborah <2an cdc. ova? Subject: CDC Report Hi Deb - hope you?re doing well! We?ve been contacted by some members of the press over the past couple of days due to the recent and unfortunate celebrity suicide and a few of them have been referencing the yet?to-be- released report coming out today regarding suicide and data. Would it be possible for our Executive Director and President to receive drafts or cmbargoed advance copies of these types of reports so they can be better prepared to answer the questions from the media? This could go a long way in helping both our membership and the general public be more prepared to handle inquiries from the media, especially when the media has been provided advance notice or data. If we need to contact someone else over there, please let us know who we should get in touch with. Thanks and looking forward to hearing from you! Chris Maxwell Communications Coordinator American Association of Suicidology 5221 Wisconsin Ave, NW Washington, DC 20015 Of?ce: 202-237-2280 ext. 306 Cell: 913-7?5?2293 AAS is a membership organization tor att those invoived in suicide prevention and intervention, or touched by suicide. MS is a ieader in the advancement of scienti?c and programmatic efforts in suicide prevention through research, education and training, the deveiopment of standards and resources, and survivor support services- Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Weekly/Vol. 67 i No. 22 June 8, 2018 Vital Signs: Trends in State Suicide Rates United States, 1999?201 6 and Circumstances Contributing to Suicide 27 States, 2015 Deborah M. Stone. 5:th 'l?homas R. Simon l?hDi; Katherine A. Fowler, l?th; Scott R. Kegler, Pth; Keniing Yuan, Kristin M. Holland, Asha Z. hey-Stephenson, I?th; Alex E. Crosby, Abstract Introduction: Suicide rates in the United States have risen nearly 30% since 1999., and mental health conditions are one of several factors contributing to suicide. Examining stateelevel trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. Methods: Trends in age-adjusted suicide rates among persons aged :10 years, by state and sex, across six consecutive 3-year periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data From the National Violent Death Reporting System, covering 27 states in 20! 5, were used to examine contributing circumstances among decedents with and without known mental health conditions. Results: During 1999?20 16, suicide rates moreased signi?cantly in 44 states, with 25 states experiencing mcreases Rates increased significantly among males and females in 34 and 43 states, rmpectively. Fifty-four percent ofdecedents in 27 states in 201 5 did not have a known mental health condition. Among decedents with available information, several circumstances were signi?cantly more likely among those without known mental health conditions than INSIDE among those with mental health conditions, including 625 Invasive Methicillin-Resistant Staphylococcus oureus relationship problemsi'loss (45.1% versus life Infections Among Persons Who Inject Drugs Six Sites, 2005?201 6 629 Tobacco Product Use Among Middle and High School Students United States, 2011?2017 634 Update: Influenza Activity in the United States During stressors (50.5% versus and recent! impending crises (32.9% versus but these circumstances were common across groups. Conclusions: Suicide rates increased significantly the 201??18 Season and Composition ofthe 2018?19 across most states during 1999?2016. Various Influenza Vaccine circumstances contributed to suicides among persons 643 Update: ACIP Recommendations for the Use of With and without known mental health conditions. Quadrivalent Live Attenuated Influenza Vaccine Implications for Public Health Practice: States United Sis??95: 2018?19 Influenza 59350" can use a comprehensivg evidence?based public 646 Notes from the Hemorrhagic health approach to prevent suicide risk before it Fever Outbreak?Central Uganda, August?September occurs, identify and support persons at risk, prevent 201? reattempts, and help friends and family members in 6?48 QuickStats the aftermath of a suicide. Continuing Education examination available at infolitmliiweekly. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Introduction in 2016. nearly 45,000 suicides population [age-adjusted? occurred in the United States among persons aged :10 years From 1999 to 2015. suicide rates increased among both sexes, ail racial/ ethnic groups, and all urbanization levels (2.3). Suicide rates have also increased among persons in all age groups <75 years, with adults aged 45?64 having the largest absolute rate increase (from 13.2 per 100,000 persons [1999] to 19.2 per 100,000 [2016]) and the greatesr number ofsuicides (232,108) during the same period (1.3). Suicide is the tenth leading cause ofdeath and is one ofjust three leading causes that are increasing in addition, rates ofemergency department visits for nonfatal self-harm, a main risk factor for suicide, increased 42% from 2001 to 2016 (1). Together, suicides and self-harm injuries cost the nation approximately $730 billion per year in direct medical and work loss costs if}. The National Strategy for Suicide Prevention calls for a public health approach to suicide prevention with efforts span? ning multiple levels (individual, famiiyfrelationship, community, and societal]. Such a comprehensive approach underscores that suicide is rarely caused by any single factor. but rather, is deter? mined by multiple factors. Despite this call to action, suicide prevention largely focuses on identifying and tefEtring suicidal persons to mental health treatment and preventing reattempts (6). in addition to mental health conditions and prior suicide attempts, other contributing circumstances include social and economic problems, access to lethal means (eg, substances, firearms) among persons at risk, and poor coping and problem- solving skills Expanded awareness of these additional circum- stances contributing to suicide risk and action to address them can be] reach the national goal, established by the National Action Alliance of Suicide Prevention and the American Foundation for Suicide Prevention, of reducing the annual suicide rate 20% by 2025 To assist states in achieving this goal, CDC analyzed state?specific trends in suicide rates and assessed the multiple contributing factors to suicide; this report presents options for strategies to include in comprehensive suicide prevention efi'orts that are based on the best available evidence. Methods Suicide rates were analyzed for persons aged :10 years because determining suicidal intent in younger children can be difficult (8). Ageaspecific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (International Class?imrion ofDireiases, Fitme- Revision, underlying?cause?ofdeath codes ?37.0. Age? specific population estimates were obtained from U.S. Census Bureau/National Center for Health Statistics bridged?race population data releases. National and staterlevel suicide rate estimates were calculated for six consecutive 3?year aggregate periods spanning i999? 2016 (1999?2001; 2002?2004; 2005?2007; 2003?2010; 2011?2013; and 2014-2016). Rate estimates were age- adjusted to the U.S. 2000 standard population and expressed The of publications is published by the Center for Surveillance. Epidemiology, and Laboratory Services. Centers For Disease Control and Prevention US. Department DE Health and Human Services, Atlanta, GA 30329-4027. Suggc?ed citation: [nudist tomes; first three. then ct .1L. if more than steel [Report title]. MMWR Morb Mortal Wkly Rep 2018;67:linc1usive page numbers]. Centers for Disease Control and Prevention Robert R. Redfield, MD, Dir-retal- Annc Schucllat. MD. Principe! Depend Dirmor Leslie Dauphin. Acting Arterial? Diremar?r .S'rz?mcr Joanne Conn. MD. 542M, Dir-emu [wire 43am.- Quality Chesiey L. Richards, MD. MPH. Deputy Public Health Erin-tri?e 5mm: Michael F. ladetnaico. MD. MPH. Din-am: Center?rr Epidemiology mm'LdiEremmq Service: MMWR Editorial and Produetion Staff [Weaklyl Charlotte K. Kent. MPH. Acting Edimn'n Chief: Executive Editor- Jacqueline Gladier. MD. Editor Mary Dotr, MD. MPH, (Julius Editor Temsa F. Rutledge. Managing fairer Douglas W. Weathuwax. Lead Tat?nimi? Wtr??f?ar Glenn Damon. Soumya Dunworth, Teresa M. Hood. MS. manual Writer-a?oat: Martha F. Boyd. Lew} Visual Specialise Maureen A. Lei-ally. Julie C. Mnrtinroe. SmphenR. Spriggs. Tong Yang. Vitae! In?rmetfm Sammie: 'Quang M. Dean. MBA. H. King. Terraye M. Starr, Mona Yang, In?ramim spa-area MMWR Editorial Boon! Timothy F. Jones. MD. Matthew L. Buuitoo. MD. MPH Virginia A. Cains. MD Katherine Daniel. PM) Jonathan E. Fielding, IulD. MPH, NIBA David Fleming. MD eta MMWR Jun88,2018 r' Vol.6? No.22 William E. Helper-in. MD. DIPH. MPH King K. Holmes. MD. Robin Ikrda. MD. MPH Rim-.1 F. Khabbaz. MD Meadows. MSN. RN Jewel Mullen. MD. MPH. MFA Patricia Quinlislt. MD. MPH Patrick L. Remington. MD. MPH Carlos R'oig. M5. MA Wait-.1.? L. Roper. MD. MPH William Seha?iter. MD US Department of Health and Human ServicesiCemers for Disease Control and Prevention Morbidity and Mortality Weekly Report per 100,000 persons per?year. Age-adjusted suicide rate trends were modeled using the same 3-year data aggregates, employ- ing weighted least-squares regression with inverse-variance weighting. Modeled rate trends are reported in terms oF average annual percentage changes. Characteristics oF persons aged 1:10 years who died by suicide, with and without known mental health conditions, and the circumstances surrounding the suicides were compared in the 27 states? with complete data participating in CDC's National Violent Death Reporting System in 2015. defines mental health conditions as disorders and listed in the Diagnostic and Statistical Manual Disorders, Farr; Edition (9), with the exception oF problematic alcohol use and other subsranee use that are captured separately in VDRS aggregates data From three primary data sources: death certi?cates, coroneri'medical examiner reports (including toxi? cologyl, and law en Forcement reports. A range oF circumstances (relationship problems, life stressors, and recent or impending crises)I have been identi?ed as potential risk Factors For suicide in Circumstances captured are those identi?ed as con? tributing to suicide in coronerfmeclical examiner or law en Force? ment reports, which re?ect inForntation provided by Family and Friends at the time oF death. Decedents could have experienced multiple circumstances. Decedents with and without known mental health conditions were compared using chi-square tests. Logistic regression analyses were used to estimate adjusted odds ratios (aORsl with 95% confidence intervals (Cls), controlling For sex, age group, and tacoll ethnicity. Results The most recent overall suicide rates (representing 2014? 2016} varied FourFold, From 6.9 (District oF Columbia]I to 29.2 (Montana) per [00,000 persons per year (Supplementary Table; Across the study period, rates increased in all states except Nevada (where the rate was consistently high throughout the study period}, with absolute increases ranging From 0.8 per 100,000 (Delaware) to (Wyoming). Percentage increases in rates ranged From 5.9% (Delaware) to 57.6% (North Dakota), with increases >50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2013 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:31:? State Flate Change 2:33"; 1999 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Flank (State Rank} 1l (State Rink} 35111 12.3 We) 12.7 1+ 0.4) 12.3 1+ 0.2) 13.3 1+ 0.3) 14.5 1+ 0.3) 15.4 1+ 0.3) 1.5 31. 1p<.01) Na 3.1 0172.) 25.4 31.1mm 0.8. Male 20.311173) 2121+ 0.4) 21.3 1+ 0.0) 22.5 1+1.3) 23.5 1+ 1.0) 2451+ 1.0) 1.1 31. 1154.01) Female 4.7111711) 5.0 1+ 0.3) 5.3 1+ 0.2) 5.7 1+ 0.4) 3.2 1+ 0.5) 3.3 1+ 0.7) 2.3 31. 111.401) Both 14.31013) 13.4[ 0.91 14.1 0.31 153{+1. 31 13.4 0.71 11 25 +3.1 (311 ?1?0 [331 AL Male 25.1 {?131 23. 4 [1 .71 24.4 1.01 23. 4 2. 01 213 1.11 23.1 1. 51 1.3 ?7'0 Female 5.1 1117a 3-1 0. 3) 5.0 1+ 0.2)11+ 1 1) 341+ 0. 3) 0+10 2.3 31.113401) Both 21.0 24 3 3. 31 24.2 0.3?.4 ?7?0 1131 AK Male 33. 2 {r113} 33.1 4. 91 33.9 0.31 40 1 {4.1112140 1 0.11 42 9 2. 31 1.4 9/13 1134.01} Female 3.3011611 93(? 131 11.1{+ 21 1.21 +13% 013 Both 1?.81013) 13. 19.1 0.51131 (- 0.0) 20.4 1.31 20. 9 0. 51 1.0 ?fa {pt-1.011 15 3.1 {321 +113 ?701421 AZ Male 23.3 30. 2 1. 001 30.3 0.41 30.2 0.51 32. 0 1.31 32.4 0. 41 0.3 We {[34:05} Female 7.1 (1113) .5+1 +0 4) 2 1+ 0.7) 3 31+ 0.5) 3 2112.2 31. 11:14.01) Both 15.5 {?131 15. 3 0. 031 13.2 3. 51 17. 3 1.41 19.2 1.31 21.2 2. 01 2.2 "in 12 5.71141 33.3 "/01151 AH Male 2631013) 23. 2T2 0.5123.2(+ 1.01 31. 7' 3. 51 33.5 91 1.3 {pt-1.051 Female 5.61013)91+ 0. 031 21+ 0.41 911+ .1 3.3 2.11 3.3 ?35 {[34:01} 30111 10.31n7a) 1131+ 0. 7) 11. 010.3) 12. 0 1+ 1.0) 1131.1) 12.1 1+ 0. 3) 0.3 31.113305) 45 1.3 143) 14.3 31. 143) CA Male 17.9 (n13) .51 0.?1 10.1 .1 13.2 0.31 +0.5 ?1?0 Female 4.1 1n7a41+ 0.5) 3-10 .1) 5.3 1+ 0.3) 1.7 31. 1114.05) Beth 17.31r17a) 13.2 1+1. 3) 13.010 2) 2001+ 1.0) 2131+ 1.5) 23.2 1+ 1.3) 1.3 31.111401) 3 5.3 112) 34.1 31.122) 130 Male 233111711) 3031.5 1+ 1.0) 3341+ 1.3) 33.3 1+ 2.3) 1.4 31.113401) Female 7.01n7a) 1..11+ 0.3) 10.1 1+ 1.0) 10.4 1+ 0.3) 2.3 31. 1114.01) 30111 3.31n7a131.1) 11.0 1+ 0.3) 11.5 1+ 0.5) 1.3 31. 1114.05) 43 1.3 143) 13.2 31. 134) CT Male 13.41r17a) 14. 311.3) 15.0 1+ 0.4) 3 31+ 1.3) 17.3 1+ 1.0) 17.3 1- 0.3) 0.3 31. Female 3.3111711) 31+ 0.2) 7 1- 0.2) 41+ 0.7) 4.3 1+ 0.5) 3.2 1+ 1.3) 3.5 31.113305) Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change trorn Prior Period) Current Overall Overall State Sex 1:329? State Flate Change 2:313"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 1513113 Rank) 1 (State Hagnk) Both 13.3 1n1a) 12.2 1- 1.4) 11.0 1- 0. 3) 13. 311+ 14.2 1+ 0.3) 14.4 1+ 0.2) 0.3 31. 1115 42 0.3 150) 5.0 33150) DE Male 23.01n1?a} 2022.? 1- 0.4) 23.5 1+ 0.3) 0.3 31. 013 Female 5.3 13.13.} 5.0 1- 0.1.5} 5.2 1- 0.21 1.5 11.15 Bath 5.9 13.13.} 5.4 1+ 0.0.?1 5.9 1+ 0.3} 0.9 ofo 11.15 51 1.0 1481 15.1 01,10 (45} DC Male 10.? {Na} 11.1 1+ 0.1001-23) 11.? 1+ 0.3 1115 Female 1 11113111 2.3 1+ 0.3)11311.0) 3 1- 0.3) 3.5 31. 013 3001 14.8 13.13.} 15.2 1+ 0.1+21. 4} 15.3 1- 0.01 15.4 1+ 0.1} 0.8 ?2101134051 2'9 4- 1.5 1451 10.5 10148} FL Male 24.3 13.13.} 24.4 1+ 0.25.5 1- 0.51 25.5 1- 0.11 0.5 ofo 11.15 Female 5.3 111113.} 5.8 1+ 0.5} 31+ 0. 0} 11+2 0. 3} 7.5 1+ 0.5} 11.8 1+ 0.3} 1.4 ?fa {114.01} Both 12.9 1n13} 1321+ 0.3} 12. 31-0 .91 1321+ 0. 9} 13.? 1+ 0.5} 15.0 1+ 1.3} 0.9 ofo 1113 3'9 2.1 1401 +152 10144} GA Male 22.1 mm} 23.1 1+ 1.0) .31-1.3) 21 .0 1+0. 3) 2231+ 2441+ 0.5 34. 015 Female 5.0 131318-012151-021 0.3} 5.5 1+ 0.8} 2.1 010113405} Both 12.91313} 11. 1 1- 1.81 10. 31-0 .71 14.51+ 4.1} 14.41- 0.11 1521+ 0.8} 2.0 ?fa 1115 35 2.41351 +133 1-11 Male 20.41n1?a} 2 1-3 .1) 15.3 1- 1.0) 21.0 1+ 22.5 1+ 0.5) 24.3 1+ 1.3) 2.1 31. 013 Female 5.41313} 5.0 1- 0.41 5.5 1+ 0.5} 1 1+ 1.5} 5.2 1- 0.91 5.9 1- 0.31 1.2 11.15 Both 17.3 1313} 1921+ 2.0} 18. 3 1- 0. 91 2151+ 3. 3} 2131+ 0.3} 2431+ 2.8} 2.3 ?21011345.. 01} 3 151 51 43.2 1 7} "3 Male 28.411113} 33.1 1+ 4. 7} 3134.71-13.21 38.0 1+ 3.3} 1.15 0110113405} Female 7.2 .11110.5} 11.8 1+ 2.3} 4.4 ?1101134051 Bath 9.9 11113} 9. 8 1- 0.11 71-0511 10. 5 1+ 0. 8} 11.2 1+ 0.5} 12.2 1+ 1.0} 1.5 0210113405} 44 2.3 1381 22.8 ?110132} lL Male 17.1 111.13} 15H1.41 15.21- 0.41 1751+ 1.4} 18.5 1+ 0.9} 19.31+1.3} +1.1 ?1101134051 Female 11113} 3.5 1-0.01810.4} 5.2 1+ 0.5} 2.4 011: {1341.01} Beth 13.011113} 131491+ 0. 5} 13.4 1+ 1.4} 17.1 1+ 0.7} +1.9 ?fa {1:14.011 25 4.1 1231 31.9 ?313125} Male 22.411113} 23.2 1+ 0.8} 24. 4 1+ 1.2} 24. 7 1+ 0. 4} 25.? 1+ 2.0} 28.3 1+ 1.5} 1.5 Female 4.5 111.13} 5.0 1+ 0.0.9} 5.5 1- 0.21 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Flank 5 {State Rank) Ill (State HEnk) 1.4. Both 11.31n2a1 13.21+1.41 1231-04) 14.2 1+ 1.41 15.9 1+ 1.21 13.0 1+ 0.11 +2.1 241134.011 31 +4.31201 33.2 9.1131 1.4 Male 20.3 1n2a1 22.1 1+ 1.51 20.3 1- 1.41 23.3 1+ 2.51 23.0 1+ 2.21 25. 2 1- 0. 31 1.3 12.. 1134.051 Female 3.710131 431+ 1.0} 531+ 0.61 5.51+ 0.21 5.1 1+ 0.5171+ 0 61 3.8 ?20 113-3. 011 Bath 13.31n1?a1 15.1 1+ 1.8} 1581+ 0.71 15.31- 0.51 17.? 1+ 2.4} 19.41+1.51 2.2 ofo 011 19 5.01111 45.0 01120 1 5} KS Male 22.21n2a1 25.0 1+ 2.31 23.5 1+ 151 25.3 1- 0.91 29.1 1+ 3.51 30. 2 1+ 1.31 1.9 12.. 112.4. 011 Female 4.5 10131 5.0 1+ 1.4} 5. 7 1- 0. 31 5.41- 0.31 5.8 1+ 1.4} 3. 4 1+ 1.51 3.2 01120 (134051 Beth 14.1 1l'I1'ia} 15.41+1.3} 3.1 15.21-11.51 18.21+2.0} 19.3 1+1. 11 1.9 ?20 113-3. 011 20 +5.2 1151 +355 10115} KY Male 25.01n2a1 2331+ 1.91 23. 3 1+1 41 22.2 1- 1.01 30.1 1+ 2.9} 31.2 1+ 1 .31 1.4 02.. 11:4. 011 Female 4.8111118} 5210.1} 7.1 1+ 0.9} 711+ 0. 51 3.2 ?2?0 {114.011 Beth 13.1 {We} 12. 91-0 .1 13.41+ 0.41 1351+ 0.31 14.41+ 0.8} 1701+ 2. 51 +1.6 01120 (134051 27 3.8 112?} 29.3 10125} LA Male 22.9 1n2a1 22. 3 1- 0. 31 22.4 1+ 0 11 23.3 1+ 0.31 23.2 1+ 0.51 22.3 1+ 3 31 1.1 02.. 1115 Female 4.8 [0131 10.21 0.1 1+ 1.2} 5 1+ 1 .41 2.8 ?24 {1:14. 051 Both 14.5 1l'l1'ia15.4 1+ 1.0} 18.9 1+ 3.5} 18. 5 1- 0. 41 2.2 ?2?0 {114.051 21 4.01251 27.4 l:51'3129} ME Male 25.01n2a1 22.91.11 24.31+1 21 25.21+1.11 31.1 1+ 5.41 29.31 .31 1.312.. 1134. 051 Female 5.3 10131 5.3 1- 0012-01311 5.0 1+ 0.7} 7.6 1+ 1.5} 91+ 0. 31 3.1 ?20 113-3. 051 33111 10.010131 1031+ 0.31 101 1-0 .21 1021+ 0.11 1021+ 0.51 1031+ 0.11 0.5 0.31114 0514243 0.3149??1 3.5 :34414901 MD Male 17.511113} 1?.31? 0. 51 17.71+0.41 18.21+0.5} 18.0 1* 0.2] +0.2 019 Female 3.5 111131 3.8 1+ 0.4} 3. 9 1+ 0. 01 0.21 4.1 1+ 0.4} 4.5 1+ 0.41 1.3 ?2?0 {1:14.051 Both 1411113.} 1+ 0.1.0} 9.8 1+ 0.4} 10.0 1+ 0.31 2.3 (1214:2011 48 2.5134 111 35.3 %120 1ml) MA Male 12.1 111.13.} 12,181+ 0.?1 13 31+ 0. 51 1541+ 2.11 15.21- 0.21 1301+ 0.81 2.0 ?fa 1p<.011 Female 3.3 11113.} 2.9 1- 0.41 4.0 1+ 1.01 3.8 1- 0.11 4.8 1+ 1.0} 51* 0.21 3.0 ?2101134051 Both 11.811113} 1251+ 0.?1 1291+ 0. 41 13.91+1.01 1451+ 0.7} 15 01+1.11 +1.9 ?2?0 1134.011 33 3.9 125} 32.9 31:1241 Ml Male 20.0 11113.} 20.9 1+ 0.9} 21.0 1+ 0. 71 22.8 1+ 1.3} 23.9 1+ 1.0} 25. 0 1+ 1 .21 1.5 1p<.011 Female 4.4 111.13.} 4.8 1+ 0.4} 01+ 0. 21 5.3 1+ 0.5} 5.9 1+ 0.3171+ 0.91 2.8 1p<.011 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period} Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {51131113 Rank) Ill (State Hgnk) H. Both 10.71n13} 11.5 1+ 0.31 12.41+0.31 12. 3 1+0. 51 14.2 1+ 1.31 15.0 1+ 0.31 +2.3 31.. 1114. 011 33 +4.31131 40.3 331 31 MN Male 18.31n1?a} 13.31+1.22.3 1+ 1.31 2331+ 0.41 31. 011 Female 3.011113} 421+ 0.581+ 0.5} 91+ 1.2} 4.2 111-3. 01} Beth 12.911113} 14.1 1+ 1.1551+ 0.1} 15. 21- 0. 31 1.1 ?1151134051 35 2.3135} +173 01,10 (40} MS Male 22.9 11113.} 24.5 1+ 1.1} 25.1 1+ 0. 25. 8 1+ 25.9 1- 0.91 5. 3 1-0 .51 ?2?0 1115 Female 4.3 111130.01 5.4 1+ 0.9} 21- 0. 21 2.4 115113301) Beth 14.711113} 14.1 1- 0. 5} 15.4 1+ 1.3} 1001+ 0.7} 17.8 1+ 1.1} 2001+ 2. 3} 2.2 ?151134.011 10 5.3115} 35.4 11?} MD Male 25.3 11113.} 23.71-1 .51 25. 5 1+ 1.9} 20.6 1+ 1.0} 23.9 1+ 2.3} 32. 2 1+ 3. 3} 1.8 ?1151134051 Female 5.4111181} 5.41+ 0.1} 11+ 0. 7} 531+ 0. 2} 7.41+1.1} 3.2 ?fa 1131101} Both 21.1 1013} 22.3 1+ 1.41 23.31+10.1 11 23.? 1+ 2.01 2321+2.51 +2.1 031132.011 1 +3.01 21 33.0 :3.1111 MT Male 35.9 11118.} 37.3 1+ 0.4} 39. 3 1+ 2. 5} 39271-0 .11 41.0 1+ 1.4} 45. 5 1+ 1.3 ?151134.011 Female 371111.11 3.4 1+ 1.31 3.4 1- 0.11 10.0 1+ 1.31 12.3 1+ 2.31 13.1 1+ 0. 451 4.3 0.1. 1134.011 Both 12.71n1?a} 12.2 1- 0.51 12.3 1+ 0.41 11.71- 0.31 13.5 1+ 1.2.1 1421 13.2 :131431 NE Male 22.2 1013} 20.71- 1.51 20.3 1- 0.41 13.3 1- 0 51 22.0 1+ 2.21 23. 3 1+ 1 31 0.3 31. 013 Female 3.3 11118.} 4.2 1+ 0.4} 5.1 1+ 0.1.4} 81+ 0 3} 2.0 1115 B13111 23.3 11113.} 22.5 1- 0.51 22.1 1- 0.51 22.0 1+ 0.5} 21.41- 1.21 23. 1 1+ 1.0} - 0.2 1113 9 - 0.2151} - 1.0 (?10 1511 N11 Male 38.3 111151} 3071-17} 35.1 1- 1.8} 35.6 1+ 0.5} 32.5 1- 3.0.7 ?51: 1113 Female 8.911113} 951+ 0 5} 951+ 0.1} 1001+ 0.4} 1031+ 0.0} 1121+ 4010. +1.5 ?fa {114.01} 30111 13.511113} 12. 51- 1.01 1331+ 0.8} 15.21+1.9} 1531+ 0.5} 20 01+ 2.7 010113405} 17 5.51 81 48.3 1101 3} NH Male 22.5 11113.} 21.1 1-1 .41 21.7 1+ 0.0} 24.3 1+ 3.1} 25.4 1+ 0.5} 30. 6 1+4 5 2} 2.2 0.11:1 1134:. 05} Female 5 3 111131.0} 5.2 1+ 0.4} 5.0 1+ 0.4} 9. 8 1+ 3. 2} 3.9 011: {pt-1. 051 B13111 7.8 11113.} 1- 0.0.9} 9. 2 1+ 0 4} 1.3 ?101114.051 50 1.5 {47} 19.2 313135} NJ Male 13.011113} 13.1 1+ 0.0} 12.010 .51 1371+ 1 1} 14.51+0.8} 14.61+0.1} Female 3 2 11113.} 9 1- 0.31 001+ 9-01.11 3.8 1+ 0.9} 4. 4 1+ 0. 0} 2.3 1115 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2018 Age-Adjusted Annual Rate per 100,000 Persons [Change 1mm Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2008 2010 2011 2013 2014 2016 Rank 5 1513113 Rank) Ill (State Hgnk) H. Both 22.0 (n13) 22.0 1- 0.1) 21.0 1- 0.2) 23.0 1+ 1.2) 24.1 1+ 1. 1) 20.0 1+ 1 .0) 1.1 01.113405) 4 4.0 124) 13.3 =14. 130) NM Male 38.8 111131.2} 35.8 1- 0.8} 87.1 1+ 1.8} 40.7 1+ 8.8} 0.4 810 1115 Female 8511113.} 1.1} 8.21+0.7} 10.71+2.8} 12.0 1+ 0.8} +3.8 1114. 05} Beth 2.2111151) 1-01 .1) 7111+1. 1) 31- 0.1) 2.1 c1011:1401) 40 2.1 141) 20.3 01.12?) NY Male 12.51n13} 12.210 3) 13.01.+10) 15..41+14) 1451-00) +1.4%1p4.05} Female [010} 01-0 .1) 3.01+0.3) 3.5 4.01+0.5) +4.2 01. 1p4 01) 80111 18.811113} 18.51-13.11 18.71+0.1} 14.21+0.5} 14.51+0.4} 15.31+0.8} +0.8ofo 1114.01} 84 +1.7144} +127 810141} NC Male 22.711113} 22.? 1+ 0.0} 22.2 1- 0.8} 23. 3 1+ 1.1} 28. 3 1+ 0.0} 23. '9 1+ 0. 8} 0.4 ofo 1115 Female 5.0 11113.} 5.5 1- 0.2} 8.2 1+ 0.8} 8.0 1- 0.2.0 ?191134.05} 80111 18.811113} 14.8 1+ 1.8} 10.0 1+ 1.4} 1881+ 0.8} 18.4 1+ 1.9} 2091+ 2. 5} 2.9 810113401} 14 1.81 5} 57.8 8?31 1} ND Male 21.41n1a) 24.0 1+ 3.2) 20.0 1+ 3.4) 2?.1 1- 0.2.5 c1.4113401) Female 5.8 11113.} 4.5 1- 1.0} 8.71- 0.8} 5.7 1+ 2.0} 8. 1 1+ 1.0} 8. 5 1+ 1.8} 8.9 0er 1115 80111 11.011118} 1281+ 0.8} 18.1 1+ 0.8} 13.41+ 0.2} 14. 8 1+ 1 15.81+ 1.0} 2.0 ?19 1134. 01} 82 4.2 121} 88.0 ?10119} 01-1 Male 20.41n1a) 20.0 1+ 0.5) 22.2 1+ 1.3) 22.1 1- 0.1) 24. 2 1+ 2.1) 25. 5 1+ 1.3) 1.5 0.1.1134 01) Female 4.011113} 1+ 0. 4.91+ 0.1} 581+ 0.3.4 1114. 01} 80111 17.011113} 18. 51-0 1721+ 0.8} 18.41+1.1} 20. 7 1+2. 8} 28.51+2.8} +2.8 1% 1134. 05} 7 8.4 110} 87.8%: 112} UK Male 28.5 11113.} 27. 8 1- 1. 2} 27.8 1+ 0.5} 80.8 1+ 2.5} 88. 4 1+ 8.1} 37. 8 1+ 8. 8} 2.0 810113405} Female 8.8 11113.} 8.41-0.21 5 1+ 1 1.0 1- 0.5} 8. 5 1+ 1.8} 10. 8 1+ 1.8} 2.9 1134. 05} 80111 18.411113} 11.? 1+ 1.8} 17 71- 0.0} 18.81+ 0.9} 19.81+1.2} 21.1 1+ 1.8} +1.8 1134. 01} 18 4.8118} 28.2 tT113128} OH Male 21.411113} 2951+ 2.1} 28.51- 0. 9} 2951+ 1.0} 81.4 1+ 1.8} 38.0 1+ 1.8} +1.1 0110113401} Female 8.511113} 1.1 1+ 0.8} 71+ 0. 8} 841+ 0.7} 8. 8 1+ 0. 4} 881+ 0. 9} 2.7 0.11: 1134. 01} 80111 12.1 11113.} 12.5 1+ 0.4} 12.81+0.8} 18.91+1.1} 15.0 1+1. 1} 18.81+1.2} +2.0 ?10 1114.01} 30 +4.1 122} +848 ?310121} PA Male 21.011113} 2131+ 0.8} 2191+ 0. 8} 28.1 1+ 1.2} 24 11+1.7} 28.1 1+ 1.8} +1.5 1134. 01} Female 4.2 11113.} 4.8 1+ 0.8} 81+ 0. 0} 5.4 1+ 0.9} 8. 0 1+ 0.8} 1+ 11} 8.5 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {State Hank) Ill (State Hgnk) H. Bath 9.4 {ma} 9.0 (- 0.3} 9.0 (- 0.0} 12. 51+ 3. 5} 11.9 (- 0.9} 12. 511+ 0. 7} 2.5 92. 032.05} 43 3.2 (30 34.1 35 (23 at Male 15.4 {ma} 15.2 0.2} 14.5 1- 0.3} 21.2 5.4} 19.2 1- 2.11.5 Female 4.0 {Na} 3.3 (- 0.7} 3.3 0.4} 5.1 1.3} 5.1 0.0} 1.0} (p4. 05} Beth 12.301113} 13.0 0.2} 13.7 0.7} 18.0 11} 2.3 ofo (D4. 01} 23 4.9 33.3 We (10} 80 Male 21.3 {ma} 2251+ 1 22.31- 0.1} 2451+ 2.2} 25.1 1+ 1.5} 25.0 1+ 1 9} 1.5 95 {52. 01} Female 5.401.113} ?(ill 6.0 1.3} 5.2 0.1.4} 3.4 ofo (p4. 05} Beth 15.701113} 17.1 {[3401} 10 +44.5 ?Vc? 5} SD Male 2?.5 {ma} 2531.3} 229 1+ 1.5} 30.11.5} 1.5 54. {p4. 01} Femaie 4.2 {ma} 5.5 5.4 1+ 0.1.(p2. 01} Beth 14.501113} 15.2 0.6} 16.1 0.8} 1?.2 1.1} 17.2 0.0} +1.4 ofo (p4. 01} 22 3.5128} 24.2 3?3 (31} TN Male 25.1 {ma} 25.4 1+ 0.3} 25.5 1+ 1.3} 25.0 1+ 1.2} 25.5 1+ 0.5} 29. 5 1+ 1.2} 1.2 54. (52. 01} Female 5.4 {Na} 5.3 0.9} 6.7 0.4} 7.5 0.8} 6.9 0.6} 16 0. 7} 1.9 ofo (D4. 05} Both 12.20118} 12.? 0.6} 12. 0. 4} 13.2 0.9} 13.6 0.3} 14. 5 0. 9} 1.1 ?2?5 01} 41 2.3 (37} +139 We (36} TX Male 20.4 {Na} 20.9 0.5} 20. 4 (- 0. 5} 22.0 1.6} 22.2 0.3} 23.1 0. 9} 0.9 ofo (p4. 05} Female 4.3 {Na} 5.4 0.5} 5.0 (- 0.4} 5.2 0.2} 5.6 0.4} 0. 8} 1.6 (p4. 05} Both 17.2 (1115} 19.0 18.2 (- 0.7} 20.2 2.0} 24.0 3.8.01: 3 W) 45.5 4 11} UT Male 28.2 (0.15} 31.1 2.9} 29.4 (- 1.7} 32.1 2.7} 37.8 5.7} 38. 0 0.2} 2.1 011: 05} Female 6.3 [015} 7.4 0.6} 7.5 0.1} 8.5 10.6 2.1} 12. 6 2. 0} 4.4 ?2?5 01} Both 18.2 14.9 1.3} 18.? 2.1} 19.? +2.4 01} 13 9} +436 Wed 2} VT Male 23.6 (1115} 28.3 4.6} 24. 3 (- 4. 0} 27.3 3.0} 31.0 3.7} 32. 5 1.9 4% (D4. 05} Female 4.3 (11.15} 5. 2 0. 9} 6.4 1.3} 5.6 0.2} 7.3 0.7} 7. 6 0.3} 3.8 011: 01} Both 12.81015} 12. 12.9 0.3} 13.6 0.7} 14.6 0.9} 15. 0 0 5} +1.2 ?2?0 01} 37 2.2 (39} +174 3?5 (41} VA Male 21.6 {015} 21.3 0. 2} 21.0 0.4} 22.5 1.5} 23.6 23. 9 0. 2} 0.9 Female 5.3 {015} Ht, 5 9 0.7} 6 (- 0.3} 6.4 0.8} 5. 9 0. 5} 1.3 (D4. 05} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period) Current Overall Overall State Sex 1? State Rate Change 2:33"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Rank 5 (State Hank) (State Hagnkji Both 14.3 1n1a} 15.4 1+ 3.5} 14. 3 1-3 15. 711+ 3. 31 16.6 1+ 3.3} 17.6 1+ 1.3} 1.1 331133.351 24 2.3 1331 13.3 :13137} WA Male 24.71nra1 25.2 1+ 3.5} 24.1 11.11 25.1 1+ 1.3} 23.3 1+ 3.3} 27.1 1+ 1.1} 3.6 33 1113 Female 5.9 111.13.} 5.4 1+ 0.0.8} 3.5 1+ 0.8} 2.5 112M011 Both 15.31nra} 17.21+ 1.6} 16. 71- 3. 51 16.31.71 1321+ 3.2} 21.41+ 2.2} +1.3 33 11 5.3113} 37.133114} wv Male 27.2 {ms} 33.1 1+ 2.3} 2331-15) 27. 31- 1. 31 3151+ 3.3} 33.5 1+ 2.3} 1.1 33 1115 Female 5.3 111.13.} 5.5 1+ 0.1} 5.8 1+ 0.3} 5.3 1- 0.5} 7.5 1+ 2.3} 9.8 1+ 2.2} :1er 1115 Both 13.1 13.5 1+ 0.4} 14.0 1+ 0.5} 15.0 1+ 1.0} 15.3 1+ 0.3} 15.5 1+ 1.2} 1.5 112M011 23 3.4129} 25.8 10130} w1 Male 21.71nra} 22.2 1+ 3.5} 22.7 1+ 3.5} 24.3 1+ 1.2} 24.4 1+ 3.4} 25.7 1+ 1.3} 1.1 33 1133.31 1 Female 5.1 {hrs} 5.3 1+ 3.2} 5.6 1+ 3.4} 341+ 3.71 3.5 1+ 3.1} 7.5 1+ 1.3} 2.5 33153.31} Both 20.71nra1 23.4 1+ 2.7} 22.5 1- 3.31 25.4 1+ 2.3} 23.3 1+ 3.5} 23.3 1- 3.11 2.3 031133.311 3 3.1 1 11 33.3 =13 1 3} WY Male 34.3 39.3 1+ 4.5} 35.3 1- 3.0} 41.5 1+ 5.2} 47.1 1+ 5.6} 44.5 1- 2.4} 1.8 112M051 Female 7.7111131} 3.2 1+ 3.6} 3.2 1+ 3.3} 3.4 1+ 3.2} 13.7 1+ 1.4} 12.3 1+ 1.3} 3.2 33 11:13.31 1 Rates are age?adjusted to the US. year 2000 standard. 1 Model?estimated average annual percentage change based on all reporting periods; p?value indicates statistical significance of trend; indicates trend not significant. ?5 Current state rank (50 states and the District of Columbia} is for the reporting period 2014 2016. Ranks are from highest rate (11 to lowest rate (511. Different ranks do not necessarily imply a statistically significant difference. 1 Overall rate change is between the first (1999 20011 and last [2014 20161 reporting periods. Hanks are from largest increase {11 to largest decrease 1511. Different ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the first 11999 20011 and last (2014 2015) reporting periods. Ranks are from largest percentage increase 111to largest percentage decrease 1511. Different ranks do not necessarily imply a statistically significant difference. TT Hate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. till Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. State Abbreviations: AL Alabama; AK Alaska; AZ Arizona; AR Arkansas; CA California; CO Colorado; CT Connecticut; DE Delaware; DC District of Columbia; FL Florida; GA Georgia; HI Hawaii; ID Idaho; IL Illinois; IN Indiana; IA Iowa; KS Kansas; KY Kentucky; LA Louisiana; ME Maine; MD Maryland; MA Massachusetts; MI Michigan; MN Minnesota; MS Mississippi; MO Missouri; MT Montana; NE Nebraska; NV Nevada; NH New Hampshire; NJ New Jersey; NM New Mexico; NY New York; NC North Carolina; ND North Dakota; OH Ohio; OK Oklahoma; OR Oregon; PA Fthode island; SC South Carolina; SD South Dakota; TN Tennessee; TX Texas; UT Utah; VT Vermont; VA Virginia; WA Washington; WV West Virginia; Wisconsin; WY Wyoming. #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telebrief Script_V4_pgm_DS_ 5172018_104Sa Review Tracker I NCIPC 0C Leslie Dorigo: 4/25/18 I DVP ADS Tom Simon: 4/24/18 I DVP Policy Malia Richmond-(2mm: 4/23/18 I DVP SME Deb Stone: 4/19/18, 4/24/18, 5/13 5/1? I DVP HCET Marie Ballman: 4/17/2018 I 5/1/2018 I 5/4/2013 Suicide Terminology Don't Do This Do This Instead Don't use sensationalistic headlines Kurt Cobain used shotgun to commit suicide) Do inform without sensationalizing Curt Cobain dead at Don't describe suicide as an epidemic, skyrocketing, etc. Do use the most recent CDC data and non-sensational words (rise, higher, etc.) Don't describe suicide as inexplicable or "without warning" Do include the 'warning signs' and 'what to do' info in articles Don't refer to suicides or attempts as 'successful? or 'completed? Describe as suicide, person died by suicide, or life lost to suicide Don't refer to suicide attempts as 'unsuccessful,? 'failed attempt? or 'nonfatal suicide' Describe as 'suicide attempt' or 'suicidal self?directed uiolence' Don't use 'committed? suicide because this invokes the idea of a crime Describe as died by suicide Vital Signs Rising Suicide Rates Across U.S. June 7, 2018 Desired Headlines I Nearly 45,000 lives lost to suicide in 2015, but suicide is preventable. I Suicide rates up in almost all states, but suicide is preventable. I Suicide rates went up more than 30% in half of US. states between 1999 and 2016. I Many factors contribute to suicide, beyond mental health conditions alone. Moderator: Thank you (OPERATOR NAME). And thank you all for joining us today for the release of a new CDC Vital Signs report on Trends in State Suicide Rates and contributing circumstances to suicide. We are joined by Dr. Anne Schuchat, Principal Deputy Director and the Surgeon General Dr. Jerome Adams. Dr. Deb Stone, Telebrief Script_V4_pgrn_DS_ 5172018_1045a lead author of the study, is also available to help answer questions. Following remarks, we will respond to questions. I?d like to turn the call over now to Dr. Anne Schuchat. Dr. Schuchat: Good afternoon and thank you forjoining us today. CDC works 24/7 to protect Americans against health threats. Each month in Vital Signs report, we focus on one of these threats and what can be done about it. Today?s report contains new information about state suicide trends, and the range of factors that contribute to suicide. In 2016 alone, 45,000 people in the U.S. lost their lives to suicide. Between 1999 and 2015, sSuicide rates have increased among all age groups younger than 75 years, with the h+ghestla_rge_st percent increase and the most suicides occurring among those aged 45-64, end?thesewaged?lG?Mw We found that suicide rates have increased in nearly every state across the nation and suicide is one ofjust three leading causes of death that are on the rise. Telebrief Script_V4_pgm_DS_ 5172018_1045a Suicide greatly impacts families, friends, colleagues, and entire communities. These findings are unacceptable. Suicide is a preventable public health problem and unfortunately, our data show that the problem is getting worse. For this Vitalegns report, we first analyzed data from the National Vital Statistics System to look at trends in suicide rates for all 50 states and Washington, D.C. We then looked at data from National Violent Death Reporting System, covering 27 states in 2015, and examined circumstances around suicides among people with and without known mental health conditions. As a side note, in the coming year CDC will have data for 40 states, D.C. and Puerto Rico, and thanks to Congress for providing funding in the fiscal year 2018 omnibus, CDC is working to expand the system to all 50 states. Suicide is often attributed solely to a mental health condition. But according to fewer than half of the people who lost their life to suicide had a known mental health condition and in many of these cases, other factors were involved. In fact, our research found that people who died by suicide and did not have a diagnosed mental health condition were somewhat more likely than those with a mental health condition to struggle with relationship problems or loss, life Telebrief Script_V4_pgm_DS_ 5172018_1045a stressors and recent or impending crises. However, and importantly, these circumstances were common to both groups. a Suicide IS preventable. 0 That?s why it?s so important to know the full range of factors that contribute to suicide risk including relationship problems, substance use, physical and mental health conditions, job issues, financial trouble, and criminal and/or legal problems. a With this information in mind, states and communities can develop a comprehensive approach to suicide prevention. For example, The United States Air Force Suicide Prevention Program, inclusive of 11 policy and education initiatives geared broadly towards increasing social support, social skills, and help- seeking, shifted the culture of the Air Force away from viewing suicide as an individual-oriented mental health condition to a larger service-wide problem impacting the whole community. The program was associated with a 33% relative risk reduction in suicide and reductions in other related problems. 0 Increased awareness of the range of circumstances contributing to suicide risk, and the needed to address them, can help the nation reach its goal of reducing the annual suicide rate 20 percent by 2025. Telebrief Script_V4_pgm_DS_ 5172018_1045a I Today?s report suggests we have a lot of important work to do to reach this goal. Nearly all states had increasing suicide rates between 1999 and 2016, and 25 states experienced rate increases of more than 30 percent. 0 So how do we work together to reverse these numbers and help save lives? a Close coordination of activities between public health agencies and other sectors of society is critical for preventing suicide. Necessary partners include such sectors as health and mental healthcare providers; social services; first responders; educators; faith communities; employers; and the media. II States and communities can and should take action now based on the best available evidence. II To help prioritize prevention efforts, we?ve developed Preventing Suicide: A Technicai Package of Poiicy, Programs, and Practices. it features the best available evidence for states and communities to guide their prevention priorities. The link to the technical package is on our Vital Signs website. a Preventing suicide involves everyone. Parents, employers, teachers, coaches, religious leaders - everyone in the community can help prevent suicide risk, learn the warning signs of suicide, and how best to respond and get help. 0 Now I?m going to turn it over to Dr. Adams for more discussion about suicide. Telebrief Script_?v?4_pgm_DS_ 51?2018_1045am Comment Moved this down in 5 order to highlight and broaden to include the many people we lose every day who are and are not military members or veterans. Comment [2319]: We?ve been asked to change our term mental health problems 45Dr. Adams: 0 Thank you, Rear Admiral Anne Schuchat. As the nation?s doctor, I am grateful for important study and work ion suicide prevention. this?pebliehea-lt?h?erisis? Comment Izal?J]: This is a good addition but suggest keeping this a little broader since we don?t get into trauma in our study. The spirit ofthis is still retainedDr. Schuchat noted, Is a devastating national problem. Its not i i to mentalhealth canditms? i 1 acceptable that we are losing nearly 45,000 lives a year to suicide, a preventable 5 Comment In?ll: Susaestaddms thine 'i be in line with the study. Moved ACES ,5 ll down. public health problem. Almost all .. Comment lzuwl: Is this correct to add? Wanted to tie this back to ACES as I suicide, be they military members, veterans, friends, co?workers, or familybelieve is the. intent. yet the of and help seeking remains incredibly stigmatized. ti 1?1: I dd: i: ommen 1 5 IS COFFEE 0 . I firmly believe that in order to address the tragedy that is taking one?s own life,- ll we need to take a hard look at the underlying factors that can lead to suicide, as RADM Schuchat stated. it Although mental health conditions are pesha-psrone of the most contributors to suicideaeses. ll'hese include relationship problems or loss, substance use, job, financial, and health problems] Even earlier in life, factors such as adverse childhood experiences, or ACES, I contribute to suicide risk whielaand can trigger suicide attempts and mental health emblems?conditions in the future. - As I travel across the country, I have heard heartbreaking stories about? and suicide attempts. - Recently, a friend of mine shared her own connection with suicide. She nd while trying to come to terms with experienced a traumatic event rowin the pain and betrayal she experienced Telebrief Script_?v4_pgm_DS_ 51?2018_1045am own life. parents responded duicklv and effectively and she received the medical attentiong 1 LEare and needed that saved her life. {l'odav she is doing well and continues on her - This story of suicide risk is all too Iuckv as my friend who got the help she needed. has?a?meeh?mer?e?grim-eeteeme; whiehThis is why we aeemust takeiag i-m-peet?an-tfurther action to air?sidearm address suicide rates and the full range of contributing factors. 0 On the Federal level, government agencies are tracking the problem of suicide to understand trends and groups at greatest risk. We are developing, implementing, and evaluating what works to prevent suicide in communities. And we are working with public and private partners to advance the National Strategyr for Suicide Prevention. report reminds us that health care svstemsE inclusive of physical and behavioral of suicide so that nobody falls through the cracks. Semespeei?e thingehealsheareproviders and healthca re svstems ?ca nydee Put into place policies 0 and protocols inaslaeethat prioritize patient safety including screeni_ng and assessing for suicide risk! per clinical guidelines. and-train?stafm 0 Can 0 engage and support people in ongoing care using evidenceebased treatments for suicide prevention, and health care jandprovidersl have ?important roles to plav in preventing the risk i Comment In?ll: Suggest broadening II what she received here. Comment [2am]: Suggest adding this, as I, afield we are trving to also highlight that a lot of people who attempt don?t go on tto die by suicide but live fulfilling lives. Comment In?ll: Suggest striking this because the paragraph above is also about prevention so these would be in addition to those things. Comment In?ll: The remaining called ?Zero Suicide? (in our technical Action AllianCe for Suicide Prevention] which is based on an evidence based program out of Henrv Ford hospital L?Perfect depression carehis Vitolb'i'gns package and is a priorlg of the National 1 comments are in reference to a program 1 .JL Comment In?ll: Theses comments have] been integrated above now. Telebrief Script_V4_pgm_DS_ 51?2018_1045am can with people who are at risk and their families . I about how to store lethal means such as medications and firearmsToday?s report shows that there are many footers?that oohtribute to iris?k: Everyone has a responsibility to help stop this deeming-concerning trend. - Thank you, I?ll turn it back to Dr. Schuchat now. - Thank you for your comments, Dr. Adams. From: Omisore, Shannon L. Sent: 15 Feb 2018 03:21:28 -0500 To: Stone, Deborah Cc: Sokler, Brandy Richard A. Subject: FW: Clarification of meeting dates and details Hi Deb, Please see below. The podcast is not on the calendar because it's now optional. Most programs have opted to haye one. it typically only takes an hour or less to review the script and the recording can be attended by conference call. Would you like to have a podcast for the June Shannon Shannon Omisore, MA Health Communication Specialist Office of the Associate Director for Communication 2500 Century Parkway, MS E-21 Atlanta, GA 30345 Office. 404- 498- 0153 mail. hyl5Q.cdc gov Sax-mg Luwg. Feap'n" From: Stone, Deborah Sent: Monday, February 12, 2018 12:49 PM TO: Sokler, ; mgdyak@eiconline.org; iohnd@mhaofnyc.org; fgonzalez@mhaofnyc.org; Gass, Jesse Hausman, Bridgette Hedegaard, Holly Holland, Kristin Kulp Kurnit, Molly Regina wendv.e.lakso.civ@mail.mil; plauricella@reingold.corn; Chris Maxwell McElroy, James McShane, Kristen (SAMHSAIOQ ADBrien@afsp.org; D'Keefe, Lindsey jpearson@nih.gov; Pearson, Jane Reed, Jerry dreidenberg@save.org; Richmond-Crum, Malia mrosen@mhaofnyc.org; michaeilescanlon@nih.gov; Sobottka, Linda Stone, Deborah Stout, Elly AVactor@mhaofnyc.org; Warner, Margaret Wright, James Subject: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates In prep for our call today to discuss our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, attached is an embargoed copy of the Fact Sheet. The Vital Signs includes state?level trends in suicide rates from 1999?2016, and, with data from National Violent Death Reporting System, looks at the circumstances ofsuicide among people with and without known mental health conditions. We appreciate this partnership and hope you can all help us disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Erin The CDC Vitai Signs series, launched in 2010, addresses a single, important public health topic each month. This month's edition presents trends in suicide rates across all states and DC, examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This email contains an advance copy of the four-page Virai Signs fact sheet. This latest edition of CDC Virai Signs will be released today, Thursday, June 7, 2018! at 1:00 pm (EST) following a media telebrie?ng at noon; the attachment is EMBARGOED until 1pm EST. Key points in the Vitai Signs report include: I In 2016, nearlyr 45,000 suicides occurred in the US among people 10 years and older II From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each a Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half ofpeople who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webpage to ?nd the MMWR article, fact sheet, and other materials. Take advantage of CDC '5 social media tools, such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you tojoin us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vimi Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Original Appointment-m- From: Torguson, Kimberly Sent: Monday, May 14, 2018 6:59 PM To:Torguson, Kimberly; Belyeu, Avery; ibenson@reingold.com; Black, Erin Bray, Miranda Bruce, Carr, Colleen; SCoggin@afsp.org; ccreighton@suicidologyorg; Crosby, Alexander Curtin, Sally C. Daniel, Valerie M. mgdyak@eiconline.org; iohn0@mhaofnyc.org; Gass, Jesse; Hausman, Bridgette; Hedegaard, Holly Holland, Kristin aikulp@suicidology.org; Kurnit, Molly Regina wendy.e.lakso.civ@mail.mil; plauricella@reingold.com; sheriJunn@thetrevorprojectorg; cmaxwell@suicidoiogy.org; McElroy, James McShane, Kristen eneely@reingold.com; AOBrienQafsgorg; O'Keefe, Lindsey ipearsonQnihgov; Pearson, Jane Reed, Jerry; dreidenberg@save.org; Richmond- Crum, Malia mrosen@mhaofnyc.org; michaelIe.scanlon@nih.gov; Sobottka, Linda; Stone, Deborah Stout, Elly; AVactor?Jmhaofnycorg; Warner, Margaret Wright, James Subject: Media Messaging Work Group Call When: Thursday, June 7, 2018 11:00 AM Eastern Time 8: Canada). Where: Phone Number: 366-3?0-2808 (access code Phone Number: 866?370-2808 (access code Email Context [From 5l14}: Hello Media Messaging Work Group Following the email below, we wanted to let you know that the CDC data expected to be released on June 5 will now be releasii on Jun?lei Additionally, we received word that we will not be receiving an embargoed copy so we?ll be rescheduling our MMWG group call [originally scheduled for Thursday, May 31) to Thursday, June 7 at 11:00 a.m. The goal of this call is to convene our partners to: 1) discuss the data, and 2) develop consensus on our messaging that will be used to craft a statement. If you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you can join us on Thursday, June 7 at 11:00 am. Lastly, we want to thank CDC for giving us the heads up about the data. Best, Hello Media Messaging Work Group, We wanted to call to your attention to a just-released article published in the American Journal of Preventive Medicine that looks at county?specific estimates of suicide rates. The paper titled "County- level Trends in Surcide Rates in the U.S., 2005-2015" was written by our Partner, CDC {authors include: Lauren M. Rossen, Holly Hedegaard, Diba Khan and Margaret Warner from Key findings include: I Posterior predicted mean county-level suicide rates increased by >10% from 2005 to 2015 for 99% of counties in the U.S., with 87% of counties showing increases of I Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S., with the exception of southern California and parts of Washington. I Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the U.S. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement (written in collaboration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. ?rou?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please find below some tailorable social media posts to help further promote the data: I Data released by featured in @AmJPrevMed shows county-level trends in suicide rates in the US I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts I Trends about suicide, like geographic patterns, helps us develop more targeted community-based #suicideprevention strategies so we can reduce annual suicide rate 20% by 2025 I Rural counties in the U.S. had the highest estimated suicide rates from 2005-2015 according to just-released @AmlPrevMed I Tracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts I Together we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: I Mion Alliance I @AASuicidology - (afafsgnational I @CDCIniury I I mtofDe-ferg I @DeptVetAffairs I @EDCTweets . I @NiMHgov I I @samhsagg I @SAVEvoicesofedu I I @TrevorProiect I Some resources that you may also find helpful as you promote the data include: I Action Alliance's Transforming Communities: Key Elements for the implementation of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. I Preven tingSuicide: A Technical Package oLPolicyirogramsLand Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this groUp to develop consensus messaging around this impending data release. In preparation for this larger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Please join us Jfor a planning call on Thursday, May 31 at 2:00 p.m. ET to plan ahead for collective statement about CDC data. We will send you a calendar invite (containing callrin information) to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC for giving us the heads up about the data. Thank you. From: Smith, Lakeesha (Shakiyla) (CDCKONDIEHINCIPCJ Sent: 7 Jun 2018 09:37:24 -0400 To: Stone, Deborah Subject: FW: Embargoed until 1pm June 7: Vital Signs: Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates Attachments: FACT Signs_ Suicide_6.7.2018_article.pdf, MMWR Supplemental tab e_VS Suicide_ Congratulations? Good luck today! i know you?ll rock it! 5 From: Core VIPP (CDC) Sent: Thursday, June 7, 2018 9:12 AM Subject: Embargoed until 1pm June 7: Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Dear Colleague: The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and DC, examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity: and Mortality Weekb= Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, one 7, 2018, at 1:00 pm (EST) following a media telehrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: In In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each IData from states participating in the National Violent Death Reporting System in 2015 indicate that more than halfof people who died by suicide did not have a known mental health condition IA range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Sions Webpage to ?nd the MMWR article, fact sheet, and other materials. Take advantage of CDC ?s sooal media tools, such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you tojoin us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Thank you for your support. James A- Irritant}!= Debra Hoary, MD. MPH Director Director Dixision of Violence Prweu?on National Center for Injury Preven?on and Control Na?oml Center for Injury Prevention and Control #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Weekly/Vol. 67 i No. 22 June 8, 2018 Vital Signs: Trends in State Suicide Rates United States, 1999?201 6 and Circumstances Contributing to Suicide 27 States, 2015 Deborah M. Stone. 5:th 'l?homas R. Simon l?hDi; Katherine A. Fowler, l?th; Scott R. Kegler, Pth; Keniing Yuan, Kristin M. Holland, Asha Z. hey-Stephenson, I?th; Alex E. Crosby, Abstract Introduction: Suicide rates in the United States have risen nearly 30% since 1999., and mental health conditions are one of several factors contributing to suicide. Examining stateelevel trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. Methods: Trends in age-adjusted suicide rates among persons aged :10 years, by state and sex, across six consecutive 3-year periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data From the National Violent Death Reporting System, covering 27 states in 20! 5, were used to examine contributing circumstances among decedents with and without known mental health conditions. Results: During 1999?20 16, suicide rates moreased signi?cantly in 44 states, with 25 states experiencing mcreases Rates increased significantly among males and females in 34 and 43 states, rmpectively. Fifty-four percent ofdecedents in 27 states in 201 5 did not have a known mental health condition. Among decedents with available information, several circumstances were signi?cantly more likely among those without known mental health conditions than INSIDE among those with mental health conditions, including 625 Invasive Methicillin-Resistant Staphylococcus oureus relationship problemsi'loss (45.1% versus life Infections Among Persons Who Inject Drugs Six Sites, 2005?201 6 629 Tobacco Product Use Among Middle and High School Students United States, 2011?2017 634 Update: Influenza Activity in the United States During stressors (50.5% versus and recent! impending crises (32.9% versus but these circumstances were common across groups. Conclusions: Suicide rates increased significantly the 201??18 Season and Composition ofthe 2018?19 across most states during 1999?2016. Various Influenza Vaccine circumstances contributed to suicides among persons 643 Update: ACIP Recommendations for the Use of With and without known mental health conditions. Quadrivalent Live Attenuated Influenza Vaccine Implications for Public Health Practice: States United Sis??95: 2018?19 Influenza 59350" can use a comprehensivg evidence?based public 646 Notes from the Hemorrhagic health approach to prevent suicide risk before it Fever Outbreak?Central Uganda, August?September occurs, identify and support persons at risk, prevent 201? reattempts, and help friends and family members in 6?48 QuickStats the aftermath of a suicide. Continuing Education examination available at infolitmliiweekly. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Introduction in 2016. nearly 45,000 suicides population [age-adjusted? occurred in the United States among persons aged :10 years From 1999 to 2015. suicide rates increased among both sexes, ail racial/ ethnic groups, and all urbanization levels (2.3). Suicide rates have also increased among persons in all age groups <75 years, with adults aged 45?64 having the largest absolute rate increase (from 13.2 per 100,000 persons [1999] to 19.2 per 100,000 [2016]) and the greatesr number ofsuicides (232,108) during the same period (1.3). Suicide is the tenth leading cause ofdeath and is one ofjust three leading causes that are increasing in addition, rates ofemergency department visits for nonfatal self-harm, a main risk factor for suicide, increased 42% from 2001 to 2016 (1). Together, suicides and self-harm injuries cost the nation approximately $730 billion per year in direct medical and work loss costs if}. The National Strategy for Suicide Prevention calls for a public health approach to suicide prevention with efforts span? ning multiple levels (individual, famiiyfrelationship, community, and societal]. Such a comprehensive approach underscores that suicide is rarely caused by any single factor. but rather, is deter? mined by multiple factors. Despite this call to action, suicide prevention largely focuses on identifying and tefEtring suicidal persons to mental health treatment and preventing reattempts (6). in addition to mental health conditions and prior suicide attempts, other contributing circumstances include social and economic problems, access to lethal means (eg, substances, firearms) among persons at risk, and poor coping and problem- solving skills Expanded awareness of these additional circum- stances contributing to suicide risk and action to address them can be] reach the national goal, established by the National Action Alliance of Suicide Prevention and the American Foundation for Suicide Prevention, of reducing the annual suicide rate 20% by 2025 To assist states in achieving this goal, CDC analyzed state?specific trends in suicide rates and assessed the multiple contributing factors to suicide; this report presents options for strategies to include in comprehensive suicide prevention efi'orts that are based on the best available evidence. Methods Suicide rates were analyzed for persons aged :10 years because determining suicidal intent in younger children can be difficult (8). Ageaspecific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (International Class?imrion ofDireiases, Fitme- Revision, underlying?cause?ofdeath codes ?37.0. Age? specific population estimates were obtained from U.S. Census Bureau/National Center for Health Statistics bridged?race population data releases. National and staterlevel suicide rate estimates were calculated for six consecutive 3?year aggregate periods spanning i999? 2016 (1999?2001; 2002?2004; 2005?2007; 2003?2010; 2011?2013; and 2014-2016). Rate estimates were age- adjusted to the U.S. 2000 standard population and expressed The of publications is published by the Center for Surveillance. Epidemiology, and Laboratory Services. Centers For Disease Control and Prevention US. Department DE Health and Human Services, Atlanta, GA 30329-4027. Suggc?ed citation: [nudist tomes; first three. then ct .1L. if more than steel [Report title]. MMWR Morb Mortal Wkly Rep 2018;67:linc1usive page numbers]. Centers for Disease Control and Prevention Robert R. Redfield, MD, Dir-retal- Annc Schucllat. MD. Principe! Depend Dirmor Leslie Dauphin. Acting Arterial? Diremar?r .S'rz?mcr Joanne Conn. MD. 542M, Dir-emu [wire 43am.- Quality Chesiey L. Richards, MD. MPH. Deputy Public Health Erin-tri?e 5mm: Michael F. ladetnaico. MD. MPH. Din-am: Center?rr Epidemiology mm'LdiEremmq Service: MMWR Editorial and Produetion Staff [Weaklyl Charlotte K. Kent. MPH. Acting Edimn'n Chief: Executive Editor- Jacqueline Gladier. MD. Editor Mary Dotr, MD. MPH, (Julius Editor Temsa F. Rutledge. Managing fairer Douglas W. Weathuwax. Lead Tat?nimi? Wtr??f?ar Glenn Damon. Soumya Dunworth, Teresa M. Hood. MS. manual Writer-a?oat: Martha F. Boyd. Lew} Visual Specialise Maureen A. Lei-ally. Julie C. Mnrtinroe. SmphenR. Spriggs. Tong Yang. Vitae! In?rmetfm Sammie: 'Quang M. Dean. MBA. H. King. Terraye M. Starr, Mona Yang, In?ramim spa-area MMWR Editorial Boon! Timothy F. Jones. MD. Matthew L. Buuitoo. MD. MPH Virginia A. Cains. MD Katherine Daniel. PM) Jonathan E. Fielding, IulD. MPH, NIBA David Fleming. MD eta MMWR Jun88,2018 r' Vol.6? No.22 William E. Helper-in. MD. DIPH. MPH King K. Holmes. MD. Robin Ikrda. MD. MPH Rim-.1 F. Khabbaz. MD Meadows. MSN. RN Jewel Mullen. MD. MPH. MFA Patricia Quinlislt. MD. MPH Patrick L. Remington. MD. MPH Carlos R'oig. M5. MA Wait-.1.? L. Roper. MD. MPH William Seha?iter. MD US Department of Health and Human ServicesiCemers for Disease Control and Prevention Morbidity and Mortality Weekly Report per 100,000 persons per?year. Age-adjusted suicide rate trends were modeled using the same 3-year data aggregates, employ- ing weighted least-squares regression with inverse-variance weighting. Modeled rate trends are reported in terms oF average annual percentage changes. Characteristics oF persons aged 1:10 years who died by suicide, with and without known mental health conditions, and the circumstances surrounding the suicides were compared in the 27 states? with complete data participating in CDC's National Violent Death Reporting System in 2015. defines mental health conditions as disorders and listed in the Diagnostic and Statistical Manual Disorders, Farr; Edition (9), with the exception oF problematic alcohol use and other subsranee use that are captured separately in VDRS aggregates data From three primary data sources: death certi?cates, coroneri'medical examiner reports (including toxi? cologyl, and law en Forcement reports. A range oF circumstances (relationship problems, life stressors, and recent or impending crises)I have been identi?ed as potential risk Factors For suicide in Circumstances captured are those identi?ed as con? tributing to suicide in coronerfmeclical examiner or law en Force? ment reports, which re?ect inForntation provided by Family and Friends at the time oF death. Decedents could have experienced multiple circumstances. Decedents with and without known mental health conditions were compared using chi-square tests. Logistic regression analyses were used to estimate adjusted odds ratios (aORsl with 95% confidence intervals (Cls), controlling For sex, age group, and tacoll ethnicity. Results The most recent overall suicide rates (representing 2014? 2016} varied FourFold, From 6.9 (District oF Columbia]I to 29.2 (Montana) per [00,000 persons per year (Supplementary Table; Across the study period, rates increased in all states except Nevada (where the rate was consistently high throughout the study period}, with absolute increases ranging From 0.8 per 100,000 (Delaware) to (Wyoming). Percentage increases in rates ranged From 5.9% (Delaware) to 57.6% (North Dakota), with increases >50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2013 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:31:? State Flate Change 2:33"; 1999 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Flank (State Rank} 1l (State Rink} 35111 12.3 We) 12.7 1+ 0.4) 12.3 1+ 0.2) 13.3 1+ 0.3) 14.5 1+ 0.3) 15.4 1+ 0.3) 1.5 31. 1p<.01) Na 3.1 0172.) 25.4 31.1mm 0.8. Male 20.311173) 2121+ 0.4) 21.3 1+ 0.0) 22.5 1+1.3) 23.5 1+ 1.0) 2451+ 1.0) 1.1 31. 1154.01) Female 4.7111711) 5.0 1+ 0.3) 5.3 1+ 0.2) 5.7 1+ 0.4) 3.2 1+ 0.5) 3.3 1+ 0.7) 2.3 31. 111.401) Both 14.31013) 13.4[ 0.91 14.1 0.31 153{+1. 31 13.4 0.71 11 25 +3.1 (311 ?1?0 [331 AL Male 25.1 {?131 23. 4 [1 .71 24.4 1.01 23. 4 2. 01 213 1.11 23.1 1. 51 1.3 ?7'0 Female 5.1 1117a 3-1 0. 3) 5.0 1+ 0.2)11+ 1 1) 341+ 0. 3) 0+10 2.3 31.113401) Both 21.0 24 3 3. 31 24.2 0.3?.4 ?7?0 1131 AK Male 33. 2 {r113} 33.1 4. 91 33.9 0.31 40 1 {4.1112140 1 0.11 42 9 2. 31 1.4 9/13 1134.01} Female 3.3011611 93(? 131 11.1{+ 21 1.21 +13% 013 Both 1?.81013) 13. 19.1 0.51131 (- 0.0) 20.4 1.31 20. 9 0. 51 1.0 ?fa {pt-1.011 15 3.1 {321 +113 ?701421 AZ Male 23.3 30. 2 1. 001 30.3 0.41 30.2 0.51 32. 0 1.31 32.4 0. 41 0.3 We {[34:05} Female 7.1 (1113) .5+1 +0 4) 2 1+ 0.7) 3 31+ 0.5) 3 2112.2 31. 11:14.01) Both 15.5 {?131 15. 3 0. 031 13.2 3. 51 17. 3 1.41 19.2 1.31 21.2 2. 01 2.2 "in 12 5.71141 33.3 "/01151 AH Male 2631013) 23. 2T2 0.5123.2(+ 1.01 31. 7' 3. 51 33.5 91 1.3 {pt-1.051 Female 5.61013)91+ 0. 031 21+ 0.41 911+ .1 3.3 2.11 3.3 ?35 {[34:01} 30111 10.31n7a) 1131+ 0. 7) 11. 010.3) 12. 0 1+ 1.0) 1131.1) 12.1 1+ 0. 3) 0.3 31.113305) 45 1.3 143) 14.3 31. 143) CA Male 17.9 (n13) .51 0.?1 10.1 .1 13.2 0.31 +0.5 ?1?0 Female 4.1 1n7a41+ 0.5) 3-10 .1) 5.3 1+ 0.3) 1.7 31. 1114.05) Beth 17.31r17a) 13.2 1+1. 3) 13.010 2) 2001+ 1.0) 2131+ 1.5) 23.2 1+ 1.3) 1.3 31.111401) 3 5.3 112) 34.1 31.122) 130 Male 233111711) 3031.5 1+ 1.0) 3341+ 1.3) 33.3 1+ 2.3) 1.4 31.113401) Female 7.01n7a) 1..11+ 0.3) 10.1 1+ 1.0) 10.4 1+ 0.3) 2.3 31. 1114.01) 30111 3.31n7a131.1) 11.0 1+ 0.3) 11.5 1+ 0.5) 1.3 31. 1114.05) 43 1.3 143) 13.2 31. 134) CT Male 13.41r17a) 14. 311.3) 15.0 1+ 0.4) 3 31+ 1.3) 17.3 1+ 1.0) 17.3 1- 0.3) 0.3 31. Female 3.3111711) 31+ 0.2) 7 1- 0.2) 41+ 0.7) 4.3 1+ 0.5) 3.2 1+ 1.3) 3.5 31.113305) Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change trorn Prior Period) Current Overall Overall State Sex 1:329? State Flate Change 2:313"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 1513113 Rank) 1 (State Hagnk) Both 13.3 1n1a) 12.2 1- 1.4) 11.0 1- 0. 3) 13. 311+ 14.2 1+ 0.3) 14.4 1+ 0.2) 0.3 31. 1115 42 0.3 150) 5.0 33150) DE Male 23.01n1?a} 2022.? 1- 0.4) 23.5 1+ 0.3) 0.3 31. 013 Female 5.3 13.13.} 5.0 1- 0.1.5} 5.2 1- 0.21 1.5 11.15 Bath 5.9 13.13.} 5.4 1+ 0.0.?1 5.9 1+ 0.3} 0.9 ofo 11.15 51 1.0 1481 15.1 01,10 (45} DC Male 10.? {Na} 11.1 1+ 0.1001-23) 11.? 1+ 0.3 1115 Female 1 11113111 2.3 1+ 0.3)11311.0) 3 1- 0.3) 3.5 31. 013 3001 14.8 13.13.} 15.2 1+ 0.1+21. 4} 15.3 1- 0.01 15.4 1+ 0.1} 0.8 ?2101134051 2'9 4- 1.5 1451 10.5 10148} FL Male 24.3 13.13.} 24.4 1+ 0.25.5 1- 0.51 25.5 1- 0.11 0.5 ofo 11.15 Female 5.3 111113.} 5.8 1+ 0.5} 31+ 0. 0} 11+2 0. 3} 7.5 1+ 0.5} 11.8 1+ 0.3} 1.4 ?fa {114.01} Both 12.9 1n13} 1321+ 0.3} 12. 31-0 .91 1321+ 0. 9} 13.? 1+ 0.5} 15.0 1+ 1.3} 0.9 ofo 1113 3'9 2.1 1401 +152 10144} GA Male 22.1 mm} 23.1 1+ 1.0) .31-1.3) 21 .0 1+0. 3) 2231+ 2441+ 0.5 34. 015 Female 5.0 131318-012151-021 0.3} 5.5 1+ 0.8} 2.1 010113405} Both 12.91313} 11. 1 1- 1.81 10. 31-0 .71 14.51+ 4.1} 14.41- 0.11 1521+ 0.8} 2.0 ?fa 1115 35 2.41351 +133 1-11 Male 20.41n1?a} 2 1-3 .1) 15.3 1- 1.0) 21.0 1+ 22.5 1+ 0.5) 24.3 1+ 1.3) 2.1 31. 013 Female 5.41313} 5.0 1- 0.41 5.5 1+ 0.5} 1 1+ 1.5} 5.2 1- 0.91 5.9 1- 0.31 1.2 11.15 Both 17.3 1313} 1921+ 2.0} 18. 3 1- 0. 91 2151+ 3. 3} 2131+ 0.3} 2431+ 2.8} 2.3 ?21011345.. 01} 3 151 51 43.2 1 7} "3 Male 28.411113} 33.1 1+ 4. 7} 3134.71-13.21 38.0 1+ 3.3} 1.15 0110113405} Female 7.2 .11110.5} 11.8 1+ 2.3} 4.4 ?1101134051 Bath 9.9 11113} 9. 8 1- 0.11 71-0511 10. 5 1+ 0. 8} 11.2 1+ 0.5} 12.2 1+ 1.0} 1.5 0210113405} 44 2.3 1381 22.8 ?110132} lL Male 17.1 111.13} 15H1.41 15.21- 0.41 1751+ 1.4} 18.5 1+ 0.9} 19.31+1.3} +1.1 ?1101134051 Female 11113} 3.5 1-0.01810.4} 5.2 1+ 0.5} 2.4 011: {1341.01} Beth 13.011113} 131491+ 0. 5} 13.4 1+ 1.4} 17.1 1+ 0.7} +1.9 ?fa {1:14.011 25 4.1 1231 31.9 ?313125} Male 22.411113} 23.2 1+ 0.8} 24. 4 1+ 1.2} 24. 7 1+ 0. 4} 25.? 1+ 2.0} 28.3 1+ 1.5} 1.5 Female 4.5 111.13} 5.0 1+ 0.0.9} 5.5 1- 0.21 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Flank 5 {State Rank) Ill (State HEnk) 1.4. Both 11.31n2a1 13.21+1.41 1231-04) 14.2 1+ 1.41 15.9 1+ 1.21 13.0 1+ 0.11 +2.1 241134.011 31 +4.31201 33.2 9.1131 1.4 Male 20.3 1n2a1 22.1 1+ 1.51 20.3 1- 1.41 23.3 1+ 2.51 23.0 1+ 2.21 25. 2 1- 0. 31 1.3 12.. 1134.051 Female 3.710131 431+ 1.0} 531+ 0.61 5.51+ 0.21 5.1 1+ 0.5171+ 0 61 3.8 ?20 113-3. 011 Bath 13.31n1?a1 15.1 1+ 1.8} 1581+ 0.71 15.31- 0.51 17.? 1+ 2.4} 19.41+1.51 2.2 ofo 011 19 5.01111 45.0 01120 1 5} KS Male 22.21n2a1 25.0 1+ 2.31 23.5 1+ 151 25.3 1- 0.91 29.1 1+ 3.51 30. 2 1+ 1.31 1.9 12.. 112.4. 011 Female 4.5 10131 5.0 1+ 1.4} 5. 7 1- 0. 31 5.41- 0.31 5.8 1+ 1.4} 3. 4 1+ 1.51 3.2 01120 (134051 Beth 14.1 1l'I1'ia} 15.41+1.3} 3.1 15.21-11.51 18.21+2.0} 19.3 1+1. 11 1.9 ?20 113-3. 011 20 +5.2 1151 +355 10115} KY Male 25.01n2a1 2331+ 1.91 23. 3 1+1 41 22.2 1- 1.01 30.1 1+ 2.9} 31.2 1+ 1 .31 1.4 02.. 11:4. 011 Female 4.8111118} 5210.1} 7.1 1+ 0.9} 711+ 0. 51 3.2 ?2?0 {114.011 Beth 13.1 {We} 12. 91-0 .1 13.41+ 0.41 1351+ 0.31 14.41+ 0.8} 1701+ 2. 51 +1.6 01120 (134051 27 3.8 112?} 29.3 10125} LA Male 22.9 1n2a1 22. 3 1- 0. 31 22.4 1+ 0 11 23.3 1+ 0.31 23.2 1+ 0.51 22.3 1+ 3 31 1.1 02.. 1115 Female 4.8 [0131 10.21 0.1 1+ 1.2} 5 1+ 1 .41 2.8 ?24 {1:14. 051 Both 14.5 1l'l1'ia15.4 1+ 1.0} 18.9 1+ 3.5} 18. 5 1- 0. 41 2.2 ?2?0 {114.051 21 4.01251 27.4 l:51'3129} ME Male 25.01n2a1 22.91.11 24.31+1 21 25.21+1.11 31.1 1+ 5.41 29.31 .31 1.312.. 1134. 051 Female 5.3 10131 5.3 1- 0012-01311 5.0 1+ 0.7} 7.6 1+ 1.5} 91+ 0. 31 3.1 ?20 113-3. 051 33111 10.010131 1031+ 0.31 101 1-0 .21 1021+ 0.11 1021+ 0.51 1031+ 0.11 0.5 0.31114 0514243 0.3149??1 3.5 :34414901 MD Male 17.511113} 1?.31? 0. 51 17.71+0.41 18.21+0.5} 18.0 1* 0.2] +0.2 019 Female 3.5 111131 3.8 1+ 0.4} 3. 9 1+ 0. 01 0.21 4.1 1+ 0.4} 4.5 1+ 0.41 1.3 ?2?0 {1:14.051 Both 1411113.} 1+ 0.1.0} 9.8 1+ 0.4} 10.0 1+ 0.31 2.3 (1214:2011 48 2.5134 111 35.3 %120 1ml) MA Male 12.1 111.13.} 12,181+ 0.?1 13 31+ 0. 51 1541+ 2.11 15.21- 0.21 1301+ 0.81 2.0 ?fa 1p<.011 Female 3.3 11113.} 2.9 1- 0.41 4.0 1+ 1.01 3.8 1- 0.11 4.8 1+ 1.0} 51* 0.21 3.0 ?2101134051 Both 11.811113} 1251+ 0.?1 1291+ 0. 41 13.91+1.01 1451+ 0.7} 15 01+1.11 +1.9 ?2?0 1134.011 33 3.9 125} 32.9 31:1241 Ml Male 20.0 11113.} 20.9 1+ 0.9} 21.0 1+ 0. 71 22.8 1+ 1.3} 23.9 1+ 1.0} 25. 0 1+ 1 .21 1.5 1p<.011 Female 4.4 111.13.} 4.8 1+ 0.4} 01+ 0. 21 5.3 1+ 0.5} 5.9 1+ 0.3171+ 0.91 2.8 1p<.011 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period} Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {51131113 Rank) Ill (State Hgnk) H. Both 10.71n13} 11.5 1+ 0.31 12.41+0.31 12. 3 1+0. 51 14.2 1+ 1.31 15.0 1+ 0.31 +2.3 31.. 1114. 011 33 +4.31131 40.3 331 31 MN Male 18.31n1?a} 13.31+1.22.3 1+ 1.31 2331+ 0.41 31. 011 Female 3.011113} 421+ 0.581+ 0.5} 91+ 1.2} 4.2 111-3. 01} Beth 12.911113} 14.1 1+ 1.1551+ 0.1} 15. 21- 0. 31 1.1 ?1151134051 35 2.3135} +173 01,10 (40} MS Male 22.9 11113.} 24.5 1+ 1.1} 25.1 1+ 0. 25. 8 1+ 25.9 1- 0.91 5. 3 1-0 .51 ?2?0 1115 Female 4.3 111130.01 5.4 1+ 0.9} 21- 0. 21 2.4 115113301) Beth 14.711113} 14.1 1- 0. 5} 15.4 1+ 1.3} 1001+ 0.7} 17.8 1+ 1.1} 2001+ 2. 3} 2.2 ?151134.011 10 5.3115} 35.4 11?} MD Male 25.3 11113.} 23.71-1 .51 25. 5 1+ 1.9} 20.6 1+ 1.0} 23.9 1+ 2.3} 32. 2 1+ 3. 3} 1.8 ?1151134051 Female 5.4111181} 5.41+ 0.1} 11+ 0. 7} 531+ 0. 2} 7.41+1.1} 3.2 ?fa 1131101} Both 21.1 1013} 22.3 1+ 1.41 23.31+10.1 11 23.? 1+ 2.01 2321+2.51 +2.1 031132.011 1 +3.01 21 33.0 :3.1111 MT Male 35.9 11118.} 37.3 1+ 0.4} 39. 3 1+ 2. 5} 39271-0 .11 41.0 1+ 1.4} 45. 5 1+ 1.3 ?151134.011 Female 371111.11 3.4 1+ 1.31 3.4 1- 0.11 10.0 1+ 1.31 12.3 1+ 2.31 13.1 1+ 0. 451 4.3 0.1. 1134.011 Both 12.71n1?a} 12.2 1- 0.51 12.3 1+ 0.41 11.71- 0.31 13.5 1+ 1.2.1 1421 13.2 :131431 NE Male 22.2 1013} 20.71- 1.51 20.3 1- 0.41 13.3 1- 0 51 22.0 1+ 2.21 23. 3 1+ 1 31 0.3 31. 013 Female 3.3 11118.} 4.2 1+ 0.4} 5.1 1+ 0.1.4} 81+ 0 3} 2.0 1115 B13111 23.3 11113.} 22.5 1- 0.51 22.1 1- 0.51 22.0 1+ 0.5} 21.41- 1.21 23. 1 1+ 1.0} - 0.2 1113 9 - 0.2151} - 1.0 (?10 1511 N11 Male 38.3 111151} 3071-17} 35.1 1- 1.8} 35.6 1+ 0.5} 32.5 1- 3.0.7 ?51: 1113 Female 8.911113} 951+ 0 5} 951+ 0.1} 1001+ 0.4} 1031+ 0.0} 1121+ 4010. +1.5 ?fa {114.01} 30111 13.511113} 12. 51- 1.01 1331+ 0.8} 15.21+1.9} 1531+ 0.5} 20 01+ 2.7 010113405} 17 5.51 81 48.3 1101 3} NH Male 22.5 11113.} 21.1 1-1 .41 21.7 1+ 0.0} 24.3 1+ 3.1} 25.4 1+ 0.5} 30. 6 1+4 5 2} 2.2 0.11:1 1134:. 05} Female 5 3 111131.0} 5.2 1+ 0.4} 5.0 1+ 0.4} 9. 8 1+ 3. 2} 3.9 011: {pt-1. 051 B13111 7.8 11113.} 1- 0.0.9} 9. 2 1+ 0 4} 1.3 ?101114.051 50 1.5 {47} 19.2 313135} NJ Male 13.011113} 13.1 1+ 0.0} 12.010 .51 1371+ 1 1} 14.51+0.8} 14.61+0.1} Female 3 2 11113.} 9 1- 0.31 001+ 9-01.11 3.8 1+ 0.9} 4. 4 1+ 0. 0} 2.3 1115 Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2018 Age-Adjusted Annual Rate per 100,000 Persons [Change 1mm Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2008 2010 2011 2013 2014 2016 Rank 5 1513113 Rank) Ill (State Hgnk) H. Both 22.0 (n13) 22.0 1- 0.1) 21.0 1- 0.2) 23.0 1+ 1.2) 24.1 1+ 1. 1) 20.0 1+ 1 .0) 1.1 01.113405) 4 4.0 124) 13.3 =14. 130) NM Male 38.8 111131.2} 35.8 1- 0.8} 87.1 1+ 1.8} 40.7 1+ 8.8} 0.4 810 1115 Female 8511113.} 1.1} 8.21+0.7} 10.71+2.8} 12.0 1+ 0.8} +3.8 1114. 05} Beth 2.2111151) 1-01 .1) 7111+1. 1) 31- 0.1) 2.1 c1011:1401) 40 2.1 141) 20.3 01.12?) NY Male 12.51n13} 12.210 3) 13.01.+10) 15..41+14) 1451-00) +1.4%1p4.05} Female [010} 01-0 .1) 3.01+0.3) 3.5 4.01+0.5) +4.2 01. 1p4 01) 80111 18.811113} 18.51-13.11 18.71+0.1} 14.21+0.5} 14.51+0.4} 15.31+0.8} +0.8ofo 1114.01} 84 +1.7144} +127 810141} NC Male 22.711113} 22.? 1+ 0.0} 22.2 1- 0.8} 23. 3 1+ 1.1} 28. 3 1+ 0.0} 23. '9 1+ 0. 8} 0.4 ofo 1115 Female 5.0 11113.} 5.5 1- 0.2} 8.2 1+ 0.8} 8.0 1- 0.2.0 ?191134.05} 80111 18.811113} 14.8 1+ 1.8} 10.0 1+ 1.4} 1881+ 0.8} 18.4 1+ 1.9} 2091+ 2. 5} 2.9 810113401} 14 1.81 5} 57.8 8?31 1} ND Male 21.41n1a) 24.0 1+ 3.2) 20.0 1+ 3.4) 2?.1 1- 0.2.5 c1.4113401) Female 5.8 11113.} 4.5 1- 1.0} 8.71- 0.8} 5.7 1+ 2.0} 8. 1 1+ 1.0} 8. 5 1+ 1.8} 8.9 0er 1115 80111 11.011118} 1281+ 0.8} 18.1 1+ 0.8} 13.41+ 0.2} 14. 8 1+ 1 15.81+ 1.0} 2.0 ?19 1134. 01} 82 4.2 121} 88.0 ?10119} 01-1 Male 20.41n1a) 20.0 1+ 0.5) 22.2 1+ 1.3) 22.1 1- 0.1) 24. 2 1+ 2.1) 25. 5 1+ 1.3) 1.5 0.1.1134 01) Female 4.011113} 1+ 0. 4.91+ 0.1} 581+ 0.3.4 1114. 01} 80111 17.011113} 18. 51-0 1721+ 0.8} 18.41+1.1} 20. 7 1+2. 8} 28.51+2.8} +2.8 1% 1134. 05} 7 8.4 110} 87.8%: 112} UK Male 28.5 11113.} 27. 8 1- 1. 2} 27.8 1+ 0.5} 80.8 1+ 2.5} 88. 4 1+ 8.1} 37. 8 1+ 8. 8} 2.0 810113405} Female 8.8 11113.} 8.41-0.21 5 1+ 1 1.0 1- 0.5} 8. 5 1+ 1.8} 10. 8 1+ 1.8} 2.9 1134. 05} 80111 18.411113} 11.? 1+ 1.8} 17 71- 0.0} 18.81+ 0.9} 19.81+1.2} 21.1 1+ 1.8} +1.8 1134. 01} 18 4.8118} 28.2 tT113128} OH Male 21.411113} 2951+ 2.1} 28.51- 0. 9} 2951+ 1.0} 81.4 1+ 1.8} 38.0 1+ 1.8} +1.1 0110113401} Female 8.511113} 1.1 1+ 0.8} 71+ 0. 8} 841+ 0.7} 8. 8 1+ 0. 4} 881+ 0. 9} 2.7 0.11: 1134. 01} 80111 12.1 11113.} 12.5 1+ 0.4} 12.81+0.8} 18.91+1.1} 15.0 1+1. 1} 18.81+1.2} +2.0 ?10 1114.01} 30 +4.1 122} +848 ?310121} PA Male 21.011113} 2131+ 0.8} 2191+ 0. 8} 28.1 1+ 1.2} 24 11+1.7} 28.1 1+ 1.8} +1.5 1134. 01} Female 4.2 11113.} 4.8 1+ 0.8} 81+ 0. 0} 5.4 1+ 0.9} 8. 0 1+ 0.8} 1+ 11} 8.5 0110113401} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons [Change irorn Prior Period) Current Overall Overall State Sex [10:32? State Rate Change 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2016 Rank 5 {State Hank) Ill (State Hgnk) H. Bath 9.4 {ma} 9.0 (- 0.3} 9.0 (- 0.0} 12. 51+ 3. 5} 11.9 (- 0.9} 12. 511+ 0. 7} 2.5 92. 032.05} 43 3.2 (30 34.1 35 (23 at Male 15.4 {ma} 15.2 0.2} 14.5 1- 0.3} 21.2 5.4} 19.2 1- 2.11.5 Female 4.0 {Na} 3.3 (- 0.7} 3.3 0.4} 5.1 1.3} 5.1 0.0} 1.0} (p4. 05} Beth 12.301113} 13.0 0.2} 13.7 0.7} 18.0 11} 2.3 ofo (D4. 01} 23 4.9 33.3 We (10} 80 Male 21.3 {ma} 2251+ 1 22.31- 0.1} 2451+ 2.2} 25.1 1+ 1.5} 25.0 1+ 1 9} 1.5 95 {52. 01} Female 5.401.113} ?(ill 6.0 1.3} 5.2 0.1.4} 3.4 ofo (p4. 05} Beth 15.701113} 17.1 {[3401} 10 +44.5 ?Vc? 5} SD Male 2?.5 {ma} 2531.3} 229 1+ 1.5} 30.11.5} 1.5 54. {p4. 01} Femaie 4.2 {ma} 5.5 5.4 1+ 0.1.(p2. 01} Beth 14.501113} 15.2 0.6} 16.1 0.8} 1?.2 1.1} 17.2 0.0} +1.4 ofo (p4. 01} 22 3.5128} 24.2 3?3 (31} TN Male 25.1 {ma} 25.4 1+ 0.3} 25.5 1+ 1.3} 25.0 1+ 1.2} 25.5 1+ 0.5} 29. 5 1+ 1.2} 1.2 54. (52. 01} Female 5.4 {Na} 5.3 0.9} 6.7 0.4} 7.5 0.8} 6.9 0.6} 16 0. 7} 1.9 ofo (D4. 05} Both 12.20118} 12.? 0.6} 12. 0. 4} 13.2 0.9} 13.6 0.3} 14. 5 0. 9} 1.1 ?2?5 01} 41 2.3 (37} +139 We (36} TX Male 20.4 {Na} 20.9 0.5} 20. 4 (- 0. 5} 22.0 1.6} 22.2 0.3} 23.1 0. 9} 0.9 ofo (p4. 05} Female 4.3 {Na} 5.4 0.5} 5.0 (- 0.4} 5.2 0.2} 5.6 0.4} 0. 8} 1.6 (p4. 05} Both 17.2 (1115} 19.0 18.2 (- 0.7} 20.2 2.0} 24.0 3.8.01: 3 W) 45.5 4 11} UT Male 28.2 (0.15} 31.1 2.9} 29.4 (- 1.7} 32.1 2.7} 37.8 5.7} 38. 0 0.2} 2.1 011: 05} Female 6.3 [015} 7.4 0.6} 7.5 0.1} 8.5 10.6 2.1} 12. 6 2. 0} 4.4 ?2?5 01} Both 18.2 14.9 1.3} 18.? 2.1} 19.? +2.4 01} 13 9} +436 Wed 2} VT Male 23.6 (1115} 28.3 4.6} 24. 3 (- 4. 0} 27.3 3.0} 31.0 3.7} 32. 5 1.9 4% (D4. 05} Female 4.3 (11.15} 5. 2 0. 9} 6.4 1.3} 5.6 0.2} 7.3 0.7} 7. 6 0.3} 3.8 011: 01} Both 12.81015} 12. 12.9 0.3} 13.6 0.7} 14.6 0.9} 15. 0 0 5} +1.2 ?2?0 01} 37 2.2 (39} +174 3?5 (41} VA Male 21.6 {015} 21.3 0. 2} 21.0 0.4} 22.5 1.5} 23.6 23. 9 0. 2} 0.9 Female 5.3 {015} Ht, 5 9 0.7} 6 (- 0.3} 6.4 0.8} 5. 9 0. 5} 1.3 (D4. 05} Supplementary Table. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 - 2015 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period) Current Overall Overall State Sex 1? State Rate Change 2:33"; 1999' 2001 2002 2004 2005 2007 2003 2010 2011 2013 2014 2015 Rank 5 (State Hank) (State Hagnkji Both 14.3 1n1a} 15.4 1+ 3.5} 14. 3 1-3 15. 711+ 3. 31 16.6 1+ 3.3} 17.6 1+ 1.3} 1.1 331133.351 24 2.3 1331 13.3 :13137} WA Male 24.71nra1 25.2 1+ 3.5} 24.1 11.11 25.1 1+ 1.3} 23.3 1+ 3.3} 27.1 1+ 1.1} 3.6 33 1113 Female 5.9 111.13.} 5.4 1+ 0.0.8} 3.5 1+ 0.8} 2.5 112M011 Both 15.31nra} 17.21+ 1.6} 16. 71- 3. 51 16.31.71 1321+ 3.2} 21.41+ 2.2} +1.3 33 11 5.3113} 37.133114} wv Male 27.2 {ms} 33.1 1+ 2.3} 2331-15) 27. 31- 1. 31 3151+ 3.3} 33.5 1+ 2.3} 1.1 33 1115 Female 5.3 111.13.} 5.5 1+ 0.1} 5.8 1+ 0.3} 5.3 1- 0.5} 7.5 1+ 2.3} 9.8 1+ 2.2} :1er 1115 Both 13.1 13.5 1+ 0.4} 14.0 1+ 0.5} 15.0 1+ 1.0} 15.3 1+ 0.3} 15.5 1+ 1.2} 1.5 112M011 23 3.4129} 25.8 10130} w1 Male 21.71nra} 22.2 1+ 3.5} 22.7 1+ 3.5} 24.3 1+ 1.2} 24.4 1+ 3.4} 25.7 1+ 1.3} 1.1 33 1133.31 1 Female 5.1 {hrs} 5.3 1+ 3.2} 5.6 1+ 3.4} 341+ 3.71 3.5 1+ 3.1} 7.5 1+ 1.3} 2.5 33153.31} Both 20.71nra1 23.4 1+ 2.7} 22.5 1- 3.31 25.4 1+ 2.3} 23.3 1+ 3.5} 23.3 1- 3.11 2.3 031133.311 3 3.1 1 11 33.3 =13 1 3} WY Male 34.3 39.3 1+ 4.5} 35.3 1- 3.0} 41.5 1+ 5.2} 47.1 1+ 5.6} 44.5 1- 2.4} 1.8 112M051 Female 7.7111131} 3.2 1+ 3.6} 3.2 1+ 3.3} 3.4 1+ 3.2} 13.7 1+ 1.4} 12.3 1+ 1.3} 3.2 33 11:13.31 1 Rates are age?adjusted to the US. year 2000 standard. 1 Model?estimated average annual percentage change based on all reporting periods; p?value indicates statistical significance of trend; indicates trend not significant. ?5 Current state rank (50 states and the District of Columbia} is for the reporting period 2014 2016. Ranks are from highest rate (11 to lowest rate (511. Different ranks do not necessarily imply a statistically significant difference. 1 Overall rate change is between the first (1999 20011 and last [2014 20161 reporting periods. Hanks are from largest increase {11 to largest decrease 1511. Different ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the first 11999 20011 and last (2014 2015) reporting periods. Ranks are from largest percentage increase 111to largest percentage decrease 1511. Different ranks do not necessarily imply a statistically significant difference. TT Hate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. till Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. State Abbreviations: AL Alabama; AK Alaska; AZ Arizona; AR Arkansas; CA California; CO Colorado; CT Connecticut; DE Delaware; DC District of Columbia; FL Florida; GA Georgia; HI Hawaii; ID Idaho; IL Illinois; IN Indiana; IA Iowa; KS Kansas; KY Kentucky; LA Louisiana; ME Maine; MD Maryland; MA Massachusetts; MI Michigan; MN Minnesota; MS Mississippi; MO Missouri; MT Montana; NE Nebraska; NV Nevada; NH New Hampshire; NJ New Jersey; NM New Mexico; NY New York; NC North Carolina; ND North Dakota; OH Ohio; OK Oklahoma; OR Oregon; PA Fthode island; SC South Carolina; SD South Dakota; TN Tennessee; TX Texas; UT Utah; VT Vermont; VA Virginia; WA Washington; WV West Virginia; Wisconsin; WY Wyoming. From: Sokler, Sent: 20 Apr 2018 14:26:25 -0400 To: Simon, Thomas Deborah Cc: Sokler, Richard A. Brandy Shannon L. icocxooxoaocl Subject: FW: June Vital Signs - Suicide Prevention - MMWR early draft Attachments: MMWR Text_V1_4.10.18_4.30pm D5.docx, MMWR Tables_V1_4.10.18_4.30pm DS.docx Hi Folks, Just wanted you to know that Dr. Redfielo? asked for a copy of the MMWR now so that he can determine whether he or Anne Schuchat will do the Telebriefing. Either one is probably a good thing! Will keep you posted. From: Sokler, Sent: Friday, April 20, 2018 2:21 PM To: Daniel, Katherine Lyon Subject: June Vital Signs - Suicide Prevention - MMWR early draft This is an early draft of the MMWR. Currently, the pre-brief with Anne accommodate her trayel schedule we set up the media telebrief and launch of the Vital Signs for Thursday, June 7. Invites have been issued. If Dr. Redfield is able to and wants to do this one, is it possible to change to our normal Tuesday, June 5 schedule? FYI and isn?t any deciding factor at all, but i am on leave and on a plane on June 7, but I am here on June 5. Please let us know, Thanks, OJ woo-4Rev 4.10.18 Short Title: Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Deborah M. Stone, ScD,?l Thomas R. Simon Katherine A. Fowler, Scott R. Kegler, Keming Yuan, Kristin M. Holland, Asha Z. Ivey-Stephenson, Alex E. Crosby, M01 Background: Suicide rates in the United States have risen nearly 30% since 1999. Mental health problems (MHP) are just one factor contributing to suicide. Examining state-level trends in, and the multiple contributing circumstances to, suicide can inform comprehensive state suicide prevention planning. Methods: Trends in age?adjusted suicide rates among people aged 210 years, by state and sex, across six consecutive three?year periods (1999-2016), were assessed using data from the National Vital Statistics System for 50 states and Washington, D.C. Data from the National Violent Death Reporting System, covering 2? states in 2015, were used to examine contributing circumstances among decedents with and without known mental health problems (MHP). Results: From 1999-2015, suicide rates increased significantly in 44 states, with 25 states experiencing increases of more than 30%. Rates increased significantly among males and females in 34 and 43 states, respectively. In 2015, more than half of decedents in 27 states did not have a known MHP. Among people with circumstance information, several circumstances, including relationship problems/loss (45.1% vs life stressors (54.2% vs and recent/im pending crises (32.9% vs 26.0%) were significantly more likely among those without a known MHP than decedents with MHP, but were common across groups. Conclusions: Suicide rates increased significantly across most states from 19992016. Various circumstances contributed to suicides among people with and without known MHP. Implications for Public Health Practice: States can use a comprehensive evidence~based public health approach to prevent suicide risk before it occurs, identify and support people at risk, prevent reattempts, and help friends/family after a suicide occurs. INTRODUCTION BACKGROUND AND PURPOSE In 2016, nearly 45,000 suicides [age?adjustedii occurred in the United States (US), among people 210 years old (1). Between 1999 and 2015, suicide rates increased across sexes, racialfethnic groups, and urbanization levels Suicide is the 10"h leading cause of death and is one ofjust three leading causes that are increasing (1, Additionally, rates of emergency department visits for nonfatal self?ha rm, a key risk factor for suicide, increased nearly 45% between 2001 and 2015 (1). Together, suicides and self-harm injuries cost the nation more than $69 billion in direct medical and work loss costs (1). The National Strotegyfor Suicide Prevention{NSSP) calls for a public health approach to suicide prevention with efforts spanning across multiple levels individual, familylrelationship, community, and societal}. Such a comprehensive approach underscores that suicide is rarely caused by any single factor, but rather, is multi- determined. Despite the NSSP guidance, suicide prevention largely focuses on identifying suicidal people, providing treatment for mental health problems (MHP) and preventing re?attempts (6). In addition to and prior attempts, other contributing circumstances to suicide include social and economic problems, access to lethal means substances, firea rms} among people at risk, and poor coping and problem?solving skills Expanded awareness of these additional circumstances contributing to suicide risk and action to address them, can help reach the nation?s goal of reducing suicide rates 20% by 2025 (7). To assist states in achieving this goal, Rev 4.10.18 this study analyzes state-specific trends in suicide rates, assesses the multiple contributing factors to suicide, and provides options for multi~leve comprehensive suicide prevention based on the best available evidence. METHODS Suicide rates were analyzed for people aged 3:10 years only, as determining suicidal intent in younger children can be difficult Age-specific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (international Classi?cation of Diseases 10*? Revision, underlying-cause-of death codes X60- X84, Y87.0, Age-specific population estimates were obtained from U.S. Census Bureaquational Center for Health Statistics bridged-race population data releases. National and state-level suicide rate estimates were calculated for six consecutive three-year aggregate periods spanning 1999-2016. Rate estimates were age-adjusted to the U.S. year 2000 standard population and expressed per 100,000 persons per year. Age-adjusted suicide rate trends were modeled using the same three-year data aggregates, employing weighted least squares regression with inverse-variance weighting. Modeled rate trends are reported in terms of average annual percentage changes Characteristics and circumstances of suicide decedents 210 years old, with and without known MHP, were compared in the 27 states with complete data participating in National Violent Death Reporting System in 2015. defines MHP as disorders and listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with the exception of alcohol and other substance dependence, which are captured separately in aggregates data from three primary data sources: death certificates, coroner/medical examiner reports (including toxicology], and law enforcement reports. Decedents with and without known MHP were compared using Chi-square tests. Logistic regression analyses estimated adjusted odds ratios with 95% confidence intervals controlling for age group, sex, and racelethnicity. RESULTS The most recent overall suicide rates {representing 2014-2016] varied four-fold, from 6.9 to 29.2 (Montana) per 100,000 persons per year (Table Across the study period, rates increased in all states, except Nevada (which had a consistently high rate throughout], with absolute increases ranging from +0.8 {Delaware} to +8.1 [Wyoming] per 100,000. Percentage increases in rates ranged from +5.53% [Delaware] to +57.6% (North Dakota], with increases of more than 30% observed in 25 states {Table 1, Figure Modeled suicide rate trends indicated significant increases for 44 states, for males {34 states] and females {43 states], as well as for the U.S. overall (Table Nationally, the model?estimated AAPC for the overall suicide rate was By sex, estimated national rate trends further indicated significant increases for males (AAPC and females (AAPC Suicide decedents without known MHP were compared to those with MHP in 27 states. While all decedents were predominately male [Table 2; 76.8%] and non-Hispanic white those without known MHP, relative to those with MHP, were more likely male {83.6% vs. 68.8%; odds ratio 95% CI 2.2-2.5] and racial/ethnic minorities range: Suicide decedents without known MHP also had significantly greater odds of perpetrating homicideesuicide {adjusted odds ratio 2.9, 95% CI 2.23.8]. Among adult decedents, 20.1% ofthose without known MHP and 15.3% of those with MPH ever served, or were currently serving, in the US. military. While firearms were the most common method of suicide used overall and for both groups, decedents without known MHP were more likely to die by firearm (55.3% vs. 40.6%] and less likely to die by 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 Rev 4.10.18 {26.9% vs 31.3%) or poisoning {10.4% vs 19.8%) than those with known MHP. These differences remained significant in the adjusted models. Decedents without known MHP were less likely to receive toxicology testing. Among those with toxicology results, decedents without known MHP were less likely to test positive for any substance overall 95% such asopioids (3082.90 95% but more likely to test positive for alcohol 95% All suicide decedents with MHP and approximately 85% without known MHP had available circumstances information {Table 3). People without known MHP were less likely to have any substance abuse problems 95% While two-thirds of those with known MHP had a history of mental health or substance abuse treatment just over half were in current treatment. Decedents without, versus those with, known MHP, had significantly greater likelihood of any relationship problemfloss {45.1% vs. specifically intimate partner problems {30.2% vs. arguments/conflicts {12.5% vs. and recently perpetrating interpersonal violence vs. They also were more likely to have experienced any life stressors {54.2% vs such as criminal~legal problems vs. or evictionfloss of home vs. and were more likely to have had a crisis within the preceding or upcoming two weeks {32.9% vs. All of these differences remained significant in the adjusted models. Among all people with crises, intimate partner problems were the most common types and did not differ by group. Similarly, among people without versus with MHP, physical health problems (23.2% and 21.4%) and jobffinancial problems {15.6% and 16.8%) were commonly experienced by both groups. Decedents without known MHP had significantly lower odds of recent release from any institution 95% but among those who were recently released {5196), they were significantly more likely to be released from a correctional facility {25.7% vs. hospital [43.7% vs. or other facility alcoholfsubstance treatment) 95% than those with a known MHP. Among decedents with known MHP who were recently released from an institution 46.7% of this group were released from facilities. Decedents without known MH P, compared to those with MH P, were significantly less likely to have a history of suicidal ideation {23.0% vs. 40.8%) and prior suicide attempts {10.3% vs. More than one in five people in both groups disclosed suicide intent (22.4% vs. Conclusions and Comments From 1999-2016, 44 states saw significant increases in suicide rates and 25 states experienced substantial increases in suicide rates of more than 30%. Rates increased significantly among males, in 34 states, and females, in 43 states. This finding is consistent with prior research showing a decreasing gender gap in male? female suicide rates between 1999-2014 Additional research into the specific causes of these trends is necessary. Fortunately, data from the 2? states participating in provides important insight into suicide circumstances and can help states identify prevention priorities. Suicidologists regularly state that suicide is not caused by a single factor; however, suicide prevention is often oriented towards identification of suicidal people, treatment of MHP and prevention of reattempts. Additional focus on non?mental health factors, further upstream, is essential to a public health approach as the current study found that more than half of suicide decedents in did not have a known MHP. This group suffered more from relationship problems and other life stressors such as criminal-legal matters, eviction/loss of home, and recent or impending crises. 125 126 127 128 129 130 131 132 133 134 135 .136 13?? 138 139 140 141 142 143 144 145 146 147r 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 Rev 4.10.18 Similarly, people with MHP often experienced relationship problems and other life stressors such as job/?financial and/'or physical health problems. These findings point to the need to both help people manage the conditions associated with mental health problems in the first place, and to support people with known MHP to decrease their risk of poor outcomes Two?thirds of this group had a history ofany mental health andfor substance abuse treatment, with over half in treatment when they died. This suggests the need for additional safety supports, including broader implementation of affordable and effective treatment modalities such as doctor-patient collaborative care models and proven cognitive-behavioral therapies. Additionally, greater access to behavioral health providers in underserved areas is needed, as is expansion of healthcare systems needed that integrates physical and behavioral health with a priority on suicide prevention and patient safety, especially through care transitions Comprehensive statewide suicide prevention activities are needed to address the full range of factors contributing to suicide. Prevention strategies include: strengthening economic supports housing stabilization policies, household financial support]; teaching coping and problem-solving skills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social connectedness to increase a sense of belongingness and access to informational, tangible, emotional, and social support; and identifying and better supporting people at risk Veterans, people with physicalfmental health problems) (121. Other strategies include creating protective environments reducing access to lethal means among people at risk, creating organizational and workplace policies to promote help-seeking, easing transitions into and out of work for people with MHP and other life challenges], supporting family and friends after a suicide, and assuring safe reporting by the media in order to prevent suicide contagion (12). Some states, such as Colorado, are planning to implement such a comprehensive approach to suicide prevention These findings have at least three limitations. In the state?level analysis, rankings for four states (MD, MA, RI, might have been impacted by large proportions of injury deaths of undetermined intent (potentially biasing reported suicide rates downward), or decreased percentages of such deaths over time [potentially biasing estimated rate trends upward}. Second, is not yet nationally representative; the 27 states included represent 49.6% of the population Third, abstractors of data are limited to information contained in investigative reports. Therefore, the extent of informant knowledge can impact data completeness and accuracy. Studies including more in-depth interviews with next-of-kin often see greater attributions to mental disorders however many methodological variations across studies exist it is likely that some people without known MHP in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. Nonetheless, the high prevalence of diverse contributing circumstances among those with and without known MHP suggests the importance of addressing the broad range of factors that contribute to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are available. States and communities can use data from and resources such as Preventing Suicide: a Technical Package of Policies, Programs, and Practices (12) to better understand their suicide problem, prioritize evidence-based comprehensive suicide prevention, and save lives. Acknowledgments Rev 4.10.18 The authors acknowledge Robert Anderson, Holly Hedegaard, and Margaret Warner from the Division of Vital Statistics, National Center for Health Statistics, CDC, for their statistical consultation. Conflict of Interest No conflicts of interest were reported. Corresponding author: Deborah M. Stone, dstone3@cdc.gov 770-438-3942 Author Affiliations: 1Division of Violence Prevention, National Centerfor Injury Prevention and Control, 2Division of Analysis, Research, and Practice Integration, National Center for Injury Prevention and Control, CDC References: 1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System Atlanta, GA: National Center for Injury Prevention and Control. Retrieved March 15, 2018. In. 2. lvey?Stephenson AZ, Crosby AE, Jack SPD, Haileyesus T, Kresnow-Sedacca MJ. Suicide Trends Among and Within Urbanization Levels by Sex, Race/Ethnicity, Age Group, and Mechanism of Death - United States, 2001-2015. MMWR Surveill Summ 3. Curtin SC, Warner M, Hedegaard H. increase in suicide in the United States, 1999?2014. In: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics Hyattsviile, 2016. 4. Kochanek K, Murphy 5, Xu J, Arias E. Mortality in the United States, 2016. NCHS Data Brief, no 293. National Center for Health Statistics 201?. 5. Office of the Surgeon General, National Action Alliance for Suicide Prevention. 2012 National strategy for suicide prevention: Goals and objectives for action: a report of the US Surgeon General and of the National Action Alliance for Suicide Prevention. 2012. 6. Zalsman G, Hawton K, Wesserman D, van Heeringen K, Arensman E, Sarchia pone M, et al. Suicide prevention strategies revisited: 10-year systematic review. The Lancet 7. Torguson K, O'Brien A. Leading Suicide Prevention Efforts Unite to Address Rising National Suicide Rate. in. Washington, 2017. 8. Crepeau-Hobson F. The Autopsy and Determination of Child Suicides: A Survey of Medical Examiners. Archives of Suicide Research 9. American Association. Diagnostic and statistical manual of mental disorders American Pub; 2013. 10. Caine ED, Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Injury prevention 11. World Health Organization. Risks to mental health: An overview of vulnerabilities and risk factors. Geneva: WHO 2012. 12. Stone DM, Holland KM, Bartholow BN, Crosby AE, Davis SP, Wilkins N. Preventing suicide: A technical package of policies, programs, and practice. 2017. 13. Milner A, Sveticic J, De Leo D. Suicide in the absence of mental disorder? A review of autopsy studies across countries. Int Soc 14. Pouliot L, De Leo D. Critical issues in autopsy studies. Suicide Life Threat Behav Attachments: MMWR TablesgV1_4.10.18_4.30pm_DS Word Count: 1903} 1800 Table 1. Trends in Suicide Rates among Persons 1: 19 Years of Age, by State and Sex, National Vital Statistics System, 1999 2015 Age-Adjusted Annual Rate per 109,999 Persons {Change from Prior Period) Current Overall Overall State Sex State Rate Change 2:229"; 1999 2091 2002 2904 2095 2007 2903 2010 2011 2913 2914 2015 Rank (State Rank) 11 (State Ragnk) H. Both 12.3 (We) 1271+ 0.4) 12.9 0.2) 13.31+ 0.9) 14.5 1+ 0.3) 1541+ 0.9) 1.5 c111154.01) nia 3.1 (Na) 25.4 a. (nia) U.S. Male 29.9 (nia) 2121+ 0.4) 2131+ 0.0) 22.5 23.51+1.0) 24.51+1.0) Female 4.7 5.0 1+ 0.3) 5.3 1+ 0.2) 5.7 1+ 0.4) 5.2 1+ 0.5) 5.9 1+ 0.7) 2.5 %1p<.01) Both 14.3 (nia) 13.41- 0.9) 14.1 1+ 0.5) 15.51+1.5) 15.41+ 0.7) 17. 51+ .1) +1.5 %1p<.05) 25 3.1131) 21.9 %133) AL Male 25.1 (nia) 23.4 (- 1.7) 24.41+ 1.0) 25.41+ 2.0) 27.5 1+ 1.1) 29.1 1+ 1. 5) 1. 3 ?/61 (cs. 05) Female 5.1 (nia) 4.31- 0.3) 501+ 0.2) 1 5.41+ 0.3) .01+ 0. 7) 2. 5 5'41 01) Both 21.0 (nia) 2431+ 3.3) 24.21- 0.5) 2501+ 1.7) 25.41- 0.5) 2331+ 3.4) +1 7 (psi 05) 2 7.31 4) 37.4 113) AK Male 33.2 (nia) 3311+ 4.9) 3391+ 0.3) 40.1 1+ 1.2) 40.1 1- 0.1) 42. 9 1+ 2. 3) +1.4 1p<. 01) Female 3.51nia) 11.41+ 2.9) 9.31-1.5) 11.1 1+ 1.2) 991-12nis Both 17.31nia) 1351+ 0.7) 19.1 1+ 0.5) 19.11- 0.0) 20. 4 1+ 1.3) 20. 9 1+ 0. 5) +1.0 %11.p< 01) 15 3.1132) 17.3 142) .42 Male 29.3 (nia) 3021+ 1.0) 30. 5 1+ 0.4) 30. 2 1? 0.5) 32. 0 1+ 1.1pc. 05) Female 7.1 (nia) 7.51+ 0.4) 21+ 0.7) 51+ 0.5) 21+ 0.5) 91+ 0. 5) 2. 2 1p<. 01) Both 15.5 We) 1531+ 0.3) 15.21+0.5) 1751+ 1.4) 1921+ 1.5) 21 g..21+20) 01) 12 +5.7114) +35.3%115) AR Male 25 71nia) 2571+ 0.0) 27. 2 1+ 0.5) 23. 2 1+ 1.0) 31. 7 1+ 3.5) 33. 5 1+ 1. 9) 1.5 5'41 1pc. 05) Female 5.5 (nia) 5.91+ 0.3) 5. 2 1+ 0 4) 91+ 1.7) 7.51- 0.4) 51+ 2.1) 3. 5 31:1 01) Both 10.5 (nia) 11.3 11 .01- 03) 12.01+1.0) 11.31- 0.1) 121 05) 45 1.5145) +14.3%145) CA Male 17.9 (nia) 1341+ 0.5) 17.7-( l0.7) 19.1 1+ 1.4) 13.9 (-0.2) 19.21+0.3) +05% nis Female 4.1 (nia) 501+ 09) 4. 0. 1) 41+ 0.5) 5. 3 1- 0.1) .51+ 0. 3) 7 5'41 1pc. 05) Both 17.31nia) 19.21+1.9) 19. 01-0 2) 20. 0 1+ 1.0) 21.51+1.5) 2321+ 15) 1.3 (psi 01) 3 5.9112) 34.1 122) CO Male 23.5 (nia) 3091+ 2.3) 30.510 .4) 31.51+1.0) 33.41+1.9) 35. 3 1+ 2. 9) +1.4 1p<. 01) Female 7.0 (nia) 3.21+1.3) 321+ 0.0) 11+ 0.9) 10.1 1+ 1.?/61 (cs. 01) Both 9.5 (nia) 3.91? 0.7) 9.1 1+ 0.2) 10. 2 1+ 1.1) 11.01+ 0.3) 1151+ 0.5) +1.5 (cs. 05) 45 1.9143) +192 11211134) CT Male 15.4 (nia) 14.5 1? 1.3) 1501+ 0.4) 15. 5 1+ 1.5) 17. 5 1+ 1.0) 17.31- 0.3) 0.9 his Female 3.5 (nia) 331+ 0.2) 3.71- 0.2) 41+ 0.7) 91+ 0.5) 5.21+ 1.3) 3.5 %1p<.05) Rates are age-adjusted to the US. year 2000 standard. Model-estimated average annual percentage change (MPG) based on all reporting periods; p?yalue indicates statistical signi?cance oftrend; nis indicates trend not significant. Current state rank (59 states and the District of Columbia) is for the reporting period 2014 2015. Ranks are from highest rate 11) to lowest rate (51). Differences between ranks do not necessarily imply a statistically signi?cant difference. 17 Overall rate change is between the first (1999 2001) and last 12014 2015) reporting periods. Ranks are from largest increase 11) to largest decrease (51). Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the first (1999 2001) and last (2014 2015) reporting periods. Ranks are from largest percentage increase 11} to largest percentage decrease 151). Differences between ranks do not necessarily imply a statistically signi?cant difference. if Rate based on 20 suicides. 59 Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. Table 1. Trends in Suicide Rates among Persons 7: 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period}* Current Overall Overall State Sex State Rate Change 2:21:19"; 1999 2001 2002 2004 2005 2007 2008 2010 2011 2013 2014 - 2016 Rank 5 {State Rank} 1? (State REnk} Both 13.6 1n1a1 12.21.41 1191? 0.31 13.61+ 1.71 14.21+ 0.61 14.41+ 0.21 0.9 nis 42 0.81501 5.9 ?it: 1501 DE Male 23. 0 1n1a1 20.31.71 1991- 0.41 23.1 1+ 3.21 22. 71- 0. 41 2351+ 0.81 0.6 ?fa Female 31ni'a1 010 .21 4.61? 0.41 91+ 0.31 6. 41 1.51 21- 0.21 1.6 nl's Both 91nia1 6.41+ 0.51 6.41? 0.01 31+ 0.81 6?01.71 6.91+ 0.31 0.9 ?fa 51 1.01481 16.1 ?it 1451 DC Male 10.71n1a1 11.11+ 0.41 10.31; 0.81 12.71+ 2.41 10. 012 .61 11. 71+ 1.71 0.3 ?it: nis Female 1.71nia1?FT 2.31+ 0.611?r 331+ 1.01 61- 0.71 3.61+ 1018-0181 3.5 ?fa Both 14.81n1a1 1521+ 0.41 14.91- 0.31 16. 3 1+ 1.41 16. 31?0 .1 16.41+ 0.11 0.8 301p<.051 29 1.61451 10.6 i131481 FL Male 24.3 1n1a1 24.41+ 0.11 23.61- 0.81 26. 2 1+ 2.61 25. 61 0. 61 25.6 1?0. 11 0.5 ?it. Ms Female 6 3 (ma) 681+ 0.51 6.81+ 0.0111+ 0.31 7.61+ 0.51 81+ 0.31 1.4 301p<011 Both 12.91n1a1 13.21+ 0.31 12.31? 0.91 13. 2 1+ 0.91 13.71+ 0.51 1501+ 1.31 0.9 ?it; nits 39 2.1 1401 +162 131441 GA Male 22.1 1n1a1 23.1 1+ 1.01 21311.81 .91+ 0.61 2261+ 0.71 24.-41+ 1.71 0.5 ?fa nl's Female 5.0 1n1a1810.21 4.6 1- 0.2151+ 0.91 5.8 1+ 0.31 6.6 1+ 0.81 2.1 ?fa 1p<.051 Both 12.91nla1 11. 1 11.81 10.31- 0.71 14. 5 1+ 4.11 14.41? 0.11 1521+ 0.81 2.0 ?fa 35 2.41351 18.3 I1111381 HI Male 20.4 1n1a1 17.21.11 15.3 1- 1.91 21. 91+ 6.71 2251+ 0.51 24.31+ 1.81 2.1 ?fa Female 5.4 1n1a1010.41 551+ 0.5111+ 1.51 21- 0 91 5.91- 0.31 1.2 ?fa nl's Both 17.31n1a1 1921+ 2.01 18.31? 0.91 21. 61+ 3.31 2191+ 0.31 24.71+ 2.81 2.3 3611:1101} 6 7.51 61 43.2 1 71 ID Male 28.4 1n1a1 33.1 1+ 4.71 31.1 1? 2.01 3 91+ 3.81 71- 0 21 3801+ 3.31 1.6 301p<051 Female 7.2 1n1a1 6.1 1- 1.11 6.1 1+ 0.0101+ 2.91 9.51+ 0.51 11.81+ 2.31 4.4 1p<.051 Both 9.9 1n1a1 9.81? 0.11 9.71- 0.11 10. 6 1+ 0.81 11.21+ 0.61 1221+ 1.01 1.5 3131p<.051 44 2.31381 22.8 ?it 1321 IL Male 17.1 1n1a1 16.71? 0.41 16.2 1- 0.41 17. 61+ 1.41 18.51+ 0.91 1981+ 1.31 1.1 36113105) Female 3.7 1n1a1 3.814 0.01 381+ 0.2121+ 0.41 4.51+ 0.41 521+ 0.61 2.4 301p<011 Both 13.01n1a1 13.71+ 0.71 14.41+ 0. 71 1491+ 0.51 16.41+1.41 17.11+ 0.71 +1.9 31: 1p<.011 26 4.11231 31.9 13125} IN Male 22.4 1n1a1 23.21+ 0.81 24. 41+ 1.21 24. 71+ 0.41 2671+ 2.01 28.31+ 1.61 1.5 36113101} Female 4.6 1n1a1 501+ 0.41 531+ 0.2191+ 0.61 681+ 0.91 6.61? 0.21 2.7 361131011 Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change 1AAPC1 based on all reporting periods; p-yalue indicates statistical signi?cance of trend; nits indicates trend not significant. Current state rank 150 states and the District of Columbia1 is for the reporting period 2014 2016. Ranks are from highest rate 111 to lowest rate 1511. Differences between ranks do not necessarily imply a statistically signi?cant difference. ?7 Overall rate change is between the first (1999 20011 and last (2014 2016) reporting periods. Ranks are from largest increase 111 to largest decrease 1511. Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst (1999 20011 and last (2014 20161 reporting periods. Ranks are from largest percentage increase 111 to largest percentage decrease 1511. Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. Table 1. Trends in Suicide Rates among Persons 7: 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Rate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex [10:35? State Rate Change 2:21:19"; 1999 2001 2002 2004 2005 200? 2008 2010 2011 2013 2014 - 2016 Rank 5 (State Rank) 17 (State ank) Both 11.8 (nia) 13.2 1.4) 12 8 0.4) 14.2 1.4) 15.9 16.0 0.1) 2.1 31 4.3 (20) 36.2 ?it: (18) IA Male 20.6 (nia) 22.1 1.5) 20.8 (-1.4) 23.3 2.5) 26.0 25.7 (0 3.) 1.6 ?fa Female (nia) 4.7 1.0) 30(+ .6) 0.2) 0.6) 0.6) 3.8 Both 13.3 (nia) 15.1 15.3( 0.5) 2.4) 19.4 1.6) +2.2 i1110.14.01) 19 +6.0(11) +450 5) KS Male 22.? (nia) 25.0 2.29.1 3.5) 30.? 1.6) 1.9 Female 4.6 (nia) 6.0 1.4) 7(0 3) 4( 0. 3) 6.8 1.4) 8.4 1.6) 3.2 ?fa Both 14.1 (nia) 15.4 1.3) 16. 7 1 .3) 16.2 (.5) 18.2 2.0) 19.3 1.1) +1.9 31: 20 5.2 (16) 36.6 ?it (16) KY Male 25.0 (nia) 26.8 1.9) 28. 3 1.4) 6-2( 1. 0) 30.1 2.9) 31.? 1.6) 1.4 ?fa Female 4.8 (nia) 0 .4) 0. 8) 0.1) 7.1 0.9) 0.6) 3.2 Both 13.1 (nia.4) 13.6 0 3) 14.4 0.8) 17.0 2.5) +1.6 ?it; 27 3.8 29.3 14(26) LA Male 22.9 (nia) 3 0. 6) 22. 4 0.1) 3. 3 0. 8) 23.? 0.5) 27.3 3.6) 1.1 ?fa Female 4.8 (nia) 7( 0.1) 0. 5) 9( 0. 2) 6.1 1.2) 7.5 1.4) 2.8 31;? Both 14.5 (nla) 1310) 18.9 3.5) 18. 0.4) 2.2 51: 21 4.0 (25) 2?.4 ?11} (29) ME Male 25.0 (nia) 22. 9 2. 1) 24.6 1.7) 25. 7 1.1) 31. 5 .4) 29. 8(1 .3) +1.8 ?fa Female 5.3 (nia) 5.3 (- 0.0) 2( 0.1) 0.7) 6( 1.6) 7.9 0.3) 3.1 ?it. Both 10.0 (nia) 10.3 0.3) 10.1 0. 2) 10.2 0.1) 10.? 0.5) 10. 8 0.Male 17.6 (nia) 17.8 0.4.) 18.2 0.5) 18.0 .2) 0.2 nis Female 3.5 (nia) 3.8 0.4) 0.0) 7(02) 4.1 0.4) 4.5 0.4) 1.3 ?fa Both 7.4 (nia9.8 0.4) 10.0 0.3) 2.3 31: 48 2.6 (34 35.3 (20 MA Male 12.1 (nia) 12.8 15.4 2.1) 15200.2) 16.0 0.8) +2.0 Female 3.3 (nia) 90(4 . 4) 1.0) 0.0.2) 3.0 Both 11.8 (nia) 12.5 0.7) 12. 9 0 .4) 1315.6 1.1) +1.9 31: 33 3.9 (26) 32.9 Ml Male 20.0 (nia) 20.9 0.9) 21.6 0. 7) .8 1.3) 23. 9( 1.0) 25.0 1.2) 1.5 ?fa Female 4.4 (nia) 4.8 0.0.9) 2.8 31;? Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change (AAPC) based on all reporting periods; p-yalue indicates statistical signi?cance of trend; nits indicates trend not significant. Current state rank (50 states and the District of Columbia) is for the reporting period 2014 2016. Ranks are from highest rate (1) to lowest rate (51). Differences between ranks do not necessarily imply a statistically signi?cant difference. ?7 Overall rate change is between the first (1999 2001) and last (2014 2016) reporting periods. Ranks are from largest increase (1) to largest decrease (51). Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst (1999 2001) and last (2014 2016) reporting periods. Ranks are from largest percentage increase (1) to largest percentage decrease (51). Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. Table 1. Trends in Suicide Rates among Persons 7: 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2015 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period) Current Overall Overall State Sex [10:35? State Rate Change 2:21:19"; 1999 2001 2002 2004 2005 2007 2005 2010 2011 2013 2014 - 2015 Rank 5 {State Rank) 17 (State ank) Both 10.71n1a) 11.51+ 0.9) 12.41+ 0.5) 12.91+ 0.5) 14.21+1.3) 15. 01 0. 9) 2.3 701p<.01) 35 4.3119) 40.5 fit-r1 5) MN Male 15.3 1nia) 1931+ 1.1) 20.41+ 1.0) 2091+ 0.5) 22.9 81+ 1.9) 2331+ 0.4) 1.7 ?fa 1p<.01) Female 3.5 1n1a) 4.21+ 0.5) 51+ 0.5) 1 1+ 0.4) 05) 591+ 1.2) 4.2 55113101) Both 12.91nia) 14.1 1+ 1.2) 14. 7 1+ 0. 5) 1551+ 0.5) 1551+ 0.1) 15. 210 .3) +1.1 3511:1105) 35 2.3135) 17.8 i55140) M5 Male 22.9 1n1a) 24.5 1+ 1.7) 25.1 1+ 0 5) 2551+ 1.7) 25.910 .9) 25. 31.5) 0.7 nlis Female 4.3 1nia) 501+ 0.541+ 0.9) 210.2) 2.4 1p<.01) Both 14.71n1a) 14.1 1? 0 5) 15.41+1.3) 1501+ 0. 7) 17.51+ 1.7) 20. 0 1+ 2.3) 2.2 15 5.3115) 35.4 i15117) MD Male 25.3 1nia) 23.71? 1.5) 25. 5 1+ 1 .9) 2551+ 1.0) 2591+ 2.3) 32. 21+ 3.3) 1.5 501p<.05) Female 5 41n1a) 5.41+ 0.1) 11+ 0. 7) 31+ 0.2) 7.41+ 1.1) 51+ 1.2) 3.2 501p<.01) Both 21.1 1nia) 2251+ 1.4) 23. 5 1+ 1 .0) 24.71+1.1) 2571+ 2.0) 29.21+ 2.5) 2.1 1 5.01 2) 35.0 35111) MT Male 35.9 1n7a) 3731+ 0.0.1) 41 0.1+ 1 .4) 4551+ 4.4) 1.3 55113101) Female 5.71nia) 5.41+1.5) 41 0.1) 10. 0 1+ 1. 5) 12.51+ 2.5) 1311+ 0.5) 4.5 3511:1101) Both 12.71ni'a) 1221? 0 5) 12. 51+ 0 .4) 11. 71?0 5) 1351+ 1.5) 14.51+1.3) +1.0 ?fa 40 2.1 142) 15.2 i111143) NE Male 22.21nia) 2071-1523.91+19.) 0.5 ?fa nis Female 3.5 1n7a) 4.21+ 0.4)11+ 0 9) 01 1.2.5 ?70 his Both 23.31nia) 22.51- 0 5) 22.1 1 0. 5) 2251+ 0. 5) 21.4 2) 23.1 0.2 ?it. n15 9 0.2151) -1.0 55151) NV Male 35.3 1n1a) 35.714 1.7) 35.1 1 1 .5) 35510.7 51; 1115 Female 5.91nia) 951+ 0.5) 51+ 0.1) 100111.21+ 0. 5) +1.5 ?fa 1p<.01) Both 13.51n1a) 12.51?1.) 13.31+0.5) 15.21 1. 9) 15.51+0.5) 20.0 +2.7 3131p<.05) 17 +5.51 5) +453 %1 3) NH Male 22.51n1a) 21.1 11.4) 21.71+ 0. 5) 24. 5 1+ 3.2.2 5511:1105) Female 5.3 1n1a) 510.5) 91+ 1.3.9 501p<.05) Both 7.5 1n1a)7?01 1) 51 0.2 01+ 0.551.5147) 19.2 35135) NJ Male 13.01n1a) 13.11+ 0.0) 12.51 0.55) 13. 71+ 1.1 14.51+ 0.5) 1451+ 0.1) 0.9 %1p<.05) Female 3.2 1nia) 91? 0.3) 301+ 0.0) 91 0.Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change 1AAPC) based on all reporting periods; p-yalue indicates statistical signi?cance of trend; nits indicates trend not significant. Current state rank 150 states and the District of Columbia) is for the reporting period 2014 2015. Ranks are from highest rate 11) to lowest rate 151 Differences between ranks do not necessarily imply a statistically signi?cant difference. ?7 Overall rate change is between the first (1999 2001) and last (2014 2015) reporting periods. Ranks are from largest increase 11) to largest decrease (51). Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst (1999 2001) and last 12014 2015) reporting periods. Ranks are from largest percentage increase 11) to largest percentage decrease 151). Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. Table 1. Trends in Suicide Rates among Persons 7: 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Rate per100,000 Persons {Change from Prior Period}* Current Overall Overall State Sex [10:35? State Rate Change 2:21:19"; 1999 2001 2002 2004 2005 2007 2006 2010 2011 - 2013 2014 2016 Rank 5 {State Rank) 17 (State REnk} 55m 22.01n1a1 2201- 011510.21 2301+ 1.21 24.1 1+ 1.11 25.01+1.91 +1.1351p<.051 4 4.01241 15.3 351391 NM Male 36.6 1nfa1 3737.1 1+ 1 .31 4071+ 3.61 0.4 35 nis Female 5.5 1n1a1411.1121011.71+ 0. 91 1201+ 0.31 3.3 351114.051 Both 7.2 1n1a1 110 .1+1. 11 310 .11 21351114011 49 2.1 1411 25.5 351271 NY Male 12.51n1a1 12.210.31 1291+ 0.71 1391+ 1. 01 1541+ 1.41 14.510 .51 1.4 351p<.051 Female 2.71nfa161-0.11 301+ 0311+ 0. 51 4.2 1+0. 71 461+ 0.51 +4.2 35 1p<.011 55m 13.61nl'a1 13510 .11 1371+ 0.11 14.21+0.51 14.5.1+041 15..31+051 +0.5 35154011 34 1.71441 12.7 35 1471 no Male 22.7 1n1a1 2271+ 0.01 22.2 1- 0.51 2331+ 1.11 2331n75 Female 5 61nfa1 51- 0 21 621+ 0.2.0 35113905} Both 13.31nl'a1 14.61+1.31 1601+ 1.41 16. 6 1+ 0. 61 1641+ 1.91 20. 9 1+ 2. 51 2.9 351p<.011 14 7.61 51 57.6 351 11 no Male 21.4 1n1a1 2451+ 3.21 23012.5 351114.011 Female 5.5 1n1a1 51- 1.01 371- 0.5171+ 2 01 5. 7 1+ 1.01 551+ 1 5.1 3.9 35 n75 Both 11.5 1n1a1 1231+ 0.51 131 1+ 0.51 1341+ 0.21 14.51+ 1.41 15.51+1.01 +2.0 35 1p<.011 32 +4.21211 +350 351191 OH Male 20.4 1n1a1 2091+ 0.51 2221+ 1.31 221p<.011 Female 4.0 1n1a1 471+ 0.71 491+ 0.1131+ 0.51091 5. 7 1+ 0. 51 3.4 351114.011 Both 17.0 1n1'a1 16. 511641+ 1.11 20. 7 1+ 2 31 2351+ 2.61 2.3 35109051 7 6.41101 37.6 i151121 OK Male 26.5 1nfa1 27.31.21 2761+ 0. 51 3031+ 2.51 3341+ 3. 11 3731+ 3.61 2.0 351139051 Female 6.6 1nfa1401- .21 7. 5 1+ 1.11 01- 0.51 651+ 1.61 10.31+ 1.61 2.9 1p<.051 Both 16.41nta1 17.71+1.31 17.71.01 16. 61+ 0.91 19. 6 1+ 1 .21 21.1 {+1.31 +1.6 351p<.011 13 4.61161 26.2 i551261 OR Male 27.41nl'a1 2951+ 2.11 25.51 0. 91 29.51+1.01 31.41+1.51 33 01+ 1.51 +1.1 351154.011 Female 6.51nfa1 1 1+ 0.61 7.71+ 0.6141+ 0.71 6612.7 35109011 Both 12.1 We] 1251+ 0.41 12.61+ 0.31 13. 9 1+ 1.11 15. 0 1+1. 11 16.31+1.21 2.0 351p<.011 30 4.1 1221 34.3 351211 PA Male 21. cm n1a a1 2131+ 0.31 21 .91+051 231 1+ 1.21 2471+ 17.1 25.11+1.31 1.5 351114.011 Female 4.2 1nl'a1 451+ 0.31 451+ 0.0141+ 0.91 5. 0 1+ 0.5111+ 1. 11 3.5 35 1114.011 Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change 1AAPC1 based on all reporting periods; p-yalue indicates statistical signi?cance of trend; nis indicates trend not significant. Current state rank (50 states and the District of Columbia) is for the reporting period 2014 2016. Ranks are from highest rate 111 to lowest rate 1511. Differences between ranks do not necessarily imply a statistically signi?cant difference. ?7 Overall rate change is between the first (1999 20011 and last (2014 2016) reporting periods. Ranks are from largest increase 111 to largest decrease 1511. Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst (1999 20011 and last 12014 20161 reporting periods. Ranks are from largest percentage increase 111 to largest percentage decrease 1511. Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. Table 1. Trends in Suicide Rates among Persons 7: 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period1" Current Overail Overall State Sex [10:35? State Rate Change 2:21:19"; 1999 2001 2002 2004 2005 2007 2008 2010 2011 2013 2014 - 2016 Rank 5 {State Rank) 17 (State REnk} Both 9.41n1a10103101 0.0 01 1281+ 3. 81 11.91.91 12. 6 1+ 0. 71 2.6 ?fa 1p<.051 43 3.2130 W1 34.1 ?fa 123 W1 RI Male 15.41n7a1 1521-0 .21 14.81- 0. 31 21.21+6.41 1912?: 2.01 19..61+041 +2.2 ?fa Female 4.0 1n1a1310.7181+ 0. 41 11+ 1.31001 6.1 1+ 1 .01 3.7 ?fa 1p<.051 Both 12.81n1a1 13.01+ 0.1601+ 1.11 17.71+1.71 2.3 ?fa 1p<.011 23 4.91171 38.3 ?161101 SC Male 21.31n1a1 22.5 1+ 1.21 22.31.11 24. 6 1+ 2. 21 26.11+1.51 28.01+1.91 +1.8 ?fa 1p<.011 Female 5 4 [n7a171-0.7101+ 1.3121+ 0. 21 701+ 0.81 8. 4 1+ 1.41 3.4 ?fa 1p<.051 Both 15.71n1a1 15.81+0. 11 17.1 1+ 1.31 19.31+2.21 1971+ 0.41 22.6 +2.91 +2.5 ?fa 1p<.011 10 +7.01 71 +44.5%1 61 SD Male 27.6 [n1a1 26. 311 .31 27. 9 1+ 1.61 30.1 1+ 2. 21 3201+ 1.91 33. 6 1+ 1.61 1.6 ?fa 1p<.011 Female 4.2 1n1a1 5.81+1.6141+ 0 6131+ 2. 01 31-1 01 11. 31 4. 01 5.8 ?fa 1p<.011 Both 14.61n1a1 1521+ 0.61 16111721+ 0.01 18. 2 1+ 1 .01 +1.4 ?fa 1p<.011 22 3.51281 24.2 ?161311 TN Male 25.1 1n1a1 2541+ 0.31 2681+ 1.31 8 01+ 1. 21 2861+ 0 61 29. 8 1+ 1.21 1.2 ?fa 1p<.011 Female 5.4 [n1a1 631+ 0.91 6 71+ 0 4151+ 0. 81 6.9 (a 0.61 7. 6 1+ 0. 71 1.9 ?fa 1p<.051 Both 12.21nfa1 12.71+ 0.61 12.31- 0.41 13211451+ 0. 91 +1.1 ?fa1p<.011 41 2.31371 18.9 ?161361 TX Male 20.4 [n7a1 2091+ 0.51 20.4 1- 0.61.0123.1 1+ 0. 91 0.9 ?fa 1p<.051 Female 4.8 [his] 5.4 1+ 0.61 5.0 1+ 0.4121+ 0. 21 0.41 6. 4 1+ 0. 81 1.6 ?fa 1p<.051 Both 17.21n1a1 19.0 1+ 1.81 18.21? 0.2521+ 1.21 2.7 ?fa 1p<.011 5 8.01 3 46.5 ?fa 1 4 1W1 UT Male 28.21n1a1 31.1 1+ 2.91 29.4 1- 1.71 32 512.1 ?fa 1p<.051 Female 6.8 [n7a1 7.41+ 0.61 7.51+ 0.2.11 1261+ 2.01 4.4 ?fa 1p<.011 Both 13.21n1a1 16.2 (+3.01 14.91-131 16.61+1.71 18.71+ 2.11 19.71+ 1.01 2.4 ?fa 1p<.011 18 6.41 91 48.6 ?Va 1 21 VT Male 23.6 [n1a1 28. 31+ 61 24.31- 4.01 2731+ 3.01 3101+ 3. 71 3251+ 1.51 1.9 ?fa 1p<.051 Female 4.3 1n1a1 21+4 0. 91 641+ 1.31 6 61+ 0.21 7. 31+ 0. 71 761+ 0.31 3.8 ?fa 1p<.011 Both 12.81n1a1 12.71-011 1291+ 0.31 1361+ 0.71 1461+ 0. 91 1501+ 0.51 +1.2 ?fa 1p<.011 37 2.21391 17.4 ?161411 17.4 Male 21.6 1n1a1 21.31- 1 2101? 0.41 2251+ 1.51 23.61 1 2.1 2391+ 0.21 0.9 ?fa 1p<.051 Female 5.3 [n1a1 5.21? 0.11 591+ 0.71 5.61? 0.31 6. 4 1+ 0 81 691+ 0.51 1.8 ?fa 1p<.051 Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change 1AAPC1 based on all reporting periods; p-yalue indicates statistical signi?cance of trend; indicates trend not significant. Current state rank 150 states and the District of Columbia) is for the reporting period 2014 2016. Ranks are from highest rate 111 to lowest rate 1511. Differences between ranks do not necessarily imply a statistically signi?cant difference. ?7 Overall rate change is between the first (1999 20011 and last (2014 2016) reporting periods. Ranks are from largest increase 111 to largest decrease 1511. Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst (1999 20011 and last (2014 20161 reporting periods. Ranks are from largest percentage increase 111 to largest percentage decrease 1511. Differences between ranks do not necessarily imply a statistically significant difference. TT Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. Table 1. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2018 Age-Adjusted Annual Rate per 100,000 Persons {Change from Prior Period} Current Overall Overall State Sex State Rate Change 2:21:19"; 1999 2001 2002 - 2004 2005 2007 2008 2010 2011 - 2013 2014 2018 Rank 5 {State Rank) 17 (State ank) Both 14.8 (nia) 15411781+ 1.0) 1.1 5511:1405) 24 2.8133) 18.8 c15137) WA Male 24.? [nfa) 2521+ 0 5) 2527.1 1+ 1.1) 13.5 '14 Female 5.0 (We) 8. 4 1+ 0 8) 81+0 .7) 7. 71 0. 8) 851+ 0.8) 2.5 '181p<.01) Both 15.81n1a) 1721+1.8) 1501?0 .7) 19.2.1+32) 21.41+2.2) +18% 11 +58113) +37.1 i?15114) WV Male 27.2 (nia) 3011+ 2. 9) 5.81 1.+11% Female 5.3 (Na) 551+ 0.581+ 2. 2) 3.7 ?it: Both 13.1 1111a) 13.5.1+04) 1501+ 1.0) 15.31+0.3) 1551+ 1.2) 1.5 31: 1p<.01) 28 +3.4129) +258 ?it 130) WI Male 21.7 (We) 22. 2 1+ 0.5) .01+ 1.2) 24. 4 1+ 0 .4) 25.751+ 1.3) +1.1%1ps01) Female 5.1 (nia0.1) 1+ 1.0) 2.5 38113101) Both 20.7 1111a) 23.41.+27) 25.41+28) 28.91+3.5) 28.581- 01) +2.3 251p<.01) 3 +8.1 1 1) 9) WY Male 34.8 (We.2) 47. 1158) 44. 8 1 2. 4) 1.8 ?fa 1p<.05) Female (ma) 521+ 0.5) 41+ 5 52) 1+ 1.4) 1251+ 1. 9) 3.2 '14. 1p<.01) Rates are age-adjusted to the U5. year 2000 standard. Model-estimated average annual percentage change 1AAPC) based on all reporting periods; p?yalue indicates statistical signi?cance of trend; nis indicates trend not significant. Current state rank 150 states and the District of Columbia) is for the reporting period 2014 2018. Ranks are from highest rate 11) to lowest rate 151 Differences between ranks do not necessarily imply a statistically signi?cant difference. ?7 Overall rate change is between the first (1889 2001) and last (2014 2018) reporting periods. Ranks are from largest increase 11) to largest decrease (51). Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the ?rst (1999 2001) and last (2014 2018) reporting periods. Ranks are from largest percentage increase 11) to largest percentage decrease 151). Differences between ranks do not necessarily imply a statistically significant difference. 0 Rate based on 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. Figure 1 Percentage Changes in Annual Suicide Rates (per 100,000, Age?Adjusted) 2014-2016 Compared Against 1999-2001 :Decrease 1.0% I:1lnr:rease 59% - 18.3% - Increase - 29.3% - Increase 31.9% - 37.4% - increase 316% - 57.8% Table 2. Select Demographic and Descriptive Characteristics of Suicides among Decedents 310 years of age with and without Known Mental Health Problems--National Violent Death Reporting System, 2? states*, 2015 Characteristics Total Mental Health No Known Chi- Adjusted 0R11 {n=20,446} Problemf Mental Square (95% Cl] [95% Cl) (n=9,407} Health Problem (n=11,039] Sex Male 15,702l768} 9,233l83.6} Female 1,806l16.4] p<.01 DANA-0.5) Age" 10?24 1,593l14.4} p<.01 2544 45-64 3,898853] p<.01 65+ p<.01 White, non?Hispanic [0-ch Black, non-Hispanic Mil-4.4] 81717.4) p<.01 American Indian/Alaska Native, non- Hispanic 378(18} 112(12] 2669.4) Asian, non-Hispanic 576(28} 235(25} 3418.1) p<.05 Hispanic ?63019] 6336.7) Other 2103.2) 4s{0.4) Extended demographics Ever served in militarWr 2,075i20.l] Homeless 240(12} 104(1.1] 13641.3) incident Type Single suicide 20,063i982} 10343914) Homicide followed by suicide 319(1.6) 64(0.7} 255(23) p<.01 Multiple suicides 6483.3) 25(03} Method Firearm Ha 23671269] p<.01 Poisoning Substance class causing death?? Other over-the-counter) Opioids Antidepressants Benzodiazepines Other Toxicology Results Any toxicology testing Positive for 1 substance? Substance Alcohol Tested Positive Opioids Tested Positive Benzodiazepines Tested Positive Cocaine Tested Positive Amphetamines Tested Positive Marij ua na Tested Positive Antidepressants Tested Positive 1.021(340) 944(314) 300(266) 6241208} 219013) 13,317l65.1} 3,554i41s) 499(6.3} 73619.7) 666(35.8} 603(322) 6441346} 468i25.1} 1951105) 230(33) 6,658i70.8) 4,258i453) 1,238i29.1) 3,866i41.1) 216(56) 376(102} 210(227) 355(311) 336(29.4) 156{13.7) 24(2.1) 315(14) 5.541(50.2) 3.398(353) 325(212) 4.1121372) 283(63) 3.919(355] 360(92) 3.442(312) 261(221) 2.322(210) 479{20.6) p<.01 p<.01 p<.01 p<.05 p<.01 p<.01 p<.01 p<.01 p<.01 p<.05 p<.Dl p<.01 05004-05) O.5i0.4-0.6] 0.210.103) 0.910.310) 1.111.012) 03(07-03) 1.211.015) 10(09?11) 09(0340) news-.99) 0.5035406) 0.940.910) 09400-10) Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carol ina, Ohio, Oklahoma. Oregon. Rhode Island, South Carolina. Utah, Vermont, Virginia, and Wisconsin. Decedent had been identi?ed as having a current diagnosis of mental health problem in coronen?medical examiner or law enforcement reports. ?Ddds ratio re?ects the risk among those without known mental health problem relative to those with known MHP. Logistic regression was used to estimate adjusted odds ratio with 95% CIs after controlling for age, sex, race and ethnicity. Known MHP was used as the reference group. Dcecdents were aged 10 years and older, as per standard in the suicide prevention literature. Denominator is decedents aged 13 years of age and older with reported military service status. Denominator is decedents who died by poisoning, including overdose. Denominator is decedents with any toxicology tested. Denominator for each positive group is the number tested for the substance in that group. Table 3. Circumstances Preceding Suicide among Decedents 310 years of age with and without Known Mental Health Problems--Nationa Violent Death Reporting System, 27 states*, 2015 Characteristics Total Mental Health No Known Chi- Adjusted DR11 Problem* Mental Square [95% Cl] (95% Cl] Health Problem Suicide with known circumstances 18364913) 9,407i100) 9,357l84.8] p<.01 Mental Health Any Current Diagnosed Mental Health Problem? Anxiety disorder Bipolar disorder Schizophrenia 5096.4] PTSD 424{4.5l 226{2.4j Unknown 760{8.1] Current depressed mood p<.01 Substance Problems Any Current substance problem 5319(283) p<.01 Alcohol problem 3,268l17.4) 1,406l15.0] p<.01 Other substance problem 3,084l16.4) p101 Treatment Current mental abuse treatment 5,141l27.4) 64(0.7) p<.01 0.01} Ever treated for mental health/substance 0.02(0.02- problem 394(4.2} p<.01 0.02} Relationship Problems?oss Any relationship problem?oss 7,948t42.4) 3326896) 4,222l45.1) p<.01 Intimate partner problem 5,098l27.2) 2,828l30.2) p<.01 Perpetrator of interpersonal violence past month 414(22) 131{1.4) 283(30} p<.01 Victim of interpersonal violence within past month 84(0.4) 53(0.6) 31(03) p<.05 Familyr relationship problem 8738.3) 798(35} Other relationship problem (non-intimate) 40342.1) 202l2.1) 201(2.1) Argument or conflict (not specified) 2,914l15.5) 1,636l17.5) p<.01 Death of a loved one (any) 826l8.8) 671(12} p<.01 Non?suicide death 534(57): p<.01 Suicide of family or friend 217(23) 162(1.7) p<.01 Other Life Stressors Any life stressor 9343619) 4,6?5l?93) Recent criminal legal problem 1,588l8.5) 586l6.2) p<.01 Other legal problem 748(4?) 373{4.0) Physical health problem 4.179(223) 2,167l23.2) p<.01 Jobg?Financial problem? 2941(16.2) 1530(16.8) 1411(15.6) p<.05 Eviction or loss of home 7228.8) 405(43} p<.01 School problem?? 162(193) 92(21.9) Recent release from an institution? 941(10.2) p<.01 0.5(0.4u0.5} Jailfprisonldetention facility 203(14.4) 121(25.7) Hospital 51786.6) 31183.0) 206043.?) p<.01 1.3i1.0-1.7) hospital/institution 46983.2) 4i39(46.7) 30(6.4) p?.01 Other (includes alc/SA treatment facilities) 223(15.8) 109(11.6) 114(24.2] p<.01 Recent or Impending Crisis Crisis within past or upcoming two 5,525l29.4) 2,444l26.0) 3,081l32.9) p<.01 Intimate partner problem crisis 1968856) 854(343) 1114(36.2) Physical health problem crisis 739(13.4) 315(12.9) 424(13.8] 1.003.842) Criminal legal problem crisis 621(11.2) 2031283) 418(13.6) p<.01 1.711.511} Family relationship problem crisis 4300.8) 2180.1) p105 Job problem crisis 354(6.4) 1910.8) 163(5.3) p<.01 Suicide Event/History Left a note assatsas) 3,182l33.8) 3,286t35.1) Disclosed suicide intent 4,405l23.5) 2,306l245) 2,099l22.4) p<.01 History of ideation 5,990l313) 3,838l40.8) 2,152l23.0) p<.01 History of attempts 3,732l19.9) 2,770l29.4) 962(103} [3101 *Alaska, Arizona. Colorado, Connecticut. (Lienrgia. Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey. New Mexico, New York, North Carolina. Ohio, Oklahoma. Oregon, Rhode Island, South Carolina. Utah, Vermont, Virginia, and Wisconsin. Decedent had been identi?ed as having a current diagnosis ofmental health problem in coronen?medical examiner or law enforcement reports. iiOdds ratio re?ects the risk among those without known mental health problem relative to those with known MHP. Logistic regression was used to estimate adjusted odds ratio with 95% after controlling for age, sex, race and ethnicity. Known MHP was used as the reference group. includes decedents with one or more diagnosed current mental health problems. which are not mutually exclusive. Therefore sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health problems. Denominator is decadents aged 18 years of age and older. Denominator is decedents aged 10-18 years. '"15 Denominator of institution subgroup is decedents with recent release from an institution. Recent release from an institution is de?ned as having occurred within the past month. int? Denominator of crisis subgroup is decedents with any crisis within past or upcoming two weeks. Crises depicted here represent the most commonly occurring categories. April 10, 2018 From: Dorigo, Leslie Sent: 25 May 2018 10:50:13 -0400 To: Simon, Thomas Deborah Cc: Ballman, Marie R. Erin Jennifer Courtney Subject: FW: Note on the upcoming Vital Signs Attachments: VS summary for family ld d52.docx FYI. Note edited 0&A?please update the file you have. From: Guest, Megan Sent: Friday, May 25, 2018 10:47 AM To: Dorigo, Leslie Cc: Solder, Heldman, Amy B. Bonds, Michelle E. Middlebrooks, Jennifer (CDCIDNDIEHINCIFCJ Lenard, Courtney (CDCIDNDIEHINCIPC) Galatas, Kate Subject: FW: Note on the upcoming Vital Signs See below. She edited the QA so want to be sure you all get that in your materials. From: Daniel, Katherine Lyon Sent: Friday, May 25, 2018 10:42 AM To: Dee, Deborah L. 2 cdc. ov> Cc: Schuchat, Anne MD Subject: RE: Suicide Vital Signs brief update and fact sheet Offering my edits here for page 3 and for fact sheet (Tom, this is the same I just sent you). I'm really excited about the fact sheet! It looks great! Deb From: Ferdon, Corinne Sent: Friday, May 11, 2018 1:08 PM To: Simon, Thomas (CDCIDNDIEHINCIPC) Cc: Stone, Deborah Richmond-Cram, Malia Daniel, Valerie M. uh8 cdc. 0v); Black, Erin Crosby, Alexander Dahlberg, Linda L. Bruce, Subject: Suicide Vital Signs brief update and fact sheet Hi everyone, The pre-brief with Dr. Schuchat went very well. She is highly supportive and interested in the topic of suicide prevention. She and others in the room had helpful comments and suggestions related to the range of VS materials but their comments were fairly specific and will not result in substantive changes to our approach. We are continuing to refine the fact sheet. have attached a copy of the fact sheet with embedded stickies to describe specific edits we are making. These reflect the changes we discussed with Dr. Schuchat and the VS office during and after the pre-brief. I?m also attaching a Word document that describes the changes that we are making to page 3. We are providing shortened text for the figure that was at the top of page 3. The VS graphics artists are going to modify the layout on this page but will use the text we provided. We are also adding the 5 steps to take when you are concerned about someone who may be Suicidal. This was a good outcome from the discussion at the pre?brief. The MMWR has completed review by DADS and their comments were quite minor. We addressed them this morning and Deb will be working closely with the MMWR editors early next week to finalize the MMWR. Please let us know if you have any questions or suggestions. ?Tom From: Simon, Thomas (CDCIDNDIEHXNCIPC) Sent: Wednesday, May 2, 2018 12:59 PM To: Mercy, James Ferdon, Corinne (CDCIONDIEHINCIPC) Hou ry, Debra E. (CDCIONDIEHINCIPQ Greenspan, Arlene (CDCIONDIEHINCIPQ Dorigo, Leslie Subject: RE: Suicide Vital Signs Fact Sheet head's up Hi everyone, I just received the integrated version of the fact sheet with the new graphics and latest text. As I described below, I need to get changes back to the VS office tomorrow so that they can be integrated in the version that will go to Dr. Schuchat. If you have time to review it please send me changes by cob today and I?ll integrate them. If not, there will still be time next week to make changes so this is not your last chance. I just wanted to give you an opportunity to weigh in on anything problematic before it goes to Dr. Schuchat. Our team is reviewing it at the same time. Thankyoul -Tom From: Simon, Thomas Sent: Tuesday, May 1, 2018 6:04 PM To: Mercy, James Ferdon, Corinne (CDCIONDIEHINCIPC) Hou ry, Debra E. Cc: Stone, Deborah Richmond-Crum, Malia Daniel, Valerie M. uhB cdc. Black, Erin (CDCIONDIEHINCIPC) Crosby, Alexander Dahlberg, Linda L. Bruce, x6 cdc. ov) Subject: Suicide Vital Signs Fact Sheet head's up Hi everyone, The fact sheet process has continued, including lots of wordsmithing types of editing but nothing too substantive. I?ll share that Dr. Schuchat only had one change so far. The V5 graphic artist has been working on images separately from the wordsmithing and we have been reviewing drafts of the images. We heard today that we should be receiving an integrated version with the text and graphics tomorrow and will need to turn it around by 10:00 em. on Thursday. I wanted to give you a head?s up in case you want to review it. I?ll share it when it comes in tomorrow, but I won?t have reviewed it yet and I know that they made changes since we last reviewed it so we'll probably have corrections/edits. We have the pre?brief with Dr. Schuchat on Tuesday so the VS team wants to make our changes to the FS and provide it to her in advance of that meeting. If you send changes by COB tomorrow we can make them in the version that will go to Dr. Schuchat. If you don?t have time to review it tomorrow we should still be able to address your concerns next week so please still send them by Monday. Thankyoo! Torn From: Simon, Thomas Sent: Wednesday, April 4, 2018 4:38 PM To: Mercy, James Ferdon, Corinne Hou ry, Debra E. Greenspan, Arlene Dorigo, Leslie ; Soihtalab, Elizabeth Cc: Stone, Deborah Richmond-Crum, Malia Daniel, Valerie M. uh8 cdc. ov>; Black, Erin (CDCIONDIEHINCIPC) Crosby, Alexander Subject: Suicide Vital Signs Fact Sheet Hi everyone, We had the roundtable with the VS office yesterday and it went well. We negotiated back and forth and spent a lot of time wordsmithing. For those who don?t know, the round table lasts 3 hours and the focus is on getting the key messages into the VS fact sheet template. The fact sheet is 4 pages long but there are 14 pages of fact sheet rules and guidance [yes literally). Some things that might seem odd about the word choices, brevity, and headings in the draft attached are the result of this style guidance. We and the VS team are feeling very good about where we are with this version. We think it really helps the reader to walk away knowing that suicide rates are increasing across states, that suicide is not only a mental health problem, and that there are a range of effective actions that can be taken to prevent suicide. The team worked quickly to revise the fact sheet last night and today to incorporate the changes from the round table. We are going to continue to tweak this but we would like for you to review and please send us any requests for changes by cob Friday, if possible. We know that some people are on leave and won?t be able to review this until Monday. We need to submit a revised version to the VS office on Tuesday. That version will be further edited by them, shared up the chain, and used to create better graphics. The graphics included now are placeholders. They have artists who will improve on these. We anticipate sharing the fact sheet with you again as it progresses but now is the time to let us know if there is anything substantial that you would like changed. Thank you for your support on this Vital Signs! -Tom and Deb Healthcare providers can treat patients at risk by phone or online where services are not widely.r avalla ble. Strengthen .ccess to and . I, is Employers can apply policies that I '1 create a healthy environment and reduce stigma about seeking help. States can help ease unemplovm an: and housing stress by providing F?i uvitl?- temporarv help. Financial Support 'eliverv of are Create protective to Individuals environments Ir i Need Preventing . . an provide helping . Suicide involves Connlect Communities can promote df . reven 60 In -. 1. resources an ol ow . Everyone the . programs and events Improve ?390mm! ??lms the" resident! sense of belonging. Community nommunities aftera solcioe Everyone can learn the signs of I suicideJ how to respond, and where identify and to get help. 1.33.31 Djpinq Schools can teach students skills to and manage challenges like relationship [Re-living Skills and school problems. Support People at Risk Healthcare providers can o?er at? patients effectiVE treatment options. Note 1. Title shortened to CAN WE DO TO PREVENT Note 2. We agreed to change the layout for the figures on page 3. Please use the text above to replace the original text. We are cutting about 25 words with these changes. Note 3. There are two changes to the text of the warnings signs. Please use "Looking for a Way to Access Lethal Means" and ?Talking or Posting About Wanting to Die" instead of what is there now. These changes are indicated in the file too. Note 4. The text for the steps to be listed on the right side under the warning signs should be: 5 Steps to help - Ask - Keep them safe I Be there I Help them connect - Follow up Find out why' this can save a life by visiting: Note 5. The source listed on the bottom right could be "Source: bethelto.com" since they provide the warning signs and steps. V3 v5 #vitalsigns JUN 2018 Vitalsignsm in 2016. I45 lasuicides I I I I 45K Suicule "er across the US More than just a mental health problem Suicide is a leading cause of death in the US. Suicide rates increased in nearly every state from 1999 through 2016. Mental health problems are often seen as the cause of suicide, but suicide is rarely caused by any single factor. In fact, many people who die by suicide are El not known to have a diagnosed mental health problem at the time 0 Suicide rates increased of death. Other problems often contribute to suicide, such as /0 more than 30% in haltc 0f relationship problems or loss, substance use disorders, physical health US states since 1999- problems, and job, money, legal, or housing stress. Government, public health, healthcare, business, education, media and community organizations working together is important for preventing suicide. Public health departments can bring together these partners to locus on comprehensive state and community efforts with the greatest likelihood of preventing suicide. More than half of people 0 who died by suicide did 0 not have a known mental States and communltles can: health roblem. 0 Identify and support people at risk of suicide. 0 Teach coping and problem?Solving skills to help people manage challenges with their relationships, jobs, health, or other concerns. I Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. Conne'geople to others in their community so they don't feel alone. 0 Connect people at risk to effective and coordinated mental and physical healthcare. 0 Expand options rnporary help for those struggling to make ends meet? I Prevent future risk of suicide among those who have lost a loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. increase 38 - 58% Increase 32 - Increase 19 - 29% Increase 6 - 18% Decrease 1% SOURCE: CDC's Nationai Vita! Statistics System. Differences exist among those with and without mental health problems. People without known mental health problems were more likely to be male and to die by firearm. No known mental health problems Known mental health problems Sex Method Sex Method Female Other Female Other 15% 3% Firearm H196 . 10/3 17 8% 31% Poisoning 20% Firearm 55% Male 32" 69%- Suffocation Suffocation 27% 31% Many factors contribute to suicide among those Relationship problem with or without mental health problems. fw- Crisis in the 7 past upcoming two weeks lg Substance use problem . Criminaigal r" Physical health problems problem (22?16) Job/Financial problem (1 coca Nationai Vioient Death Reporting System lg Loss of Housing WHAT CAN STATES, DDMMUNITIES, AND INDIVIDUALS DD TD PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices a. usagov/XOBGc. Healthcare providers can make services available by phone or online where treatments are not widely available. A Strengthen . A. . Statescan helpeasejobloss ?955 can Employerscan putin place policies dh st 11' Provide .- an ousmg ress that create a healthy environment and . . .. C. . temporary support FinanCIaI I am reduce stigma about seeking help. to Individuals in Need to? Preventing . . . Media can describe helping I. :2 Suicide Involves Ensure People are ?35: Communltles can offer activities . . Eve one in the Conn cted to . that bring people together so resources and avOId headlines eo le don?t feel alone or details that increase risk. .. . Community Others "1 the" Community . Everyone can learn the signs of Li a - - Identify and Teach Coping 5c Ham Schools can teach skills that help young suiode how best to respond and Problem - peo le mana echallen ess cha and where to access help. Support People Solving Skills I at Risk and school problems. Heatthcare providers can offer effective prevention services to those atrisk Increased Feeling Trapped or in I'k Substance Use Unbearable Pain Increased eelng I An erorRa a Burden 9 Extreme Mood Swings Safely Storing Lethal Means Know the Suicide WARNING Talking Posting SIGNS About Suicide Increased Anxiety Expressing Making Plans - . Hopelessness for Suicide Sleeping too little or too much Isolation SOURCE: CDC Vital Signs. June, 2013 WHAT CAN BE THE lS - Tracking the nroblem to understand trends and the groups at gr risk (for example see . Developing and evaluating suicide prevention strategies. 0 Working with local, state, tribal, national, and other partners to provi-Q uidance and distribute suicide prevention tools, or example, see I . STATES AND COMMUNITIES BAN - Identify and support people at risk of suicide. 0 Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among peeple at risk. Connect people to others in their community so they don't feel alone. I Connect people at risk to effective and coordinated mental and physical healthcare. II Expand options for temporary assistance for those struggling to make ends meet. - Prevent future risk of suicide among those who have lost a loved one to suicide. HEALTHEARE SYSTEMS CAN I Provide high quality, ongoing care focused on patient safety and suicide prevention. 0 Make sure affordable and effective mental and physical healthcare is available where people live. 0 Train providers-dopting proven treatments for patients at risk of suicide. if BAN Promote employee health and well-being, support employees at risk, and - plans in place to respond effectively. Encourage employees to seek help when they need it. Provide referrals to mental health, substance use disorder, le al, or financial counseling services as needed. Reduce access to lethal means, soc; as medications and firearms, among people at risk. Learn the warning signs of suicide and the steps to help identify and connect people at risk to appropriate services. wwaeThe?lTocom Contact the National Suicide Prevention Lifeline for help for themselves or others: {8255}. The media can avoid increasing risk leg, with dramatic headlines, and explicit details) and encourage people to seek help using recommendations available at: If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-800-273-TALK (8255} Chat: For more information, please contact Telephone: (232?4636) TTY: 1388?2326348 Web: Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Publication date: June 2013 From: Simon, Thomas Sent: 1d May 2018 15:40:20 -0400 To: Stone, Deborah Kristin (CDCIONDIEHINCIPQ Subject: FW: Suicide Vital Signs brief update and fact sheet Attachments: 5.00pm ds.pdf #3 of 4 I added some comments below From: Stone, Deborah Sent: Friday, May 11, 2018 1:24 PM To: Simon, Thomas (CDCXONDIEHXNCIPC) Subject: RE: Suicide Vital Signs brief update and fact sheet Hi Tom, I made comments on the fact sheet (see attached). Including here as well. The biggest thing is the first comment butjust throwing it out there, thinking about what the media could/may do with it. I know we can?t control everything though. 1. Page 1: Regarding main headline. Ithink it?s probably ok because we focus on prevention on the page as well but wondering if we could say "?suicide rates up' across the My only concern is that the media is going to glom onto the word rising and make it rising exponentially or who knows what else? I don't know how to prevent that. Rising is relatively tame considering what we are seeing. Hopefully they will pay attention to the media recommendations. 2. Page 1: Re bullet about temporary help. Is there any way this could be misconstrued to mean 'provide temporary help for people in need,? more generally? I liked the mention of temporary financial assistance or help. See how it looks in the new version 3. Page 2: It should be recent crisis in the past or upcoming two weeks. 4. Page 2: I think saying criminal-legal or criminal/legal might be easier than criminal legal which isn't really plain language. I agree 5. Page 3: re ?looking for a way to access lethal means?? think this sounds too passive [looking for a way to access..}. It's often noted as ?secu ring lethal means.? Other options could be ?locating or looking for lethal means..??i.e. Don?t think we need the word access. This is how the other warning signs word this. 6. Page 4: is it possible to mention implementation somehwere? Samhsa supports implementation as does NIMH via funding and the header is broad to be federal gov't so i'm a little worried what we have only reflects CDC. We had implementing in here at one point but i think it wasn't plain lang enough andjust got removed altogether. I?m fine if this will fit. Page 4: Is it possible to say train provers and graduate students? It may not work but really we need to start even earlier than training providers. Most MH care providers and PCPs don?t have adequate training 0n suicide prevention. This is well accepted in the field (though i'm not sure we mention it in the technical package this way, can't recall) If not in the TP then I would leave it out Deb From: Simon, Thomas Sent: Friday, May 11, 2018 10:07 AM To: Mercy, James Ferdon, Corinne Houry, Debra E. Greenspan, Arlene Dorigo, Leslie Solhtalab, Elizabeth Cc: Stone, Deborah Richmond-Crum, Malia Daniel, Valerie M. Black, Erin Crosby, Alexander Dahlberg, Linda L. (CDCIONDIEHINCIPC) Bruce, x6 cdc. ov) Subject: Suicide Vital Signs brief update and fact sheet Hi everyone, The pre-brief with Dr. Schuchat went very well. She is highly supportive and interested in the topic of suicide prevention. She and others in the room had helpful comments and suggestions related to the range of VS materials but their comments were fairly specific and will not result in substantive changes to our approach. We are continuing to refine the fact sheet. I have attached a copy of the fact sheet with embedded stickies to describe specific edits we are making. These reflect the changes we discussed with Dr. Schuchat and the VS office during and after the pre-brief. I?m also attaching a Word document that describes the changes that we are making to page 3. We are providing shortened text for the figure that was at the top of page 3. The V5 graphics artists are going to modify the layout on this page but will use the text we provided. We are also adding the 5 steps to take when you are concerned about someone who may be suicidal. This was a good outcome from the discussion at the ore?brief. The MMWR has completed review by DADS and their comments were quite minor. We addressed them this morning and Deb will be working closely with the MMWR editors early next week to finalize the MMWR. Please let us know if you have any questions or suggestions. -Tom From: Simon, Thomas (CDCXONDIEHJNCIPC) Sent: Wednesday, May 2, 2018 12:59 PM To: Mercy, James Ferdon, Corinne Houry, Debra E. Greenspan, Arlene Dorigo, Leslie (CDCIONDIEHINCIPQ Solhtalab, Elizabeth Subject: RE: Suicide Vital Signs Fact Sheet head's up Hi everyone, ljust received the integrated version of the fact sheet with the new graphics and latest text. Asl described below, I need to get changes back to the VS office tomorrow so that they can be integrated in the version that will go to Dr. Schuchat. If you have time to review it please send me changes by cob today and I?ll integrate them. If not, there will still be time next week to make changes? so this is not your last chance. I just wanted to give you an opportunity to weigh in on anything problematic before it goes to Dr. Schuchat. Our team is reviewing it at the same time. Thank you! -Tom From: Simon, Thomas Sent: Tuesday, May 1, 2018 6:04 PM To: Mercy, James Ferdon, Corinne Houry, Debra E. Greenspan, Arlene Dorigo, Leslie Solhtalab, Elizabeth Cc: Stone, Deborah Richmond-Cru m, Malia Daniel, Valerie M. (CDCIONDIEHINCIPC) uh8 cdc. Black, Erin Crosby, Alexander Dahlberg, Linda L. Bruce, x6 cdc. ova Subject: Suicide Vital Signs Fact Sheet head's up Hi everyone, The fact sheet process has continued, including lots of wordsmithing types of editing but nothing too substantive. I'll share that Dr. Schuchat only had one change so far. The V5 graphic artist has been working on images separately from the wordsmithing and we have been reviewing drafts of the images. We heard today that we should be receiving an integrated version with the text and graphics tomorrow and will need to turn it around by 10:00 a.m. on Thursday. I wanted to give you a heads up in case you want to review it. Hi share it when it comes in tomorrow, but I won?t have reviewed it yet and I know that they made changes since we last reviewed it so we?ll probably have correctionsfedits. We have the pre?brief with Dr. Schuchat on Tuesday so the VS team wants to make our changes to the FS and provide it to her in advance of that meeting. If you send changes by COB tomorrow we can make them in the version that will go to Dr. Schuchat. If you don't have time to review it tomorrow we should still be able to address your concerns next week so please still send them by Monday. Thankyou! Tom From: Simon, Thomas (CDCXONDIEHJNCIPC) Sent: Wednesday, April 4, 2018 4:38 PM To: Mercy, James Ferdon, Corinne (CDCJONDIEHINCIPCJ Houry, Debra E. Greenspan, Arlene Dorigo, Leslie ; Solhtalab, Elizabeth Cc: Stone, Deborah Richmond?Crum, Malia Daniel, Valerie M. uh3 cdc. ov>; Black, Erin Crosby, Alexander Subject: Suicide Vital Signs Fact Sheet Hi everyone, We had the roundtable with the VS office yesterday and it went well. We negotiated back and forth and spent a lot of time wordsmithing. For those who don?t know, the round table lasts 3 hours and the focus is on getting the key messages into the VS fact sheet template. The fact sheet is 4 pages long but there are 14 pages of fact sheet rules and guidance (yes literally}. Some things that might seem odd about the word choices, brevity, and headings in the draft attached are the result of this style guidance. We and the V5 team are feeling very good about where we are with this version. We think it really helps the reader to walk away knowing that suicide rates are increasing across states, that suicide is not only a mental health problem, and that there are a range of effective actions that can be taken to prevent suicide. The team worked quickly to revise the fact sheet last night and today to incorporate the changes from the round table. We are going to continue to tweak this but we would like for you to review and please send us any requests for changes by cob Friday, if possible. We know that some people are on leave and won?t be able to review this until Monday. We need to submit a revised version to the VS office on Tuesday. That version will be further edited by them, shared up the chain, and used to create better graphics. The graphics included now are placeholders. They have artists who will improve on these. We anticipate sharing the fact sheet with you again as it progresses but now is the time to let us know if there is anything substantial that you would like changed. Thank you for your support on this Vital Signs! -Tom and Deb V3 v5 #vitalsigns JUN 2018 Vitalsignsm in 2016. I45 lasuicides I I I I 45K Suicule "er across the US More than just a mental health problem Suicide is a leading cause of death in the US. Suicide rates increased in nearly every state from 1999 through 2016. Mental health problems are often seen as the cause of suicide, but suicide is rarely caused by any single factor. In fact, many people who die by suicide are El not known to have a diagnosed mental health problem at the time 0 Suicide rates increased of death. Other problems often contribute to suicide, such as /0 more than 30% in haltc 0f relationship problems or loss, substance use disorders, physical health US states since 1999- problems, and job, money, legal, or housing stress. Government, public health, healthcare, business, education, media and community organizations working together is important for preventing suicide. Public health departments can bring together these partners to locus on comprehensive state and community efforts with the greatest likelihood of preventing suicide. More than half of people 0 who died by suicide did 0 not have a known mental States and communltles can: health roblem. 0 Identify and support people at risk of suicide. 0 Teach coping and problem?Solving skills to help people manage challenges with their relationships, jobs, health, or other concerns. I Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. Conne?Qeople to others in their community so they don't feel alone. I Connect people at risk to effective and coordinated mental and physical healthcare. 0 Expand options mporary help for those struggling to make ends meet? - Prevent future risk of suicide among those who have lost a loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. increase 38 - 58% Increase 32 - Increase 19 - 29% Increase 6 - 18% Decrease 1% SOURCE: CDC's Nationai Vita! Statistics System. Differences exist among those with and without mental health problems. People without known mental health problems were more likely to be male and to die by firearm. No known mental health problems Known mental health problems Sex Method Sex Method Female Other Female Other 15% 3% Firearm H196 . 10/3 17 8% 31% Poisoning 20% Firearm 55% Male 32" 69%- Suffocation Suffocation 27% 31% Many factors contribute to suicide among those Relationship problem with or without mental health problems. fw- Crisis in the 7 past upcoming two weeks lg Substance use problem . Criminaigal r" Physical health problems problem (22?16) Job/Financial problem (1 coca Nationai Vioient Death Reporting System lg Loss of Housing WHAT CAN STATES, DDMMUNITIES, AND INDIVIDUALS DD TD PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices a. usagov/XOBGc. Healthcare providers can make services available by phone or online where treatments are not widely available. A Strengthen . A. . Statescan helpeasejobloss ?955 can Employerscan putin place policies dh st 11' Provide .- an ousmg ress that create a healthy environment and . . .. C. . temporary support FinanCIaI I am reduce stigma about seeking help. to Individuals in Need to? Preventing . . . Media can describe helping I. :2 Suicide Involves Ensure People are ?35: Communltles can offer activities . . Eve one in the Conn cted to . that bring people together so resources and avOId headlines eo le don?t feel alone or details that increase risk. .. . Community Others "1 the" Community . Everyone can learn the signs of Li a - - Identify and Teach Coping 5c Ham Schools can teach skills that help young suiode how best to respond and Problem - peo le mana echallen ess cha and where to access help. Support People Solving Skills I at Risk and school problems. Heatthcare providers can offer effective prevention services to those atrisk Increased Feeling Trapped or in I'k Substance Use Unbearable Pain Increased eelng I An erorRa a Burden 9 Extreme Mood Swings Safely Storing Lethal Means Know the Suicide WARNING Talking Posting SIGNS About Suicide Increased Anxiety Expressing Making Plans - . Hopelessness for Suicide Sleeping too little or too much Isolation SOURCE: CDC Vital Signs. June, 2013 WHAT CAN BE THE lS - Tracking the nroblem to understand trends and the groups at gr risk (for example see . Developing and evaluating suicide prevention strategies. 0 Working with local, state, tribal, national, and other partners to provi-Q uidance and distribute suicide prevention tools, or example, see I . STATES AND COMMUNITIES BAN - Identify and support people at risk of suicide. 0 Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among peeple at risk. Connect people to others in their community so they don't feel alone. I Connect people at risk to effective and coordinated mental and physical healthcare. II Expand options for temporary assistance for those struggling to make ends meet. - Prevent future risk of suicide among those who have lost a loved one to suicide. HEALTHEARE SYSTEMS CAN I Provide high quality, ongoing care focused on patient safety and suicide prevention. 0 Make sure affordable and effective mental and physical healthcare is available where people live. 0 Train providers-dopting proven treatments for patients at risk of suicide. if BAN Promote employee health and well-being, support employees at risk, and - plans in place to respond effectively. Encourage employees to seek help when they need it. Provide referrals to mental health, substance use disorder, le al, or financial counseling services as needed. Reduce access to lethal means, soc; as medications and firearms, among people at risk. Learn the warning signs of suicide and the steps to help identify and connect people at risk to appropriate services. wwaeThe?lTocom Contact the National Suicide Prevention Lifeline for help for themselves or others: {8255}. The media can avoid increasing risk leg, with dramatic headlines, and explicit details) and encourage people to seek help using recommendations available at: If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-800-273-TALK (8255} Chat: For more information, please contact Telephone: (232?4636) TTY: 1388?2326348 Web: Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Publication date: June 2013 From: Simon, Thomas Sent: 14 May 2018 15:35:24 -0400 To: Stone, Deborah Kristin Subject: FW: Suicide Vital Signs brief update and fact sheet #2 of 4 From: Ferdon, Corinne Sent: Friday, May 11, 2013 1:08 PM To: Simon, Thomas Cc: Stone, Deborah Richmond-Crum, Malia Daniel, Valerie M. Black, Erin Crosby, Alexander Dahlberg, Linda L. Bruce, Subject: RE: Suicide Vital Signs brief update and fact sheet Hi everyone working on this great set of products, I think this looks great! A couple ofsmall style things to maybe look at are below. Cory Page 2 of PDF, I found the following wording a bit hard to follow "Crisis in the past upcoming two weeks?. Is there a slash mark or some words needed between ?past? and ?upcoming?? Page 4 of PDF, sticky note of edit under "everyone can?. If going to include the Lifeline number here too, may want to include a to read Word document with replacement graphic. The boxes that summarize the TP strategies use a variable format. Some capitalize all words, some capitalize only first word, and others have some sort of other mix. From: Simon, Thomas Sent: Friday, May 11, 2018 10:07 AM To: Mercy, James (CDCIONDIEHINCIPC) Ferdon, Corinne (CDCIONDIEHINCIPC) Hou ry, Debra E. Greenspan, Arlene (CDCIONDIEHINCIPC) Dorigo, Leslie (CDCIONDIEHINCIPQ Cc: Stone, Deborah Richmond-Crum, Malia Daniel, Valerie M. uhB Cdc. 0v); Black, Erin Crosby, Alexander (CDCIONDIEHINCIPC) Dahiberg, Linda L. Bruce, x6 cdc. 0v> Subject: Suicide Vital Signs brief update and fact sheet Hi everyone, The pre-brief with Dr. Schuchat went very well. She is highly supportive and interested in the topic of suicide prevention. She and others in the room had helpful comments and suggestions related to the range of VS materials but their comments were fairly specific and will not result in substantive changes to our approach. We are continuing to refine the fact sheet. I have attached a copy of the fact sheet with embedded stickies to describe specific edits we are making. These reflect the changes we discussed with Dr. Schuchat and the V5 office during and after the pre?brief. I?m also attaching a Word document that describes the changes that we are making to page 3. We are providing shortened text for the figure that was at the top of page 3. The VS graphics artists are going to modify the layout on this page but will use the text we provided. We are also adding the 5 steps to take when you are concerned about someone who may be suicidal. This was a good outcome from the discussion at the pre-brief. The MMWR has completed review by DADS and their comments were quite minor. We addressed them this morning and Deb will be working closely with the MMWR editors early next week to finalize the MMWR. Please let us know if you have any questions or suggestions. -Tom From: Simon, Thomas Sent: Wednesday, May 2, 2018 12:59 PM To: Mercy, James Ferdon, Corinne (CDCIONDIEHINCIPC) Hou ry, Debra E. Greenspan, Arlene Dorigo, Leslie Cc: Stone, Deborah Richmond-Crum, Malia Daniel, Valerie M. uh8 cdc. ov>; Black, Erin Crosby, Alexander (aecl cdc. ov>; Dahlberg, Linda L. Bruce, x6 cdc. ova Subject: RE: Suicide Vital Signs Fact Sheet head's up Hi everyone, I just received the integrated version of the fact sheet with the new graphics and latest text. As I described below, I need to get changes back to the VS office tomorrow so that they can be integrated in the version that will go to Dr. Schuchat. If you have time to review it please send me changes by cob today and I?ll integrate them. If not, there will still be time next week to make changes - so this is not your last chance. I just wanted to give you an opportunity to weigh in on anything problematic before it goes to Dr. Schuchat. Our team is reviewing it at the same time. Thanky0ul ?Tom From: Simon, Thomas Sent: Tuesday, May 1, 2018 6:04 PM To: Mercy, James Ferdon, Corinne (CDCJONDIEHINCIPC) Hou ry, Debra E. Greenspan, Arlene Dorigo, Leslie Solhtalab, Elizabeth Cc: Stone, Deborah Richmond?Crum, Malia Daniel, Valerie M. (CDCXONDIEHKNCIPC) uhS cdc. mo,- Black, Erin Crosby, Alexander Dahlberg, Linda L. (CDCIONDIEHINCIPC) Bruce, Subject: Suicide Vital Signs Fact Sheet head's up Hi everyone, The fact sheet process has continued, including lots of wordsmithing types of editing but nothing too substantive. I?ll share that Dr. Schuchat only had one change so far. The VS graphic artist has been working on images separately from the wordsmithing and we have been reviewing drafts of the images. We heard today that we should be receiving an integrated version with the text and graphics tomorrow and will need to turn it around by 10:00 am. on Thursday. I wanted to give you a heads up in case you want to review it. I?ll share it when it comes in tomorrow, but I won?t have reviewed it yet and I know that they made changes since we last reviewed it so we?ll probably have corrections/edits. We have the pre-brief with Dr. Schuchat on Tuesday so the VS team wants to make our changes to the FS and provide it to her in advance of that meeting. If you send changes by C08 tomorrow we can make them in the version that will go to Dr. Schuchat. If you don?t have time to review it tomorrow we should still be able to address your concerns next week so please still send them by Monday. Thankyoul - Tom From: Simon, Thomas Sent: Wednesday, April 4, 2013 4:38 PM To: Mercy, James Ferdon, Corinne Hou ry, Debra E. Greenspan, Arlene Dorigo, Leslie Solhtalab, Elizabeth Cc: Stone, Deborah Richmond-Crum, Malia ; Daniel, Valerie M. (CDCIONDIEHINCIPC) uh8 cdc. 0v}; Black, Erin sepm??cdcgove; Crosby, Alexander Subject: Suicide Vital Signs Fact Sheet Hi everyone, We had the roundtable with the VS office yesterday and it went well. We negotiated back and forth and spent a lot of time wordsmithing. For those who don't know, the round table lasts 3 hours and the focus is on getting the key messages into the VS fact sheet template. The fact sheet is 4 pages long but there are 14 pages of fact sheet rules and guidance (yes literally). Some things that might seem odd about the word choices, brevity, and headings in the draft attached are the result of this style guidance. We and the VS team are feeling very good about where we are with this version. We think it really helps the reader to walk away knowing that suicide rates are increasing across states, that suicide is not only a mental health problem, and that there are a range of effective actions that can be taken to prevent suicide. The team worked quickly to revise the fact sheet last night and today to incorporate the changes from the round table. We are going to continue to tweak this but we would like for you to review and please send us any requests for changes by cob Friday, if possible. We know that some people are on leave and won?t be able to review this until Monday. We need to submit a revised version to the VS office on Tuesday. That version will be further edited by them, shared up the chain, and used to create better graphics. The graphics included now are placeholders. They have artists who will improve on these. We anticipate sharing the fact sheet with you again as it progresses but now is the time to let us know if there is anything substantial that you would like changed. Thank you for your support on this Vital Signs! ?Tom and Deb From: Stone, Deborah Sent: 13 May 2018 18:22:35 +0000 To: Simon, Thomas Subject: FW: Suicide Vital Signs deliverables calendar - releasing June 6 Attachments: June 2013 Deliverables calendar_21Nov2017.xlsx Here you go! From: Peaker, Brandy LSIDPHID) Sent: Tuesday, November 21, 2017 5:06 PM To: Simon, Thomas Schieber, Richard A. (CDCIOPHSSICSELSIDPHID) Cc: Mercy,James (CDCIONDIEHINCIPCJ Stone, Deborah Sokler, (CDCIODJOADC) Omisore, Shannon L. Peaker, Brandy Subject: Suicide Vital Signs deliverables calendar - releasing June 5 Hi Tom - Attached is a deliverables calendar for the suiczde VS releasing June 5. We will go over this and the overall VS process and products at the kick-off meeting. Rich will be in touch to schedule this meeting. Some key dates: Draft MMWR and Fact Sheet {Word version) due for Roundtable [clearance got required at this stage}: April 2 Roundtable: Aug 3 from 1:30-4:30 please check schedules for availability for this 3 hour meeting CID ?cleared MMWR and Fact Sheet due: April 10 CDCIDD review of MMWR and Fact Sheet {Word version): April 11 - 15 Fact Sheet (Word version} revisions and MMWR submission due: April 25 Other CID-cleared pre?brief material (Press Release, Dear Colleague letter, Telebriefing script, DBLA, critical contacts) due: April 2? Fact sheet [graphic version], MMWR, and other ore-brief material due to CDCIDD ?May 4 Pre-brief with Drs. Schuchat, Mackenzie, Lyon Daniel: week of May 7. will provide comments on all material at the pre?brief FSIgraphic version) and Press Release due to HHSIASPA: May 18 Thanks, Brandy From: Simon, Thomas Sent: Monday, November 13, 2017 3:28 PM To: Peaker, Brandy Schieber, Richard A. Subject: RE: Approval Hi Brandy. Thank you for this update. We would actually like to have the kickoff meeting as early as Rich and you are ready in January or early February. We will have a solid draft by then. We look forward to seeing the calendar next week. Thank you, Tom From: Peaker, Brandy Sent: Monday, November 13, 2017 2:29 PM To: Simon, Thomas Schieber, Richard A. Cc: Mercy, James Stone, Deborah Subject: RE: Approval Hi Tom I am the Deputy Director for V5 and develop the production calendars for each issue. I am working on calendars Feb thru June now. I won?t have your exact deliverables dates until the next week or so, but typically a good non-cleared draft of the MMWR and Fact Sheet are clue about 10 weeks before release. For your June 5 release that would be around the last week in March. We use those drafts in a Roundtable meeting where we edit the Fact Sheet for clearer messaging and language. A CID- cleared MMWR and Fact Sheet are due about a week and half after the Roundtable [early April}. Those versions will go to for review before submitting MMWR to ScholarOne and the Fact Sheet to the graphic artist. Although a fully cleared version of MMWR and Fact Sheet is not needed for the Roundtable, you?ll want to start the clearance process well before the Roundtable since Center clearance will be required about a week and a half later for review. Rich will be in touch to schedule an in-person kick-off meeting for some time in Feb. We will go over the deliverable dates in much more detail then. Thanks, Brandy From: Simon, Thomas Sent: Monday, November 13, 2017 8:45 AM To: Schieber, Richard A. Cc: Mercy, James Peaker, Brandy Stone, Deborah <2af9 cdc. ov> Subject: RE: Approval Hi Rich, Have you developed a master calendar yet? I would like to share it with our policy and communication colleagues. Thank you, Tom ?Tom From: Schieber, Richard A. Sent: Monday, October 16, 2017 5:08 PM To: Simon, Thomas (CDCXONDIEHINCIPC) Cc: Mercy, James (CDCIDNDIEHINCIPQ Peaker, Brandy Stone, Deborah Cc: Mercy, James Peaker, Brandy Subject: Approval Tom and Jim, Dr. Schuchat liked your suicide prevention proposal. It?s a green light to go ahead. Congratulations! And well-deserved, for sure. We?ll be in touch about next steps, but for now, please focus on the data analysis and MMWR write-up as you would for any other MMWR, but with the format restrictions we lay out in the MMWRIVS Instructions to Authors on-line at These indicate the abstract length (250 words), text length (1800-2000 words), number of ?gures or tables (4), and references (15). The Key Points should be written in plain language; we can help revise that part into plain language along your Comma person. I don?t have a deadline date for the MMWR first draft but you are at least several months from that time. Brandy can help you with that and other dates. Let us know your questions and issues as they come up. No question is too small! Best, Rich Sent from my iPhone June 5, 2013 Suicide AbbrEviated Timelines of Deliverabies, 11f21lZOlT Step Deliverable Begin at End bv COB Workdavs Deliver to Comments 08:00 A.M. Analysis, Direction?setting, and MMWR Prep (1: DIRECTION AND 1 Initial Meeting Tan 2 DD Planning DocumenthOHCOfDne Thing DONE R5, L5 3 CDCIOD review of ODPDISDH COfCine Thing DON Program respond in writing to questions 4 from CDCIDD DUN R5 WIWMeWmamtz-ewmm . . mptargglem HMWW their? 3.5 Principal Depuv Dir, eminent},- be sent to 7 [Basrnussem Kentlreview rare-submission CIO 11-Apr 16-Apr 4 its CDCIDD at the same time. cleared and crass-cleared MMWR Ma): 13m word text 250 word abstract 15 references Su hmit to MMWH by noon PGM revises, cross-clears and submits MMWR to MMWR Submission 3 25-Apr 7 System, Editors R5 L5 Please send v5 team a comma ntfresponse matrix on how you addressed comments from Drs. unhat. Mac Kenzie, and n? Danlel. Matrix ?i?li'f needed for comments from thesa 3 reviewers MMWR Editors and 9 MMWH edited and produced 25-Apr B-May 10 Reviewers, PGM, HS SCIENCE CLIPS: lD PGM provides citations for 21-May R5 Science Clips Bill Thomas Rich reviews citations and sends to ODIOADS and 11 22-Mav John Fskander CDC librarian . Gail Bang Sheet {Word and Graphim Versions} .33. my 3?April 13 Roundtable 1:304:30 L5, R5 Principal Depuy Dir. DEBS. 1s csers (Rasmussen, Kent, 11-Apr 15-Apr 4 Register, Martin}; CDCW review CID-dearer! 1 of 3 shame revise: from cncian, (SELs, cacw Pieesesend VS team-e anmmen?respme matrix on haw yau addressed comments from Drs. Stillman-Mac Kenzle, (Ker-It]; CDCW review full?color Director. ADS, ADC [week of S-Feb?Mmemratld Whl?lls ?Wm 515 team him and Lvaneba'niel. Matrix only needed for-comment?s from these 3 reviewers 1? Complete internal graphic development 26-Apr 4-Ma1r [5 Principal Deputy Director, ADS, 13 CDCIOD (Principal Depuy Dir, DADS, tH'vlav Princupal lite-slantsI Rs, LS pre?brief Kent. CDCW will receive courtesv copies 1 Pre-brief with Principal Deputy Director, AnsSpanish) 23 Medical Outreach Program call while F5 is being reviewed by DD LS to NME to Send FS with Press Release 20 HHSIASPA review and clear full-eelnr JIM-lay through NMB 21 CDC Lacks dawn full-color graphic 24?Mav L5 at 5:00pm . . . . L5 to send English F5 to Shannon 22 CBCfinal pLIbIIcatmrl preparatlon {English and 25-May 4mm L5 Omisere for Spanish Other Materials Produced Bra Peaker Halide",r 28-MayI Program to discuss with US potential outreach strategies for clinicians TOWN HALL MEETING PREP.- Chelsea PGM works indepen dentlv with 24 PGM finds 2 local demo B?Mav Pavne, Toma Joyner furthis for Town Hall 26 Pam revises PR 30-Apr 4-Mav DNEM 2? BABE reviews PR ?-Mav ll?Mav 28 revises FR from OADC review 14-May ?-Mav 3 PR HHSIASPA and clears ?May L5 3? 25?? L5 31 and PGM to work on "one graphle" 18-May 2+Mav L5 2 of 3 spams Final Activities [12} SOCIAL and ELECTRONIC MEDLA: 6 Weeks prior to release; 35 Meet with Kamelya Hinsun and PGM to go over lat-Apr LS, (JADE to provide PGM with a social Social and Electronic Media media template II weeks prior to release; PGM to provlde content to Hamel-fa Hlnson; PGM PGM me] a H?nso 26:33:": 35 works with LaKia Bryant to provide content on El-Mav Arezoo Rlsman 50 sends to MLS for Spanish Digital Press Kit . translation V5 WEBSITE BUILT: Spanish Website also built 3? . 25-M 31-M 4 LS, PGM provides its links and alt text to L5 3? 3" Holidav 28-May 33 Rich creates CDC Announcement 29-May Rhonda Smith CDC Announcement at 2pm on E-Mar [14} FEE-BRIEFING: 39 L5 sends latest MMWR proof, d-Ma LS PGM to send all requested version, PR, Telebrleflng Script, earn, material by 10AM Critical Contacts List and draft email 21,12thIlOor m_ ?rst.? {unless DIV: Leadership, Comm, Policy, 40 Pris-brief with Principal Denuty Director, ADS, ADC week of lit-?ay . Science SMEs traveling} . Call In number protruded Dir Conf Rm, 21, 12th floor In? erso [unless DIV: Leadership, Comm, Policy, 41 Prue-brief with to: Director week of 21-May Science SMES traveling} . . Call In number provrded [15} NOTIFICATIONS: 42 1-M l5 DNEM, PGM NPHIE call attends} 3 all #3 InternaluFinaI materials sent 4?Jun Done by L5 to ieademhip and distributors External - CDC Director sends out email to "Critical .Ema? Shim?! that 44 S?Jun Information Is embargoed until Contacts 1pm on release date 45 External [cont] - PGM sends email to "Critical unt'l Contacts" not otherwise contacted by I I 1pm on release date External {contluFGM and BRANCH: SME, Chief. Comm, 46 notify all other partners of impending s-Jun Policy; Embargo in place until 1 release Dm 4? Press receives materials under 5-Jun RS, LS, DNEM Embargo in place until 1pm embargo immediate Pre-brief 11:40; C?cnhedorcondudstMeb?e?ng ?8 Materials released to public at 1pm 54?" PGM 21? 12m floor DIV: Director, Comm, Policy BRANCH: Chief, SME, Comm, Policy [17} MEDIA METRICS ED 49 24-hour media report clue 54?" DNEM SD SIB-day Media report due 30 dew after I5, DNEM release [18} TOWN HALL . 51 PGM participate: 12?Jun SME presents ovennew 3 of 3 spams From: Herbst, Jeffrey Sent: 3 Jan 2018 15:36:10 -0500 To: Bartholow, Brad Deborah (CDCIGNDIEHINCIPC) Cc: Girod, Candace Subject: FW: Technical Package Citation Scan Attachments: TP Citations across the internet.xlsx Sharing great news from CandaceH From: Girod, Candace Sent: Wednesday, January 3, 2018 3:20 PM To: Herbst, Jeffrey Cc: Dahlberg, Linda L. Subject: Technical Package Citation Scan Hey Jeff and Linda, I'm attaching a spreadsheet with any websites that mention the technical packages. This doesn?t include any journal articles. One interesting takeaway was that of the 208 websites I found, almost 3?0 cited the suicide technical package. 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I an lam; my nnpugn nw?mn?lksl?nmhumlm?nlm INN-9M 1M nlmuinlgr -II I-rn ls :Llh??l' an mug . wit-Hm 5le Tr 12F mm ?loll mmwuw "Wm: Imam um? Wm Bin humankind MI. IHIHM ?HE?-Hm?lhl ?H'?ll?d?lhh mumnwu Imm?nwh Nr- mmudmmumruwmm l?ll'I'? COMFIIDGWIWWIIWHD MEI u? mm :I-I-Innul'puuc- lhlh? mun-mun" Inn-u uuihul I'll-m- mun-Inna mlmImml-Iu ?lard Sikh? mu IHI Arum-I mwnnIrIo-hnuww F?wl?mm Hu? minimum-hummnulhIJhIM-n Woman-nu WI .. HINDI IW mun-pa Mh??l??ri?w?wm mmnl?l wurm-unnrm mum-unwrap: lawman-II nI-swlpII Mind mnil-ni?lmul?udmn Du now-m Mammalian- ?t Nahum. sun-bemu- a: Haul-murmured ?mum mm mud- mm Hmtr?umlm II: nu In H6. am my Mil-El. no 1mm: will! In I- m: Its WHILE nu Winn]? ?lm-11' nm In nun-:1 In In Ml Ihmi? nu mm! ?will" In In rIcI In mm Mancunian ?now swim Imus-m . Mp ?mum Em! IEIEJ E?l?l?L?ll-lmll?lh? m-ijmLIWIunu-wagwy :w?m Inu?mpm rI-IhuIdDrgIm/v min-l 'Ml??hm 'w?i?bl??m'fu?lem ILIIJIJII-J m_ LWLMII . I nd :11: Jib?1m Wm?. WM WWI "5 30W. I. om_IuI_ LBEI. EM. I I I Mb mama may IlWJ-Infle-IEBMM-Mmurh?nl?m ??lma??L?uWI??-?ml "Hair?W m'a?wmwmeL?wm My; Ih?n?mlul Ex I I - I- mn- abacu? Ir ?ll-IL" EIWI mehI-Iymwn I'rIme ?hl?l From: Simon, Thomas Sent: 5 May 2018 12:58:48 -0400 To: Logan, Joseph Deborah Subject: FW: veteran suicide Attachments: DStone_Figure 1.emf, VS_Suicide_5.4.18 clean.docx, TABLE 2_New 5.4.18.docx, TABLE 1_New S.4.18.docx, DStone_Supplemental Table 1.pdf, TABLE 1_New S.4.18.docx Resending because I did not include Deb. Hi J., The V5 MMWR (attached) is not about military/Veteran Suicide but there is one line in the table showing the proportion of decedents who have served in the military (see Table 1). The Surgeon General is going to participate in the telebriefing for the V5 and he is likely to make a point about the high risk among Veterans and the need for prevention. This could generate some questions for us from the media. I?m glad that you have q?s and a?s to choose from. I don?t seem to be able to access the [1's and A?s on Sharepoint. If you could send us a few (1?s and A?s with short answers to questions you think will come up related to trends, prevention strategies, what CDC is doing, etc. that will be helpful. You have a better sense ofwhat comes up most often. We have a pre?briefing with Dr. Schuchat on Tuesday and, if possible, it would be good for us to have these with us in case it comes up. The actual launch is not until 6/7 though so we have time to finalize this once we see exactly what the SG intends to say. Thankyou! ~Tom From: Logan, Joseph U.) Sent: Saturday, May 5, 2018 9:15 AM To: Simon, Thomas Cc: Stone, Deborah Holland, Kristin (CDCXONDIEHINCIPC) Subject: RE: veteran suicide Hi Tom, If you can give me a few days, I can help. If you need the (1 and As immediately, then feel free to draw from the documents I posted on SharePoint. Just note, on Monday morning, I plan to update them in prep for Marcus so please wait on accessing them until noonish. We?ve had some significant enhancements that I need to include. All ask is that if you can please send the and As to me before sending them up the chain, I would appreciate it. just want to keep an on what we release so we don?t accidently repeat the events of the last few weeks. If you would like my help with drafting them, then please send me any background materials {Vital Signs drafts, fact sheets etc) so I understand the context. There are a lot of different ways the might be able to narrow the scope of possible key relevant questions and messages if I have more background. J. J. Logan, Suicide and Youth Violence, Emerging Topics Team Research 8; Evaluation Branch Division of Violence Prevention National Center far Injury Prevention and Control Centers for Disease Control and Prevention MS: F-63 Email: ?a3@cdc.gov Telework day: Thursday Office phone: 7711-1138-1529 Telework phone: 404r884-4379 From: Simon, Thomas Sent: Friday, May 4, 2018 11:54 AM To: Logan, Joseph (1.) Cc: Stone, Deborah Holland, Kristin Subject: veteran suicide Hi 1., We are compiling q's and a?s for the upcoming vital signs. Do you have any [1?5 and a?s related to Veteran suicide that we can pull from? The Surgeon General is participating in the launch and he is particularly interested in Veteran suicide. I think short answers to questions about trends, prevention strategies, and what CDC is doing will be helpful. Thank you! -Torn 5.4.18 Vital Signs: Trends in State Suicide Rates United States, 1999?2016 and Circumstances Contributing to Suicide 27 States, 2015 Deborah M. Stone, Thomas R. Simon Katherine A. Fowler, Scott R. Kegler, Pth; Keming Yuan, Kristin M. Holland, Asha Z. Ivey?Stephenson, Alex E. Crosby, Background: Suicide rates in the United States have risen nearly 30% since 1999, and mental health problems are just one factor contributing to suicide. Examining state-level trends in, and the multiple circumstances contributing to, suicide can inform comprehensive state suicide prevention planning. Methods: Trends in age?adjusted suicide rates among persons aged 210 years, by state and sex, across six consecutive three-year periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia (DC). Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among decedents with and without known mental health problems. Results: During 1999?2016, suicide rates increased signi?cantly in 44 states, with 25 states experiencing increases of more than 30%. Rates increased signi?cantly among males and females in 34 and 43 states, respectively. In 2015, more than half of decedents in 27 states did not have a known mental health problem. Among persons with circumstance information, several circumstances were signi?cantly more likely among those without a known mental health problems than among decedents with mental health problems, including relationship problemsfloss [45.1% vs life stressors {54.2% vs and recentfimpending crises (32.9% vs but these circumstances were common across groups. 5.4.18 Conclusions: Suicide rates increased signi?cantly across most states during 1999?2016. Various circumstances contributed to suicides among persons with and without known mental health problems. Implications for Public Health Practice: States can use a comprehensive evidence?based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friendsifamily after a suicide occurs. INTRODUCTION BACKGROUND AND PURPOSE In 2016, nearly 45,000 suicides (15.6! 100,000 population [age?adjusted]) occurred in the United States, among persons aged 310 years (1). Between 1999 and 2015, suicide rates increased among both sexes, all racialfethnic groups, and all urbanization levels Suicide is the 10th leading cause of death and is one of just three leading causes that are increasing Additionally, rates of emergency department visits for nonfatal self-harm, a key risk factor for suicide, increased 42% between 2001 and 2015 (1). Together, suicides and self-harm injuries cost the nation more than $69 billion in direct medical and work loss costs (I). The Nations! iraiegjv for Suicide Preveniion (NSSP) (5) calls for a public health approach to suicide prevention with efforts spanning multiple levels individual, familyirelationship, community, and societal). Such a comprehensive approach underscores that suicide is rarely caused by any single factOr, but rather, is determined by multiple factors. Despite the NSSP guidance, suicide prevention largely focuses on identifying suicidal persons, providing treatment for mental health problems and preventing reattempts (6). In addition to mental health problems and prior attempts, other circumstances contributing to suicide include social and economic 5.4.18 problems, access to lethal means substances, ?rearms) among persons at risk, and poor coping and problem-solving skills (5). Expanded awareness of these additional circumstances contributing to suicide risk and action to address them can help reach the nation?s goal of reducing suicide rates 20% by 2025 (7). To assist states in achieving this goal, CDC analyzed state-speci?c trends in suicide rates, assessed the multiple contributing factors to suicide, and presents options for multi-level comprehensive suicide prevention based on the best available evidence. METHODS Suicide rates were analyzed for persons aged 3:10 years only, as determining suicidal intent in younger children can be dif?cult (8). Age-speci?c suicide counts were tabulated based on National Vital Statistics System coded death ceni?cate records {International Classi?cation of Diseases 10? Revision, underlying-cause-of death codes Y87.0, U03). Age-specific population estimates were obtained from US. Census Bureaui?National Center for Health Statistics bridged-race population data releases. National and state-level suicide rate estimates were calculated for six consecutive three-year aggregate periods spanning 1999?2016 (1999?2001, 2002?2004; 2005?2002; 2008?2018; 2011? 2013; and 2014?2016). Rate estimates were age-adjusted to the US. year 2000 standard population and expressed per 100,000 persons per year. Age-adjusted suicide rate trends were modeled using the same three-year data aggregates, employing weighted least squares regression with inverse-variance weighting. Modeled rate trends are reported in terms of average annual percentage changes (AAPCs). Characteristics and circumstances of persons aged 3:10 years who died by suicide, with and without known mental health problems, were compared in the 27 states with complete data 3 5.4.18 participating in CDC ?5 National Violent Death Reporting System in 2015. de?nes mental health problems as disorders and listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (9), with the exception of alcohol and other substance use disorders, which are captured separately in aggregates data from three primary data sources: death certi?cates, coroner/medical examiner reports (including toxicology), and law enforcement reports. Decedents with and without known mental health problems were compared using Chi-square tests. Logistic regression analyses estimated adjusted odds ratios with 95% con?dence intervals (CI), controlling for age group, sex, and raceiethnicity. RESULTS The most recent overall suicide rates (representing 2014?2016) varied four-fold, from 6.9 (DC) to 29.2 (Montana) per 100,000 persons per year (available online). Across the study period, rates increased in all states except Nevada (which had a consistently high rate throughout), with absolute increases ranging from +0.8 per 100,000 (Delaware) to +8.1 (Wyoming). Percentage increases in rates ranged from +59% (Delaware) to +57.6% (North Dakota), with increases of more than 30% observed in 25 states (available online; Figure I). Modeled suicide rate trends indicated signi?cant increases in 44 states, among males (34 states) and females (43 states), as well as for the United States overall (available online). Nationally, the model?estimated AAPC for the overall suicide rate was By sex, estimated national rate trends further indicated signi?cant increases for males (AAPC and females (AAPC (available online). Suicide decedents without known mental health problems (N 11,039) were compared with those with known mental health problems (N 9,407) in 27 states. Whereas all decedents were predominately male (Table 1) and non-Hispanic white those without known 4 5.4.18 mental health problems, relative to those with mental health problems, were more likely male (83.6% versus 68.8%; odds ratio (OR) 2.3, 95% CI 2.2-2.5) and racialfethnic minorities (OR range: Suicide decedents without known mental health problems also had signi?cantly higher odds of perpetrating homicide-suicide (adjusted odds ratio 2.9, 95% C1 3.8). Among adult decedents 1318 years, 20.1% of those without known mental health problems and 15.3% of those with mental health problems had ever served, or were currently serving, in the U.S. military. Whereas ?rearms were the most common method of suicide overall and for decedents with and without mental health problems, decedents without known mental health problems were more likely to die by ?rearm (55.3% versus 40.6%) and less likely to die by (26.9% ver3us 31.3%) or poisoning (10.4% verSus 19.8%) than were those with known mental health problems. These differences remained signi?cant in the adjusted models. Decedents without known mental health problems were less likely to receive toxicology testing. Among those with toxicology results, decedents without known mental health problems were less likely to test positive for any substance overall 0.8, 95% C1 including opioids 0.90 95% CI but were more likely to test positive for alcohol 1.2, 95% CI Information on circumstances surrounding suicide were available for all decedents with mental health problems (N 9,407) and approximately 85% of those without known mental health problems (N 9,357) (Table 2). Persons without known mental health problems were less likely to have any substance use disorders 0.7, 95% Cl Whereas two thirds of 5.4.18 decedents with known mental health problems had a history of mental health or substance use treatment just over half were in current treatment. Decedents without known mental health problems had a signi?cantly higher likelihood of any relationship problemfloss than did those with known mental health problems specifically intimate partner problems (30.2% versus (17.5% versus and recently perpetrating interpersonal violence versus Decedents without known mental health problems were also more likely than those with known mental health problems to have experienced any life stressors (54.2% versus 49.7%) such as criminal-legal problems (10.7% versus or evictionx?loss of home versus and were more likely to have had a crisis a current or acute event thought to contribute to the suicide, within the preceding or impending, two weeks (32.9% versus All of these differences remained significant in the adjusted models. Among all persons with recent crises, intimate partner problems were the most common types and did not differ by group. Similarly, physical health problems and jobx??nancial problems were commonly experienced among both persons without mental health problems (23.2% and 15.6%, respectively) and those with mental health problems (21.4% and 16.8%, respectively). Decedents without known mental health problems had significantly lower odds of recent release from any institution 0.5, 95% CI but those who were recently released were signi?cantly more likely to have been released from a correctional facility (25.7% versus hospital (43.7% versus or other facility alcoholisubstance treatment) 2.5 95% CI than those with a known mental health problems. Among decedents with known mental health problems who were recently released from an institution 46.7% of were released from facilities. 5.4.18 Decedents without known mental health problems were signi?cantly less likely to have a history of suicidal ideation or prior suicide attempts compared with those with known mental health problems (40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% of persons without and with known mental health problems, respectively. Conclusions and Comments During 1999-2016, suicide rates increased signi?cantly in 44 states, and 25 states experienced increases of more than 30%. Rates increased signi?cantly among males in 34 states, and females, in 43 states. This ?nding is consistent with prior research showing a decreasing gender gap in male?female suicide rates during 1999?2014 Additional research into the speci?c causes of these trends is necessary. Fortunately, data from the 27 states participating in provides important insight into circumstances surrounding suicide and can help states identify prevention priorities. Suicidologists regularly state that suicide is not caused by a single factor (5), however, suicide prevention is often oriented toward identi?cation of suicidal persons, treatment of mental health problems and prevention of reattempts. This study found that more than half of suicide decedents in did not have a known mental health problems, indicating that additional focus on non-mental health factors, further upstream, is essential to a public health approach (10). This group suffered more from relationship problems and other life stressors such as criminal-legal matters, evictionfloss of home, and recent or impending crises. Similarly, persons with mental health problems often experienced relationship problems and other life stressors such as jobr??nancial andfor physical health problems. These ?ndings point to the need to both help persons manage the conditions associated with mental health problems in the ?rst place, and to support persons with known mental health problems to decrease their risk 7 5.4.18 of poor outcomes Two thirds of this group had a history of any mental health andfor substance use treatment, with over half in treatment when they died. This suggests the need for additional safety supports, including broader implementation of affordable and effective treatment modalities such as doctor-patient collaborative care models and proven cognitive- behavioral therapies. Additionally, increased access to behavioral health providers in underserved areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide prevention and patient safety, especially through care transitions (I2). Comprehensive statewide suicide prevention activities are needed to address the full range of factors contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household ?nancial support); teaching coping and problem- solving skills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social connectedness to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and better supporting persons at risk military veterans, persons with physicalx?mental health problems) (I2). Other strategies include creating protective environments reducing access to lethal means among persons at risk, creating organizational and workplace policies to promote help-seeking, easing transitions into and out of work for persons with mental health problems and other life challenges), supporting family and friends after a suicide, and assuring safe reporting by the media in order to prevent suicide contagion (i 2). Some states, such as Colorado, are planning to implement such a comprehensive approach to suicide prevention (10). The ?ndings in this report are subject to at least three limitations. In the state-level analysis, rankings for four states (Maryland, Massachusetts, Rhode Island, and Utah) might have been 5.4.13 affected by large proportions of injury deaths of undetermined intent (potentially biasing reported suicide rates downward), or decreased percentages of such deaths over time (potentially biasing estimated rate trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% of the population Finally. abstractors of data are limited to information contained in investigative reports. Therefore, the extent of infonnant knowledge can affect data completeness and accuracy. Studies including more in?depth interviews with next?of?kin often identify greater attributions to mental disorders however, many methodological variations across studies exist (14). It is likely that some persons without known mental health problems in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. Nonetheless, the high prevalence of diverse contributing circumstances among those with and without known mental health problems suggests the importance of addressing the broad range of factors that contribute to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are available. States and communities can use data from and resources such as Preventing Suicide: a Technical Package Programs, and Practices {12) to better understand their suicide problem, prioritize evidence-based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson, Holly Hedegaard, and Margaret Wamer, Division of Vital Statistics, National Center for Health Statistics, CDC. Conflict of Interest No con?icts of interest were reported. 9 5.4.18 'Division of Violence Prevention, National Center for .Injury Prevention and Control, 2Division of Analysis, Research, and Practice Integration, National Center for Injury Prevention and Control, CDC. Corresponding author: Deborah M. Stone, dstone3@cdc.gov 770-488?3942 References 1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: National Center for Injury Prevention and Control. Retrieved March 15, 2018. In. 2. Ivey-Stephenson AZ, Crosby AE, Jack SPD, Haileyesus T, Kresnow?Sedacca MJ. Suicide Trends Among and Within Urbanization Levels by Sex, RacefEthnicity, Age Group, and Mechanism of Death?United States, 2001?2015. MMWR Surveill Summ 3. Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 1999?2014. In: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics Hyattsville, 2016. 4. Kochanek K, Murphy S, Xu J, Arias E. Mortality in the United States, 2016. NCHS Data Brief, no 293. National Center for Health Statistics 2017. 5. Of?ce of the Surgeon General, National Action Alliance for Suicide Prevention. 2012 National strategy for suicide prevention: Goals and objectives for action: a report of the US Surgeon General and of the National Action Alliance for Suicide Prevention. 2012. 6. Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet 7. Torguson K, O'Brien A. Leading Suicide Prevention Efforts Unite to Address Rising National Suicide Rate. In. Washington, 2017. 10 5.4.18 10. 11. 12. 13. 14. Crepeau?Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2010; 14:24n34. American Association. Diagnostic and statistical manual of mental disorders American Pub; 2013. Caine ED, Reed], Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Inj Prev 2017:injuryprev-2017-042366. World Health Organization. Risks to mental health: An overview of vulnerabilities and risk factors. Geneva: WHO 2012. Stone DM, Holland KM, Bartholow BN, Crosby AE, Davis SP, Wilkins N. Preventing suicide: A technical package of policies, programs, and practice. 2017. Milner A, Sveticic J, De Leo D. Suicide in the absence of mental disorder? A review of autopsy studies across countries. Int .1 Soc Pouliot L, De Leo D. Critical issues in autopsy studies. Suicide Life Threat Behav 10. Summary Box (word count 1001100) What is already known on the topic? In 2016, nearly 45,000 lives were lost to suicide in the 11.3. What is added by this report? Between 1999-2016, suicide rates increased in nearly every state. Twenty?five states saw rate increases Mental health problems often contribute to suicide, however, 2015 data from the National Violent Death Reporting System (27' states) indicate that 54% of suicide decedents 11 5.4.18 were not known to have such problems. Other contributors included relationship, substance use, health, and jobf?nancial problems. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as those in Technical Package for Suicide Prevention, can help reach the national goal of reducing suicide rates 20% by 2025. 12 TABLE 2. Circumstances Preceding Suicide among Decedents Aged >10 years with and without known mental health problems National Violent Death Reporting System. 2? states.t 2015 No known Known mental mental health health problemi, problem, no. Chi? Adjusted Characteristics Total no. {Va} Square {95% Cl} {95% CI) Suicide with known circumstances 18.?84 {91.8) 9.40? {100} 9.35? {84.8} p<001 Mental Health Any Current Diagnosed Mental Health Problem {75.2} Anxiety disorder 1,5?9 {18.8} Bipolar disorder 1.431 {15.2} Schizophrenia 509 PTSD 424 - ADDIADHD 228 Unknown 780 Current depressed mood 3,982 {42.1} 3,0?8 {32.9} p<0.01 Substance Problems Any Current substance problem 5.319 {28.3} 2.9?8 {31.8} 2,343 {25.0} p<001 Alcohol problem 3.288 1.882 {19.8} 1.408 {15.0} p<001 Other substance problem 3.084 {18.4} {18.8} 1.318 {14.1} p<0.01 Treatment Current mental abuse 5.141 {54.0} 84 ps0.01 0.01 {0.01?0.01} 0.01 {0.01?0.01} treatment Ever treated for mental healthi?substance {35.8} 8.323 {87.2} 394 p<001 0.02 {0.02?0.02} 0.02 {0.02?0.03} problem Relationship Problemstoss Any relationship problemlloss ?.948 {42.4} 3.?28 {39.8} 4.222 {45.1} p<001 1.3 1.3 Intimate partner problem 5.098 2.2?0 {24.1} 2.828 {30.2} p<001 1.4 1.4 Perpetrator of interpersonal Violence in past 414 131 283 p<001 2.2 2.0 month Victim of interpersonal Violence in past month 84 53 31 ps0.05 0.8 0.8{0.5m1.2} Family relationship problem 1.8?1 (8.9) 8?3 ?98 0.9 1.0 Other relationship problem (non?intimate} 403 202 201 1.0 1.1 Argument or con?ict {not speci?ed} 2.914 {15.5} 1,2?8 {13.8} 1,838 [Jr-10.01 1.3 1.4 {1 Death of a loved one {any} 1.49? 828 8?1 ps0.01 0.8 0.9 Non?suicide death 1.181 84? 534 p<001 0.8 0.9 Suicide of family or friend 3?9 21? 182 p<001 0.8 Other Life Stressors Any life stressor 9.?43 {51.9} 4,8?5 5.088 {54.2} p<001 1.2 1.1 Recent criminal legal problem 1.588 588 1.002 {10.7} p<001 1.8 Other legal problem 748 378 3?0 1.0 1.0 Physical health problem 4.1?9 {22.3} 2.012 {21.4} 2.18? {23.2} p<0.01 1.1 1.0 Jobeinancial problem??r 2941 {18.2} 1530 {18.8} 1411 {15.8} ps0.05 0.9 Eviction or loss of home T22 {38} 31? 405 p<0.01 1.3 1.4 {1.2?4 .8) School problem?? 182 {19.9} ?0 92 {21.9} 1.3 1.3 Recent release from an institution? 1.412 941 (10.2} 4?1 ps0.01 0.5 0.5 Jaillprisonldetention facility 203 {14.4} 82 121 ps0.01 3.8 4.5 Hospital 51? {38.8} 311 {33.0} 208 p<0.01 1.8 1.3 hospitaifinstitution 489 (33.2} 439 30 p<001 0.1 0.1 (0.14.1) Other {includes alcohollSA treatment facilities} 223 {15.8} 109 (11.8) 114 (24.2} p<0.01 2.4 2.5 Recent or Impending Crisis Crisis within past or upcoming 2 weeks? 5.525 {29.4} 2,444 {28.0} 3.081 (32.9} ps0.01 1.4 1.4 Intimate partner problem crisis 1988 (35.8} 854 {34.9} 1114 {38.2} 1.1 1.1 Physical health problem crisis ?39 {13.4} 315 (12.9} 424 (13.8} 1.1 1.0 Criminal legal problem crisis 821 {11.2} 203 418 (13.8} p<0.01 1.8 Family relationship problem crisis 430 212 218 ps0.05 0.8 Job problem crisis 354 191 183 p<0.01 0 Suicide EventiHistory Left a note 8.488 {34.5} 3,182 {33.8} 3,288 {35.1} 1.1 1.2 Disclosed suicide intent 4.405 {23.5} 2.308 {24.5} 2.099 {22.4} p<001 0.9 0.9 History of ideation 5.990 {31.9} 3.838 {40.8} 2.152 {23.0} ps0.01 0.4 0.4 History of attempts 3.?32 {19.9} {29.4} 982 {10.3} p<0.01 0.3 0.3 Alaska. Arizona. Colorado. Connecticut. Georgia. Hawaii, Kansas. Kentucky. Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. New Jersey. New Mexico, New York. North Carolina, Ohio. Oklahoma, Oregon. Rhode Island. South Carolina. Utah, Vermont. Virginia. and Wisconsin. Decadent had been identified as having a current diagnosis of mental health problem in coronerr'medical examiner or law enforcement reports. ?5 Odds ratio reflects the risk among those without known mental health problem relative to those with known mental health problem. 1 Logistic regression was used to estimate adjusted odds ratio with 95% after controlling for age. sex. race and ethnicity. Known mental health problem was the reference group. Includes decedents with one or more diagnosed current mental health problems, which are not mutually exclusive. Therefore. some of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health problems. 11 Denominator is decedents aged 218 years. 91 Denominator is decedents aged 10?18 years. Denominator of institution subgroup is decedents with recent release from an institution. Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroup is decedents with any crisis within pastor upcoming 2 weeks. Crises depicted here represent the most commonly.I occurring categories. TABLE 1. Select demographic and descriptive characteristics of suicides aged 210 years with and without known mental health problems National Violent Death Reporting System, 2? states,? 2015 Known mental No known mental health problemT {n health problem {n Adjusted 0R1 Characteristics Total {n 20,445} 9,40?} 11,039} Chi?Square DR5 {95% Cl} {95% Sex Male 15,?02 {75.5} 5,459 {55.5} 9,233 {53.5} 2.3 Female 4,744 {23.2} 2,935 {31.2} 1,505 {15.4} ps0.01 0.4 Age 10-24 2,504 1,211 {12.9} 1,593 {14.4} p<0.01 1.1 {1 - 25?44 5,455 {31.5) 3,035 {32.3} 3,420 {31.0} {140.05 0.9 45?54 7,?15 {37.7} 3,520 {40.5} 3,595 {35.3} {340.01 0.5 .2255 3,455 1,340 {14.2} 2,125 {19.3} p<0.01 1.4 {1 Raceilethnicity White, non-Hispanic 1?,102 {53.5} 5,155 {55.5} 5,93? {51.0} ps0.01 0.5 Black, non?Hispanic 1,225 411 51? p<0.01 {1 American Indiani'AIaska Native, non- 3?5 112 255 p<0.01 2.0 {1 Hispanic Asian, non-Hispanic 5?5 235 341 p<0.05 1 2 Hispanic 1,095 453 533 {3510.05 1 2 Other 55 21 45 {340.05 1 5 Extended demographics Ever served in military??r 3,429 1,354 {15.3} 2,0?5 {20.1) p<0.01 1 4 {1 1.1 {1 Homeless 240 104 135 1 1 1.2 Incident Type Single suicide 20,053 {95.2} 9,315 {99.1} 10,?45 ps0.01 0.3 0.4 Homicide followed by suicide 319 54 255 p<0.01 3.5 2.9 Multiple suicides 54 25 39 1.3 1.5 Method Firearm 9,909 {45.5} 3,521 {40.5} 5,055 {55.3} p<0.01 1.5 {1 1.5 {1 5,90? {25.9} 2,940 {31.3} 2,95? {259} ps0.01 0.5 0.5 Poisoning 3,003 {14.7} 1,551 {19.5} 1,142 {10.4} 0.5 0.5 Substance class causing death?ti Other over-the-counter} 1,021 {34.0} 555 {35.5} 355 {31.1) p<0.01 0.5 0.9 Opioids 944 {31.4} 505 335 {29.4} 0.9 0.9 Antidepressants 500 {25.5} 544 {34.5} 155 5:001 0.3 0.3 Benzodiazepines 524 455 {25.1} 155 ps0.01 0.5 0.5 {0440.5} 219 195 {10.5} 24 p<0.01 0.2 0.2 Other 1,595 ?50 515 {3510.05 0.9 0.9 Toxicology Results Any toxicology testing 13.31? {55.1} 5,555 5,559 {50.3} p<0.01 0.5 Positive for 21 substance?l 9,913 5,192 4,?21 p<0.01 0.5 Substance Alcohol Tested 10,950 {53.5} 5,409 5,541 {50.2} p<0.01 0.5 Positive 4,442 {40.5} 2,115 {39.1} 2,32? {42.0} p<0.01 1.1 1.2 Opioids Tested 5.554 {41.5} 4,255 {45.3} 4,295 {35.9} {as-0.01 0.5 0.5 Positive 2,2?9 {25.5} 1,235 {29.1} 1,041 {24.2} p<0.01 0.5 0.9 Benzodiazepines Tested 5,124 4,225 {44.9} 3,595 {35.3} p<0.01 0.7 0.7 Positive 2,454 {30.3} 1.539 {35.5} 525 {21.2} p<0.01 0.4 0.5 Cocaine Tested {39.0) 3,555 {41.1} 4,112 p<0.01 0.9 0.9 Positive 499 215 253 {340.05 1.2 {1 1.2 {1 Amphetamines Tested ?,515 3.595 {39.3} 3,919 {35.5} p<0.01 0.9 0.9 Positive ?35 3?5 {10.2} 350 0.9 1.0 Marijuana Tested 5,559 {32.1} 3,12? {33.2} 3,442 {31.2} p<0.01 0.9 0.9 Positive 1,4?1 {22.4} ?10 ?51 {22.1} 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2,322 {21.0} ps0.01 0.5 0.5 Positive 2,214 {40.5} 1,?35 {55.9} 4?9 {20.5} ps0.01 0.2 0.2 Abbreviation: CI con?dence interval. Alaska, Arizona, Colorado, Connecticut, Georgia. Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode island, South Carolina, Utah, Vermont, Virginia, and Wisconsin. Decedent had been identified as having a current diagnosis of mental health problem in ooronerimedical examiner or law enforcement reports. Odds ratio re?ects the risk among those without known mental health problem relative to those with known mental health problem. ?5 Logistic regression was used to estimate adjusted odds ratio with 95% after controlling for age, sex, race and ethnicity. Known mental health problem was used as the reference group. Decedents were aged 1:10 years. as per standard in the suicide prevention literature. Tt Denominator ls decedents aged 218 years with reported military service status. Denominator is decedents who died by poisoning. including overdose. Denominator is deoedents with any toxicology tested. Denominator for each positive group is the number tested for the substance in that group. I able 1. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Flate per 100,000 Persons (Change 1mm Prior Period} Current Overall Overall State Sex ?310:: 3 State Rate Change 2:313"; 1999 2001 2002 - 2004 2005 - 200? 2008 - 2010 2011 - 2013 2014 - 2013 Flank (State Flank) 1 (State Flagnk) .2 Both 12.31313} 12.? 1+ 0.4} 12.91+ 0.2} 13.81+ 0.9} 14. 51+ 0. 8} 15.41+ 0.9} 1.5 ?13 11:12.01} n13 3.1 11113} 25.4 531313} US. Male 20.9 {n13} 21.2 1+ 0.4} 21.31+ 0.0} 22.5 2351+ 1.0} 24.5 1+ 1.0} 1.1 ?23 1132.01} Female 11113} 5.0 1+ 0.3} 5.3 1+ 0.2} 1+ 0.4} 8.2 1+ 0.5} 8.9 1+ 0.7} 2.8 ?13 1132.01} Both 14.3 3123} 13.41- 3.3} 14.1 1+ 3.3} 15.31+ 1.3} 1341+ 3.2} 12.5 1+ 1.1} 1. 3 33 132. 35} 25 3.1 131} 21.3 22133} AL Male 25.1 1nfa} 2341-12} 24.41+ 1.0} 2541+ 2 0} 29.1 1+ 1.5} +1.3 '23 1132.05} Female 5.1 3113} 4.31-3.31 531+ 3.2} 1+ 1 1} 341+ 3.3} 2.3 1+ 3.2} 2. 3 ?13 1112. 31} Both 21.3 {me} 24.3 1+ 3. 3} 24.21- 3.3} 23. 3 1+ 1 25.41- 3 5} 23.3 1+ 3.4} 1. 2 33 11:2. 35} 2 2.31 4} 32.4 33 113} AK Male 33.2 {We} 3311+ 4 3331+ 3.3} 43.1 1+ 1.2} 43 1 1- 3.1} 42.3 1+ 2.3} 1. 4 34.1112. 31} Female 3.31n1a} 11.4 1+ 2. 3} 331-13} 11.1 1+ 1.2} 3.31- 1.2} 1321+ 3.4} 1.2 2.: n13 Beth 12.31n1a} 13. 5 1+ 3. 2} 13.1 1+ 3.5} 13.1 1- 3.3} 2341+ 1.3} 23.3 1+ 3.5} 1.3 113 132.31} 15 3.1 132} 12.3 22142} AZ Male 23.3 {We} 33.2 1+ 1.3} 33.3 1+ 3.4} 33.2 1- 3.5} 32. 3 1+ 1. 3} 32.4 1+ 3.4} 3.3 113 1112.35} Female 2.1 1n1a} 2.5 1+ 3.4} 3.2 1+ 3.2} 3.3 1+ 3.5} 21 3. 3} 3.3 1+ 3.3} 2.2 '13 11:12.31} Beth 15.5 1n1a} 1531+ 3.3} 1321+ 3.5} 12.31+1.4} 13. 21+1 21 .2 1+ 2.3} 2.2 '23 1132.31} 12 5.2114} 33.3 33115} AR Male 23.2 {ma} 23.2 1+ 3.3} 22.2 1+ 3.5} 23.2 1+ 1 31 1+ 33.5 1+ 1.3} 1.3 113 1112.35} Female 5.3 1313} 5.3 1+ 3.3} 3.2 1+ 3.4} 2.3 1+ 1 .31- 3.4} 3.3 1+ 2.1} 3.3 33 1112.31} Both 10.8 11113} 11.3 1+ 0.2} 11.01- 0.3} 1201+ 1.0} 11. 81.1} 12.1 1+ 0.3} 0.9 93 11:12.05) 45 1.3148} 14.3 93146} CA Male 12.9 1313} 1841+ 0.5} 12.?1- 0.2} 19.1 1+ 1.4} 18. 91-0 19.2 1+ 0.3} 0.5 ?13 n15 Female 4.1 {Na} 5.3 1+ 3.3} 4.31- 3.1} 5.4 1+ 3.5} 3-31 5.3 1+ 3.3} 1.2 33 1112.35} Both 12.3 {me} 1321+ 1.3} 13.31- 3.2} 23.31+1.3} 2131+ 1.5} 23.2 1+ 1.3} 1.3 113 1112.31) 3 5.3112} 34.1 34.122} 30 Male 23.3 1n1a} 33.3 1+ 2.3} 33.51 3. 4} 31.51+1.3} 33. 41+ 1. 3} 33.3 1+ 2.3} 1.4 113 1112.31} Female 2.3 {Na} 3.2 1+ 1.3.3} 13. 1 1+ 1. 3} 13.4 1+ 3.3} 2.3 '23 1132.31) Beth 3.31n1a} 3.31- 3.2} 3.1 1+ +3 2} 13.21+1.1} 11313.3} 11.5 1+ 3.5} 1.3 '13 132.35} 43 1.3143} 13.2 22134} CT Male 13.41313} 1431-13} 15. 31+ 3. 4} 13.31+1.3} 12. 3 1+ 1. 3} 12.31- 3.3} 3.3 113 n25 Female 3.8 {Na} 3.8 1+ 0.2} 0. 2} 4.4 1+ 0.2} 91+0.5} 8.2 1+ 1.3} 3.5 11:12.05} Table 1. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Rate per 100.000 Persons {Change from Prior Period) Current Overall Overall State Sex ?10:35? State Rate Change 2:33"; 1999 2991 2992 2994 2995 299? 2999 2919 2911 2913 2914 2919 Rank 5 (State Rank} 1? (State ank) 9 Both 13.6 Enia(-0.3) 13.6 T) 14.2 0.6) 14.4 0.2) 0.9 ?To 199 42 09 E50) 5.9 E50) DE Male 23.0 EnEa23.1E 3. 2) 22.? E- 0.4) 23.5 0.9) 0.6 34: 111's Female 5.3 EnEa) 0-0E 4.6 E- 0.4) 0. 3) 6. 4 6.2 0.2) 1.6 ?39 1119 Both 5.9 EnEa) 6.4 6.4 E- 0.6.9 0.3) 0.9 39 109 51 1.0 E49) 16.1 ?To E45) DC Male 10.? EnEa) 11.1 0.4) 10.3 E- 0.9) 12. .4) 10.0 E- 2.6) 11.? 1.T) 0.3 ?34: Female 1 T0119)??r 2.3 0.6) TT 3 3 0) 6-0E .T) 3.6 2.9 0.9) 3.5 34: 111's Both 14.9 EnEa) 15. 2 0. 4) 14.9 E- 0.3) 16. 3 16.3 E- 0.0) 16.4 0.1) 0.9 ?39 Ep<.05) 29 1.6 E45) 10.6 ?To E49) FL Male 24.3 EnEa) 24. 4E 0.1) 23.6 E- 0.9) 26. 2 2.6) 25.6 E- 0.6) 25.6 0.1) 0.5 39 109 Female 6.3 EnEa0.5) T9 0.3) 1.4 ?34: Ep<.01) Both 12.9 EnEa) 13.2 0.13.? 0.5) 15.0 1.3) 0.9 34: 111's 39 2.1 E40) 16.2 ?To E44) GA Male 22.1 EnEa) 23.1 21.3 (-1.9) 21.9 0. 6) 22.6 0.T) 24.4 1 T) 0.5 ?39 1119 Female 5.0 EnEa) 9-0E .2) .2) 0. 9) 5.9 0.3) 6 6 0.9) 2.1 39 Ep<.05) Both 12.9 EnEa.1) 14.4 E- 0.1) 15 2 0.9) 2.0 ?34: 35 2.4 E35) 19.3 ?To E39) HI Male 20.4 EnEa) 1T. 52E- 3.1) 15.3 E- 1 .9) 21.9 6. T) 22.5 0.5) 24.3 9) 2.1 34: 111's Female 5.4 EnEa0.9) 5.9 E- 0.3) 1.2 ?39 1119 Both 1T.3 EnEa) 20). 19. 3 .9) 21.6 3 3) 21.9 0.3) 24.? 2.9) 2.3 39 Ep<.01) 6 T5 6) 43.2 T) )0 Male 29.4 EnEa) 33.1 4. T) 3134.? 0.2) 33.0 3.3) 1.6 ?34: Ep<.05) Female 6.1 0.0) 2.9) 9.5 0.5) 11.9 2.3) 4.4 34: Ep<.05) Both 9.9 EnEa) 9-0E .1) E- 0.12.2 1.0) 1.5 ?39 Ep<.05) 44 2.3 E39) 22.9 ?To E32) Male 1T.1En?a) .4) 16..2E-04) 19.9 3) Female EnEa4.5 0.4) 5 2 0.6) 2.4 ?34: Ep<.01) Both 13.0 EnEa16.4 1T1 +1.9 34: Ep<.01) 26 4.1 E23) 31.9 ?To E25) lN Male 22.4 EnEa) 2326.? 2.0) 29.3 1.6) 1.5 ?39 Ep<.01) Female 4.6 EnEa0.9) 6 6 E- 0.2) 39 Ep<.01) Table 1. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Hate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:35? State Rate Change 1999 2001 2002 2004 2005 - 200? 2005 2010 2011 2013 2014 2015 Flank 5 (State Rank) ll (State ank) ?11 Both 11.311113) 13.21+1.4) 1231? 04) 14.2.1+14) 15.01+0.1) +2.1?131 31 +4.3120) +35.2?13113) IA Male 20.5 111131) 22.1 1+ 1.5) 20.31?1.4) 23. 3 1+ 2. 5) 2501+ 25. 0.3) 1.5 ?13 1p<. 05) Female (Na0.?13 1p<. 01) Both 13.31n1a) 15.1 1531+ 1553?015) 19.4.1+15) 01) 19 +5.0111) 434501315) KS Male 22.? 111131) 25.0 1+ 2.3) 2551+ 1.5) 25.5 1?0 .9) 29.1 1+ 3. 5) 30.? 1+ 1 .5) 1.9 ?13 1p<. 01) Female 4.5111131) 501+ 1.4) 0.3) .41?0 .3) 531+ 1.4) 41+ 1. 5) 3. 2 ?13 1p<. 05) Both 14.1 (nfa) 1541+ 1.3) 15.? 1+ 1.3) 15. 21.5) 1321+ 2. 0) 1931+ 11) +1.9 ?13 1p<. 01) 20 5.2115) 35.5 53115) KY Male 25.01n1a) 2531+ 1.9) 2331+ 1.4) 21?1 .0) 30.1 1+ 2. 9) 31.? 1+ 1.5) 1.4 ?131p<. 01) Female 4.3 111131) 5.2 1+ 0.4) 5 1 1+ 0.3) 11+ 0.?13 1p<. 01) Both 13.1 111131) 12.91? 0.2) 13.41+ 0.4) 1351.3) 14. 4 1+ 0. 3) .5) 1.5 ?13 1p<. 05) 2? 3.3 12?) 29.3 ?13 125) LA Male 22.9 (nfa) 22.31? 0.5) 22.41+ 0.2?.31+ 3.5) 1.1 ?13 n15 Female 4.3 (We) 1? 0.1) 5.21+ 0.5) .2) 5.1 1+ 1. 2) 1.4) 2.3 ?13 1p<.05) Both 14.511031) 13.51? 0.9) 14 41+ 0 3) 15 41+ 1.0) 1391+ 3. 5) 13.51? 0.4) 2.2 ?13 1p<.05) 21 4.0 125) 2?.4 ?13 129) ME Male 250111131) 22.91? 2.1) 24.51+ 25. 1+ 1.1) 31.1 1+ 5. 4) 2931?13) 1.3 ?13 1p<.05) Female 5.31n1a) 5.31? 0.0) 5.21? 0.1) 01+ 0. 1.5) 0.3) 3.1 ?13 1p<.05) Both 10.0 (nia) 10.3 1+ 0.3) 10.1 1? 0.2) 10. .1) 10.? 1+ 0. 5) 1031+ 0.1) 0.5 ?13 1p<.05Male 1?.5 111131) 1?.31+ 0.1) 1?.31?0.5) 3?1+0 .4) 1321+ 0.5) 13.0 +0.2 ?13 n15 Female 3.5 (Me) 3.3 1+ 0.4) 3.9 1+ 0.0.4) 1.3 ?131p<. 05) Both (Na) 1+ 0.2) 3 41+ 0 3) 31+ 1.0) 9.3 1+ 0.4) 10.01+ 0.3) 2. 3 ?13 1p<. 01) 43 2.5 134 W) 35.3 ?13 120 W) MA Male 12.1 (nia) 12.31+ 13 31+ 0 5) 15. 41+2 .1) 15.21? 0.2) 1501+ 0.3) 2. 0 ?13 1p<. 01) Female 3.3 111131) 2.91? 0.4) 4 01+ 1.0) .31?0 .1) 431+ 1.0) 4.51? 0.2) 3. 0 ?13 1p<. 05) Both 11.3 (We) 12.51+ 12 91+ 0.4) 13. 91+ 1 0.) 14.51+ 1551+ 1.1) 1 .9 ?13 1p<. 01) 33 3.9 125) 32.9 ?13 124) Ml Male 20.0 (nfa) 2091+ 0.3.) 2391+ 1.0) 2501+ 1.2) 1. 5 ?13 1p<. 01) Female 4.4 (Me) 4.3 1+ 0.4) 5 0 1+ 0.2) .5) 5.9 1+ 0.3) 1+ 0.9) 2. 3 ?13 1p<. 01) Table 1. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Hate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:35? State Rate Change 1999 2001 2002 2004 2005 - 200? 2008 2010 2011 2013 2014 2018 Flank 5 (State Rank) ll (State ank) ?1 Both 10.? (nfa) 11.5 0.9) 1214.2 1.3) 15.0 0.9) 2. 3 01) 38 4.3 (19) 40.8 ?18 8) MN Male 18.3 (We) 19.3 1.1) 20.4 1 0) 20. 9 .8) 22.9 1.9) 23.3 0.4) ?18 01) Female 3.8 (nfa) 4.2 0.8) 4 8 0. 4) 5.8 0.8) 8.9 1.2) 4. 2 ?18 (pa. 01) Both 12.9 (nfa) 14.1 1.2) 14 0.8) 15. 5 .8) 15.8 0.1) 15.2 0.3) 1. 1 ?18 (pa. 05) 38 2.3 (38) 1?.8 ?18 (40) MS Male 22.9 (nfa) 24.8 2525.9 0.9) 25.3 0.8) ?18 n15 Female 4.3 (Me) 5.0 5 5 0.5) .0) 8.4 0.9) 8.2 0.2) 2. 4 ?18 01) Both 14.? (nfa) 14.1 0.8) 15.4 1 3) 18.0 1?.8 20.0 2.3) 2. 2 ?18 (pa. 01) 18 5.3 (15) 38.4 ?18 MD Male 25.3 (nfa) 23.? 1.8) 2528.9 2.3) 32.2 3.3) 1.8 05) Female 5.4 (nfa) 5.4 0.1) 8 1 0 8.3 0.2) 1.1) 8.8 1.2) 3. 2 ?18 (pk. 01) Both 21.1 (We) 22.8 1.4) 23.8 1.0) 24.? 1.1) 28.? 2.0) 29.2 2.38.0 ?18 (11) MT Male 38.9 (nfa) 3?.3 0.4) 39.8 2.5) 39. 0. 1) 41.0 1.4) 45.5 4.4) 1.3 ?18 (pa. 01) Female (nfa) 8.4 1.8) 8.4 0.1) 10. 0 1 .8) 12.8 2.8) 13.1 0.5) 4. 8 ?18 (pa. 01) Both 12.? (nfa) 12.2 0.5) 12.8 0.4) 11 0. 8) 13.5 1.8) 14.8 1.3) 1.0 ?18 n15 40 2.1 (42) 18.2 ?18 (43) NE Male 22.2 (We) 20.? 1.5) 20.3 0.4) 19. 8 0. 5) 22.0 2.2) 23.9 1.9) 0.8 ?18 Female 3.8 (nfa) 4.2 0.4) 5.1 0.9) 1.1) 5.5 1.4) 5.8 0.3) 2.8 ?18 n15 Both 23.3 (nfa) 22.8 0.8) 22.1 0.5) 22. 8 0. 5) 21.4 1.2) 23.1 1.8) - 0.2 ?18 9 - 0.2 (51) - 1.0 ?18 (51) NV Male 38.3 (nfa) 38.? 3532.5 3.0) 35.4 2.8) ?18 Female 8.9 (Me) 9.5 0.5) 9.8 0.1) 10. 0 0. 4) 10.8 0.8) 11.2 0.8) +15 01) Both 13.5 (nfa) 12.5 1.0) 13.3 0.8) 15. 2 1 9.) 15.8 0.8) 20.0 4.2) 2. ?18 (pa. 05) 1? 8.5 8) 48.3 ?18 3) NH Male 22.5 (nfa) 21.1 21.? 0.8) 24. 8 (.1) 25.4 0.8) 30.8 5.2) 2. 2 ?18 (pa. 05) Female 5.3 (nfa) 4.8 0.5) 5.9 1.0) 8.8 0.4) 9 8 3.2) 3. 9 ?18 (pk. 05) Both (We) 0.1) 0.2) 0. 5) 8.9 0.9) 9.2 0.4) 1.3 ?18 05) 50 1.5 19.2 ?18 (35) NJ Male 13.0 (nfa) 13.1 0.0) 12.8 0.5) 13 1) 14.5 0.8) 14.8 0.1) 0. 9 ?18 (pa. 05) Female 3.2 (nfa) 2.9 0.3) 3.0 0.0) . 90(? .1) 3.8 0.9) 4 4 0.8) 2.3 ?18 n15 Table 1. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Flete per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:35? State Rate Change 1999 2001 2002 2004 2005 - 200? 2005 2010 2011 2013 2014 2015 Flank 5 (State Rank) ll (State ank) 1* Both 22.011113) 22 01? 0 1) 21 .51? 0. 2) 2301+ 1 .2) 24.1 1+ 1.1) 2501+ 1.5) 1.1 51; 1p<.05) 4 4.0 124) 15.3 135) NM Male 355111151.2) 35. 51?0 .5) 3?.1 1+ 1.3) 40.? 1+ 3.5) 0.4 51.. 1113 Female 5.51n1a) .4?1 1.1) 21+ 10 2. 5) 11.? 1+ 0.5) 12.01+ 0.3) 3.3 ?11. 1p<.05) Both ?.21n1a) .1?1 0.1) 0. 5) 41+0 .5) 551+ 1.1) 5.31? 0.1) 2.1 ?11. 1p<.01) 45 2.1 141) 25.5 12?) NY Male 12.51111351+1.0) 15.41+1.4) 14.51? 0.5) +1.4 21.113505) Female 1nfa) 51 0.1) 01+ 0.3) 5+1 0.5) 4.21+ 4.51+ 0.5) 4.2 ?fa 1p<.01) Both 13.5 (We) 13.15 0.1) 13. 1+ 0.1) 14. 21+ 0. 5) 14.51+ 0.4) 1531+ 0 5) 0.5 51.113501) 34 144) NC Male 22.? (Na1.1) 2331+ 0.0) 2351+ 0.5) 0.4 ?11. 1115 Female 5.5 0. 2) 5.2 1+ 0.5) .01? 2) 1+ 1+ 0.5) 2.0 51.. 1p<.05) Both 13.3 (We) 14. 511. 3) 1501+ 1.4) 15. 51+0 .5) 1541+ 1.5) 2051+ 2.5) 2.5 51.. 1p<.01) 14 1 5) 5?.5 ?11: 1 1) ND Male 21.4 (We) 24. 51+ 3. 2) 2501+ 3.4) 1 1?0 .5) 2551+ 2.5) 32.? 1+ 3.0) 2.5 ?11. 1p<.01) Female 5.5(n1a) .5?1 1 .0) 1? 0.5) 2. 0) 1+ 1.0) 551+ 1.5) 3. 5 ?11. 1115 Both 11.5 1111a) 12. 3 1+ 0. 5) 13.1 1+ 0.5) 13 41+ 0. 2) 14.51+ 1.4) 15.51+1.0) 2. 0 51.. 1p<. 01) 32 4.2121) 35.0 ?11: 115) OH Male 20.411151) 20. 5 1+ 0. 5) 2221+ 1.3) 22.1 1?0 .1) 24.21+ 2.1) 2551+ 1.3) 1. 5 51.. 1p<. 01) Female 4.0 1n?a)?1+ 0. 4.510.5) 1+ 0.5) 3. 4 ?11. 1p<. 01) Both 1?.0 (We) 15. 51? 0. 5) 1? 21+ 0.5) 1541+ 1.1) 20.? 1+ 2.3) 2351+ 2.5) 2. 3 ?11. 1p<. 05) 5.4110) 3?.5 112) OK Male 25.511551) 31? 1 2) 2?.51+ 0.5) 30312.5) 33.41+ 3.1) 3?.3 1+ 3.5) 2. 0 51.. 1p<. 05) Female 5.5 1111a) .41? 0. 2) 1.1) .0?10.5) 551+ 1.5) 1031+ 1.5) 2. 5 ?x511.p< 05) Both 154111121) 1+ 1. 3) 0.0) 15. 51+ 0. 5) 1551+ 1.2) 21.1 1+ 1.3) +1.5 ?11. 1p<. 01) 13 4.5115) 25.2 E11.125) OH Male 2?.4 (We) 25. 5 1+ 2.1) 25.51? 0.5) 2551+ 1. 0) 31.41+ 1.5) 33.01+ 1.5) 1. 1 ?11. 1p<. 01) Female 5.5 1n?a)11+ 0. 5) 1+ 0.5) 4+1 5.5 1+ 0.4) 5.5 1+ 0.5) 51.. 1p<. 01) Both 12.1 (We) 12.51+0.4) 12.51+ 0.3) 13.51+1.1) 15.01+1.1) 15.31+1.2) +20% 1p<. 01) 30 +4.1 (22) +343 ?11: 121) FA Male 21.0 (We) 21. 3 1+ 0. 3) 2151+ 0.5) 23.1 1+ 1 .2) 24.? 1+ 25.1 1+ 1.3) 1. 5 ?11. 1p<. 01) Female 4 21n1a) 51+ 0. 3) 4 51+ 0.0) 4+1 0.5) 501+ 0.5) 1+ 1.1) 3. 5 ?11. 1p<. 01) Table 1. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National Vital Statistics System, 1999 2016 Age-Adjusted Annual Hate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:35? State Rate Change 1999 2991 2992 2994 2995 - 2997 2999 2919 2911 2913 2914 2919 Hank (State Rank) 1 (State ank) .. Both 9.4 9.0 0.3) 9.0 0.0) 12.3( 3.2.8 ?18 (pa-:05) 43 3.2 (30 W) 34.1 31: (23 W) RI Male 15.4 (We) 14.8 21.2 19.2 19. 68(+ 0.4) +2.2 38 913 Female 4.0 (Me) 3.3 3.8 1.3) 5.1 0.0) 1. 0) 39 (pa. 05) Both 13.0 0.2) 13.? 14. 9 1 .2) 18.0 1.1) 2. 3 ?18 (pa. 01) 23 4.9 38.3 (10) SC Male 21.3 (nfa) 22.5 1.2) 22.3 0.1) 24 8 2. 2) 28.1 28.0 1 9.) +1.8 39 (pk. 01) Female 5.4 (We) 8.0 1.3) 2+0( .2) 0.8) 1 .4) 3. 4 38 05) Both 15.8(+ 0.1) 1?.1 19.3(+ 2.2) 0.4) .9) +25% 01) 10 +445 8) SD Male 2?.8 (We32.0 1.9) 33 8 1.8) 1.8 34 01) Female 5.8 1.8) 8 4 0. 8) 2.0) 11 3 .0) 5. 8 ?18 01) Both 14.8 (We) 15.2 0.8) 18.1 0. 8) 1?.2 0.0) 18. 2 1. 0) +1.4 38 01) 22 3.5 (28) 24.2 38 (31) TN Male 25.1 (We) 25.4 0.3) 28.8 1 3) 28. 0 1 2.) 28.8 0.8) 29. 8 1.2) 1.2 39 (pa. 01) Female 5.4 (We) 8.3 0.9) 0.4) 50(+ 8) 8.9 0.8) 0. 1.9 ?18 (pa. 05) Both 12.2 (nfa) 12.? 0.8) 12.3 0.4) 13. 2 0. 9) 13.8 0.3) 14.5 0. 9) 1.1 39 (pk. 01) 41 2.3 18.9 (38) TX Male 20.4 (We) 20.9 0.5) 20.4 0.8) 22. 0 1. 8) 22.2 0.3) 23.1 0. 9) 0. 9 38 05) Female 4.8 (Me) 5.4 0.8) 5.0 0.4) 0.2) 5.8 0.4) 0. 8) 1.8 39 (pa. 05) Both 1?.2 (We) 19.0 1.8) 18.2 20. 2 2.0) 24.0 3.8) 25. 2 1 .2) ?18 (pc. 01) 5 8.0 3 48.5 4 W) UT Male 28.2 (nfa) 31.1 2.9) 29.4 32.1 3?.(pk. 05) Female 8.8 (We) 0.8) 0.1) 10.) 10.8 2.1) 12. 8 .0) 4. 4 01) Both 13.2 (We) 18.2 3.0) 14.9 1 .3) 18.8 18.? 2.1) 19. 0) 2. 4 39 (pa. 01) 18 8.4( 9) 48.8 2) VT Male 23.8 (We) 28.3 4.8) 24.3 4.0) 3 3.0) 31.0 32.5 1. 5) 1.9 ?18 (pa. 05) Female 4.3 (nfa) 5.2 0.9) 8.4 1.3) 0.2) 0. 3) 3. 8 39 (pk. 01) Both 12.8 (We) 12.? 0.1) 12.9 0.3) 13. 8 0. 14.8 0.9) 15. 0 0. 5) +1.2 38 01) 3? 2.2 (39) 3?0 (41) VA Male 21.8 (We) 21.3 0.2) 21.0 0.4) 22.5 1. 5) 23.8 1.(pa. 05) Female 5 3 (11(9) 5.2 0.1) 5.9 8(?0 . 3) 8.4 0.8) 0. 5) 1.8 ?18 (pa. 05) Table 1. Trends in Suicide Rates among Persons 2 10 Years of Age, by State and Sex, National lii'ital Statistics System, 1999 2016 Age-Adjusted Annual Hate per 100,000 Persons (Change from Prior Period) Current Overall Overall State Sex ?10:35? State Rate Change gigs"; 1888 2001 2002 - 2004 2005 - 200? 2008 2010 2011 - 2013 2014 2018 Rank 5 (State Rank) ll (State Railnk) ?1 Both 14.8 (nr'a) 1541+ 0.5) 14.81? 0.8) 15.?1+ 0. 8) 1881+ 0.8) 1?.81+ 1.0) 1.1 81: 24 2.8 183) 18.8 13?) WA Male 24.?1n1a) 2521+ 0.5) 24.1 1? 1.1) 25.1 1+ 1.0) 2801+ 0.8) 2?.1 1+ 1.1) 0.8 as his Female 5.8 (nta) 8.4 1+ 0.8) 8.2 1? 0.2) 8+1 1+ 0.8) 851+ 0.8) 2.5 ?11; 1p<.01) Both 15.8 (nta) 18.? 1? 0.5) 18.01.?) 18.21+ 3.2) 21.41+ 2.2) +1.8 as 11 5.8 113) 3?.1 114) WV Male 2?.21nta) 30.1 1+ 2.8) 28.8 1? 1.5) 81?1 .0) 31.51+ 3.8) 3351+ 2.0) 1.1 88 Female 5.3 (nta) 5.5 1+ 0.1) 5.8 1+ 0.3) .3?01.5) 1+ 2.3) 8.8 1+ 2.2) as his Both 13.1 (nta) 1351+ 0.4) 14.01+ 0.5) 15. 0 1+ 1.0) 1531+ 0.3) 1851+ 1 2) 1. 5 8?0 1p<. 01) 28 3.4128) 25.8 130) WI Male 21.? (nta) 2221+ 0.5) 22.? 1+ 0.5) 24. 0 1+ 1.2) 24.41+ 0.4) 25.? 1+ 1 3) 1. 1 01) Female 5.1 (nta) 5.3 1+ 0.2) 5.8 1+ 0.4) 41+ 8.5 1+ 0.1) 1+ 1.0) 2. 5 ?rs 1p<. 01) Both 20.? (nta) 2341+ 22.51? 0.8) 25. 41+ 2. 8) 2881+ 3.5) 28.81? 0.1) 2. 3 as 1p<. 01) 3 8.1 1 1) 38.0 ?In 1 8) WY Male 34.8 (nta) 38.3 1+ 4.5) 38.31? 3.0) 4 51+ 5. 2) 4?.1 1+ 5.8) 44.81? 2.4) 1.8 ?11; 1p<. 05) Female ?.?1nta41+0 .2) 10.? 1+ 1.4) 1281+ 1.8) 3. 2 as 1p<. 01) Rates are age-adjusted to the U.S. year 2000 standard. 1 Model-estimated average annual percentage change 1AAPC) based on all reporting periods; p?yalue indicates statistical significance of trend; indicates trend not significant. Current state rank 150 states and the District of Columbia) is for the reporting period 2014 2018. Hanks are from highest rate 11) to lowest rate 151). Differences between ranks do not necessarily imply a statistically significant difference. 'l Overall rate change is between the first (1999 2001) and last (2014 2016) reporting periods. Ranks are from largest increase 11) to largest decrease 151). Differences between ranks do not necessarily imply a statistically significant difference. Overall percent change in rates is between the first (1898 2001) and last 12014 2018) reporting periods. Ranks are from largest percentage increase 11) to largest percentage decrease 151). Differences between ranks do not necessarily imply a statistically significant difference. TT Ftate based on e: 20 suicides. Percentage of injury deaths for which intent was not determined exceeded 20% for both the first and last periods and might have contributed to lower reported rates. Percentage of injury deaths for which intent was not determined declined notably between the first and last periods and might have contributed to the reported rate increase. TABLE 1. Select demographic and descriptive characteristics of suicides aged 210 years with and without known mental health problems National Violent Death Reporting System, 2? states,? 2015 Known mental No known mental health problemT {n health problem {n Adjusted 0R1 Characteristics Total {n 20,445} 9,40?} 11,039} Chi?Square DR5 {95% Cl} {95% Sex Male 15,?02 {75.5} 5,459 {55.5} 9,233 {53.5} 2.3 Female 4,744 {23.2} 2,935 {31.2} 1,505 {15.4} ps0.01 0.4 Age 10-24 2,504 1,211 {12.9} 1,593 {14.4} p<0.01 1.1 {1 - 25?44 5,455 {31.5) 3,035 {32.3} 3,420 {31.0} {140.05 0.9 45?54 7,?15 {37.7} 3,520 {40.5} 3,595 {35.3} {340.01 0.5 .2255 3,455 1,340 {14.2} 2,125 {19.3} p<0.01 1.4 {1 Raceilethnicity White, non-Hispanic 1?,102 {53.5} 5,155 {55.5} 5,93? {51.0} ps0.01 0.5 Black, non?Hispanic 1,225 411 51? p<0.01 {1 American Indiani'AIaska Native, non- 3?5 112 255 p<0.01 2.0 {1 Hispanic Asian, non-Hispanic 5?5 235 341 p<0.05 1 2 Hispanic 1,095 453 533 {3510.05 1 2 Other 55 21 45 {340.05 1 5 Extended demographics Ever served in military??r 3,429 1,354 {15.3} 2,0?5 {20.1) p<0.01 1 4 {1 1.1 {1 Homeless 240 104 135 1 1 1.2 Incident Type Single suicide 20,053 {95.2} 9,315 {99.1} 10,?45 ps0.01 0.3 0.4 Homicide followed by suicide 319 54 255 p<0.01 3.5 2.9 Multiple suicides 54 25 39 1.3 1.5 Method Firearm 9,909 {45.5} 3,521 {40.5} 5,055 {55.3} p<0.01 1.5 {1 1.5 {1 5,90? {25.9} 2,940 {31.3} 2,95? {259} ps0.01 0.5 0.5 Poisoning 3,003 {14.7} 1,551 {19.5} 1,142 {10.4} 0.5 0.5 Substance class causing death?ti Other over-the-counter} 1,021 {34.0} 555 {35.5} 355 {31.1) p<0.01 0.5 0.9 Opioids 944 {31.4} 505 335 {29.4} 0.9 0.9 Antidepressants 500 {25.5} 544 {34.5} 155 5:001 0.3 0.3 Benzodiazepines 524 455 {25.1} 155 ps0.01 0.5 0.5 {0440.5} 219 195 {10.5} 24 p<0.01 0.2 0.2 Other 1,595 ?50 515 {3510.05 0.9 0.9 Toxicology Results Any toxicology testing 13.31? {55.1} 5,555 5,559 {50.3} p<0.01 0.5 Positive for 21 substance?l 9,913 5,192 4,?21 p<0.01 0.5 Substance Alcohol Tested 10,950 {53.5} 5,409 5,541 {50.2} p<0.01 0.5 Positive 4,442 {40.5} 2,115 {39.1} 2,32? {42.0} p<0.01 1.1 1.2 Opioids Tested 5.554 {41.5} 4,255 {45.3} 4,295 {35.9} {as-0.01 0.5 0.5 Positive 2,2?9 {25.5} 1,235 {29.1} 1,041 {24.2} p<0.01 0.5 0.9 Benzodiazepines Tested 5,124 4,225 {44.9} 3,595 {35.3} p<0.01 0.7 0.7 Positive 2,454 {30.3} 1.539 {35.5} 525 {21.2} p<0.01 0.4 0.5 Cocaine Tested {39.0) 3,555 {41.1} 4,112 p<0.01 0.9 0.9 Positive 499 215 253 {340.05 1.2 {1 1.2 {1 Amphetamines Tested ?,515 3.595 {39.3} 3,919 {35.5} p<0.01 0.9 0.9 Positive ?35 3?5 {10.2} 350 0.9 1.0 Marijuana Tested 5,559 {32.1} 3,12? {33.2} 3,442 {31.2} p<0.01 0.9 0.9 Positive 1,4?1 {22.4} ?10 ?51 {22.1} 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2,322 {21.0} ps0.01 0.5 0.5 Positive 2,214 {40.5} 1,?35 {55.9} 4?9 {20.5} ps0.01 0.2 0.2 Abbreviation: CI con?dence interval. Alaska, Arizona, Colorado, Connecticut, Georgia. Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode island, South Carolina, Utah, Vermont, Virginia, and Wisconsin. Decedent had been identified as having a current diagnosis of mental health problem in ooronerimedical examiner or law enforcement reports. Odds ratio re?ects the risk among those without known mental health problem relative to those with known mental health problem. ?5 Logistic regression was used to estimate adjusted odds ratio with 95% after controlling for age, sex, race and ethnicity. Known mental health problem was used as the reference group. Decedents were aged 1:10 years. as per standard in the suicide prevention literature. Tt Denominator ls decedents aged 218 years with reported military service status. Denominator is decedents who died by poisoning. including overdose. Denominator is deoedents with any toxicology tested. Denominator for each positive group is the number tested for the substance in that group. From: CDC Washington Office Sent: 16 Mar 2018 16:14:06 -0400 To: CDC Washington Office Subject: Legislative Report for CDC and ATSDR: March 16, 201B Logislative Report for CDC and ATSDR: March I6, 2018 FLOOR ACTION March 14 The House passed I [?4901 the Student, Teachers, and Of?cers Preventing (STOP) School 1Violence Act of 2013. COMMITTEE AND SUBCOMMITTEE ACTION March 12 The House Oversight and Government Reform Interior, Energy, and Environment Subcommittee held a hearing on the 2017 hurricane season, to examine the impacts on the US. Virgin Islands. The House Veterans? Affairs (VA) Health Subcommittee held a hearing to examine VA healthcare and maximizing resources in Puerto Rico. March 14 The Senate Indian Affairs Committee held an oversight hearing to examine the opioid crisis in Indian Countly. The House Energyr and Commerce Health Subcommittee held a hearing to examine the reauthorization of animal drug user fees. The House Science, Space, and Technology Committee held a hearing to focus on world- leading innovation in science, among national laboratories. The Senate Foreign Relations Multilateral lntemational Development, Multilateral Institutions, and Intcmational Economic, Energy, and Environmental Policy Subcommittee held a hearing to examine food security matters. March 15 The House Appropriations Labor, Health and Human Services, Education, and Related Agencies Subcommittee held a on Fiscal Year (FY) 2019 Budget. Secretary Alex Azar II testified on behalf of HHS. The Senate Health, Education, Labor, and Pensions (HELP) Committee held a hearing: to examine the 34013 Drug Pricing Program. The House Homeland Security Committee held a hearme to examine lessons learned from the 2017 disasters. Upcoming Como-rittee and Subcommittee Action March 21} The Senate Judiciary Committee will hold a hearing to examine the reauthorization of the Violence Against Women Act. The House Education and the Workforce HELP Subcommittee will hold a hut-urine to examine proposed rule on association health plans. The Oversight and Investigations Subcommittee will hold a hearinu to examine role in combating the opioid epidemic. The Senate Finance Committee will hold a healing to consider the nominations of John Bartrum to be an Assistant Secretary and Johnson to be an Assistant Secretary for Famin Support, both of HHS. March 21 The Health Subcommittee will hold a hearing to examine prevention and public health solutions to combat the opioid crisis. Acting Director Dr. Anne Schuchat will testify on behalf of CDC. The Senate Budget Committee Will hold a hearing on the Economic Report of the President. The Senate Indian Affairs Committee will hold a hearina on the President's FY19 Budget Request for Indian programs. The House Oversight and Government Reform National Security Subcommittee will hold a hearing to examine bureaucratic challenges to hurricane recovery in Puerto Rico. The House Ways and Means Health Subcommittee will hold a hearing to examine the implementation of the Medicare Access and CHIP Reauthorization Act?s (MACRA) physician payment policies. March 22 The Health Subcommittee will hold a hearing to examine the opioid crisis as a continuation of the previous day's hearing. BILL INTRODUCTIONS March 12 Sen. Dick Durbin introduced 5.25135 to strengthen DEA discretion in setting opioid quotas. Sen. Tina Smith introduced 2533 to allow National Health Service Corps members to provide obligated service as behavioral and mental health professionals at schools. other community-based settings. or patient homes. March 13 Rep. Ted Poe introduced H.R.5253 to authorize a grant to protect young athletes from abuse. Rep. Bill Johnson (R-OH) introduced H.R.52til to provide for regional centers of excellence in substance use disorder education. Rep. Peter Welch introduced to clarify the process for denying, revoking, or suspending a registration to manufacture. or dispense a controlled substance. Rep. Ted Budd (R-NC) introduced [4.11.5254 to direct the HHS Secretary to conduct a study on the feasibility of expanding eligibility for enrollment in Medicare Advantage plans to individuals enrolled under the Medicaid program or enrolled under a group health plan. March 14 Rep. Steve Stivers (R-DH) introduced to ensure that programs and activities that are funded by a grant. cooperative agreement, loan, or loan guarantee from HHS, and whose purpose is to prevent or treat a mental health or substance use disorder, are evidence- based. Rep. Stephen Lyneh introduced H.Res.783 to designate September as National Brain Aneurysm Awareness Month. Sen. Tina Smith introduced to authorize a special behavioral health program for Indians. March 15 Rep. Marsha Blackburn (R-TN) introduced l--l.R.53 to reauthorize and expand the Comprehensive Addiction and Recovery Act (CARA) of 2016. Rep. Eleanor Holmes Norton introduced l-l.R.5322 to provide for a national program to conduct and support activities toward the goal of signi?cantly reducing the number ofeases of overweight and obesity among individuals in the U.S. Rep. David Roe (R-TN) introduced l-l.R.5298 to deem drugs or other substances that act as opioid mu receptor agonists to be in schedule 1, subject to exceptions for substances intended for legitimate medical or research use. Sen. Dianne Feinstein (D-CA) introduced 8.2501 to authorize the Attorney General to suspend a controlled substances registration if there is a likelihood of a threat of diversion of a controlled substance. BRIEFINGS AND CONGRESSIONAL MEETINGS March 9 Subject Matter Experl'(SME) from the National Center for Chronic Disease Prevention and Health Promotion briefed by phone staff to Rep. Michael Burgess (R-TX) and majority staff to the Bid: Health Subcommittee on matema] mortality surveillance. March 12 Acting CDC Director Dr. Anne Schuchat and SME from the Center for Global Health. participated in an event on Global Health Security (GHS) in which bipartisan Congressional staff attended. The event was organized by the Kaiser Family Foundation. March 13 Acting Principal Deputy Director Dr. Stephen Redd participated in a bipartisan Congressional brie?ng on the second annual inter-agency GHS Agenda report. The brie?ng was co- sponsored by the Global Health Security Agenda Consortium and PATH. SMEs from the National Institute for Occupational Safety and Health (NIOSH) participated in a public meeting in Cincinnati on consolidation project. Staff to Sen. Sherrod Brown (D-OH) and Rep. Steve Chabot attended. March 15 SME from the National Center on Birth Defects and Development Disabilities briefed staffto Rep. Kathy Castor (D-FL) on Zika birth defects surveillance. March 16 CDCW staff and the Of?ce of briefed staff to Sen. David Perdue (R- GA) on proposed funding for a new High Containment Lab at CDC. CONGRESSIONAL REQUESTS FOR INFORMATION March 12 Majority staffto the HELP ommitteeinquired about appropriations levels of two sections in the Violence Against Women Act. Staff to Reps. Don Beyer. Jr. and John Kathe (R-NY) inquired about the history of budget as it relates to suicide and the focus of work in suicide prevention. Minority staff to the HELP ommittcc inquired about the Fire?ghter Cancer Registry Act of 2017. March 13 CDCW staff shared infomtation with Senate and House health legislative assistants and staff to the HELP and Committees on the Vital Signs Town Hall Teleconference and Clinician Outreach and Communication Activity Call on opioid overdoses treated in emergency departments. DCW staff shared information with staff to the Senate Special Aging Committee. House Congressional Seniors Task Force, and the HELP Primary Health and Retirement Security Subcommittee on the cost of falls speci?c to senior citizens. Staff to Rep. Rob Wittman (R-VA) inquired about the process to obtain birth certi?cates from Puerto Rico. Staff to Rep. Jim Renacci (R-OH) inquired about a constituent?s access to NIDSH publications. CDCW staff shared information on upcoming NIOSH mobile testing unit visits to Western Kentucky with Sens. Joe Donnelly (D-IN). Tammy Duckworth Dick Durbin Mitch McConnell (R-KY), Rand Paul and Todd Young (R-IN) and Reps. Larry Bucshon (R-IN), James Comer Brett Guthrie R-KY), and John Shimkus (R-IL). The unit offers a series of free, confidential health screenings to coal miners to provide early detection of coal workers? pneumoconiosis (CWP). also known as black lung. March 14 Minority staff to the Senate Special Aging Committee inquired about the economic impact of diabetes. CDCW staff shared information with staff to Sen. Bob Casey and Reps. Jim Langevin and Gregg Harper on recently published CDC disability state pro?les. Staffto the Congressional Budget Of?ce inquired about CDC activities related to pediatric cancer. March 15 CDCW staff shared information with staff to Members interested in tobacco issues and staff to the HELP and Committees on CDC's Morbidity and Weekly Report on e- cigarettes and youth. Staff to Sen. Tammy Baldwin inquired about news reports on HIV and syphilis in Milwaukee. Staff to Rep. Jason Smith (R-MO) inquired about work in Missouri to address the tick-borne infection. Bourbon virus. Staff to Rep. Dan Kildee (D-MIJ inquired about the Lead Exposure and Prevention Advisory CDITllnittEE. March 16 CDC staff shared infonnation with staff to the Senate Foreign Relations (SFRC) and HELP Committees, the House Foreign Affairs (HFAC) and ESLC Committees, and staff to Members of the Florida and Texas delegations on a New Engiand of'Medfc-ine article on the global threat onika virus infection during pregnancy. CDCW staff shared details with staff to the SFRC and HELP Committees, the HFAC and Committees, and the House Foreign Affairs Western Hemisphere Subcommittee for media telebrie?ng on vaccine recommendations for the Yellow Fever outbreak in Brazil. For questions about this report. please contact Aimee Sckotmer at or Marissa Thomas of Politic. gov From: Stone, Deborah Sent: 15 May 2018 22:48:29 +0000 To: Simon, Thomas Kristin Katherine A. Keming Alexander Asha Z. Cc: Kegler, Scott R. Molly Regina Erin Marie R. Valerie M. Shane P. Davis Subject: Meeting Notes and Action item for some Attachments: Bio Form MMWR JA2949 5.8.18.docx, Suicide VSWG Meeting Notes 5.15.18.docx, State-Level Suicide Trends {Candidate CE Questionsldocx Importance: High Hi Everyone, I'm attaching Kristin?s notes from our meeting today. Thank you, (I?m racking up a big debt here!) Also, per our meeting, I?m forwarding the CE info below. Scott already developed two potential questions for us [Attached here. Thank you, Scotti]. We need two more Questions so I was thinking it would be great to have one on the analyses and one on the technical package. I will work on these unless someone has a strong desire to take this on. Regardless of whether you create a question or not, all co?authors have been asked to complete the attached bio form. wish I could say that it doesn't look time?consuming! Please send this to me no later than next Wednesday COB (May Thanks, as always let me know if you have any questions or if you have a good question in mind for or tp! Deb From: Stone, Deborah Sent: Tuesday, May 15, 2018 2:17 PM To: Kegler, Scott R. Subject: FW: Vital Signs - Suicide prevention - June 8, 2018 Importance: High Thanks for the From: Stallworth, Barbara Sent: Monday, May 14, 2018 10:38 AM To: Stone, Deborah <2af9 cdc. ova Cc: Stallworth, Barbara Subject: Vital Signs - Suicide prevention - June 8, 2018 Importance: High Congratulations! Your MMWR report has been selected for the development of a continuing education (CE) activity. What we need from you. Please develop 3 CE questions and have all authors listed on the report to complete the attached bio form. Each question will need one correct answer, three incorrect answers, and an explanation. Please return to Barbara Stallworth (bysS) by COB on Friday, May 25, 2018. General Principles: 1) Continuing education (CE) is an opportunity to emphasize the key points of your report to public health and health care professionals. Think about what you want professionals to do or know after they read your report and use those key points to create CE. 2) The question, correct answer, and explanation should be identical or nearly identical to report text. Readers should not have to consult other information sources to answer MMWR CE questions. Structure of a CE question and answers (see attached guidance for examples): Question: the question should contain only enough information to orient the reader to the question, and use language adapted from the cleared text. Correct answer: the reader should be able to correctly answer the question using only information contained in the report. Wrong answers (3) (distractors): A good distractor should seem like a reasonable answer to someone who did n?t read the report carefully. Please do not use ?none of the above? or combinations of answer ?a and c? as distractors. Explanation: The explanation should be adapted from cleared text in the report and be brief (no more than 3 or 4 sentences). iTitle Weekly 1 Activity JA2949 Start date 6-8.18 Division of Scientific Education and Professional Development Center for Surveillance, EpidemiologyI and Laboratorv Services Accreditation and Compliance Team Continuing EdUCation Proposal BiolDisclosure Form Information will be kept confidential. Attach additional pages, if needed. Date submitted [mm/damn Role in Educational Activitv {Check all that apply.) Planner El FacultvaresenteriContent Expert Section 1: Demographic Data Name, credentials, Positionititle Current Employerfaddress Phone i E~maili Section 2: Education/Expertise Describe education specific to the educational activitv listed above. ree Year Institution Describe expertise specific to the educational activity listed above. Section 3: Con?ict of interest Federal employees: For the past 12 months, I have been a federal emplovee and have been covered by all of the federal ethics rules, including the bribery and illegal gratuities statute (13 U.S.C. 201], the criminal conflict of interests statutes (18 U.S.C. 202-209), and the Standards of Ethical Conduct for Employees of the Executive Branch {5 C.F.R. Part 2635). Yes No Non-federal employees: Is there an actual, potential or perceived conflict of interest for yourself or spouse/'partner within the last 12 months? Revised: August 2015 Page 1 of 2 lTitle Weekly Activity Start datelsma Yes I No If yes, complete the table below for all actual, potential, or perceived conflicts of interest. Check all that apply. Cat Descri on Salary Royaby Stock Speaker?s Bureau Consultant Other *if Pianneif, Skip sections 4, 5 and 6. Section 4: Uniabeied use Will your presentationls), or the content you contributed, include any discussion of unlabeled use of commercial products or products for investigational use? ??35 CI No If Yes, please explain your use of unlabeled products or products under investigational use. Attach additional pages, if needed. Section 5: Title of Presentation (Live) OR Content Provided Section 6: Best Availabie Knowledge Is your presentation, or the content you contributed, supported by the best available knowledge or evidence? Yes I No Section Statement of Understanding Completion of the line below serves as the electronic signature of the individual completing this form and attests to the accuracy of the information given above. Typed Signature: Name and Credentials (Required) Date FOR DEVELOPERS Indicate mechanism used to resolve real or perceived conflict of interest to be documented in Disclosure Worksheet Discussion with content expert/presenter Review of contentj?presentation Revised: August 2018 Page 2 of 2 SUICIDE VITAL SIGNS WORK GROUP MEETING MAY 15, 2018 . . J. - 12 noon 1:00 ?iaglafgl?sgi?awr Note taker: Kristin UL?ijerf?u?-?a' i Agenda 23; Set up welcome (Deb; 5?10 mins) if? Monday?s curve ball >3 Change from "mental health problems" to "mental health conditions" 3; Comms products, FS, and MMWR have all been updated with this language I Social media, telebriefing script, press release I Did You Know items will be pulled from the F5 1* Recap from last week?s pre-brief new updates, next steps Pre?brief debrief (Attendees 8L Deb; 10 mins) Next steps (see attached table] MMWR status (Deb; 5 mins] 1r Next steps (what's on the horizon} I Deb rec?d first proof on Friday II Revisions were due 8am on Monday complete I Deb rec?d additional reviewer comments from first proof on Monday I Revisions submitted on Monday spoke with Theresa on the phone I Deb rec?d second proofs yesterday late in the day 0 Revisions due by 1:00 today Will review the tables again because of concern over double set of proofs I A few changes had been made to indentations and holding of overarching categories I mental health conditions need to be indented I Kristin will help with this review I Should receive third set of proofs tomorrow - Tables need to be reviewed by Friday Err- Fact Sheet (Deb; 5 mins) 3% Next steps I Changes to ?everyone can? section I Changes to page 3 consistent with best practices for media I Graphic design elements 0 will coordinate with Molly I Tom will take first pass and forward to Deb and Kristin Next version due back to VS team 5?316 C013 3. Communication products Kristin 5 mins] Next steps I Press release with VS team I Critical contacts, dear colleague letter? with VS team Social media II Pulled directly from F5, but social media team came back with changes 0 Substance abuse - change to "substance use? Will send those to Tom I with Kristin; will send to Deb to review - Needs to be submitted to V5 team by C03 today Telebriefing introduction wording is ?Suicide: More than just a MH condition" Script talking points received from Surgeon General yesterday afternoon - Need to review will send to the group 0 will put these TPs into the overall script and send the script back out Outstanding pieces: script, media advisory Policy/Partnerships (Erin; 5 mins) Next steps I Town Hall June 12 - Need to identify state examples 0 Colorado should be one Malia can reach out to Ellie at SPRC to get another example 0 Malia will formulate email forJarrod and Deb will send it I The ask will be to do a presentation - need to pull together talking points and slides we need them by June 1 0 Second state suggestions: NC, MA, TX . State health dept seems to be involved Who does this involve? Deb has 8 mins to present, state speakers 0 We can all call in at 2:00 on this day I Malia has list of partners on board - ASTHO CEO will participate in Twitter chat It Will take part in call to give them a heads up I Will talk to DARPI about how to prime grantees - Congressional plan hill alerts to every congressional office 0 Hill visits June Will do some other Hill visits in September I AFSP Policy Summit ?June 11 Will be there for that briefing (Alex) I Erin working with NGA webinar for policy health advisors in July I Blog post for national Conference of State Legislators . Template language for all of our partners? newsletter blurb, customized emails from Jim and Deb for them to send on June Iinking V5 to priorities June 7 press briefing? Deb will be there with Dr. Schuchat 3% Other items (Deblevervone; 15-20 mins Town hall 3} Continuing education Science clips p? Next stepsfmeetinngrap-up (Deb; 5 mins) Next VS Due Dates: 0 To be provided in updates above What we need to get moving on I Town Hall - Need to nail down participant list by end of the week Continuing education - candidate questions so people can get CEUs Comparing just the ?rst and last reporting periods (1999-2001 and 2014-2016) overall suicide rates (both sexes together) were seen to increase in nearly every state. When considering all six reporting periods, what was determined more generally about trends in overall suicide rates at the state level? El Due to excessive fluctuation in rates from one period to the next, for most states nothing conclusive could be determined about general trends. Most states saw general upward trends that were further determined to be statistically signi?cant. l3] In most states. rates tended to increase over time, but these trends were not usually found to be statistically signi?cant. El Because some states experienced small numbers of suicides, it was not possible to conduct a comprehensive state-level evaluation of general trends using statistical models. Explanation: Using data for six consecutive reporting periods covering the years 1999 2016, general trends in state-level suicide rates were evaluated using statistical models. For overall suicide rates, statistically significant upward trends were identi?ed for 44 states. Considering the entire study period, most states saw statistically signi?cant upward trends in overall suicide rates (both sexes together). What was concluded about sex-specific rate trends at the state level? El When strati?ed by sex, the study data could not support evaluation of rate trends at the state level. For both males and females considered separately, a majority of states saw statistically signi?cant upward trends in suicide rates. El The upward trends in overall suicide rates were due mostly to increases in rates among males. l3] In most states. sex-speci?c rates tended to increase over time, but these trends were not usually found to be statistically signi?cant. Explanation: Using sex-stratified data for six consecutive reporting periods covering the years 1999 2016, trends in sex-specific suicide rates at the state level were evaluated using statistical models. For males, statistically signi?cant upward trends were identified for 34 states. For females, statistically signi?cant upward trends were identi?ed for 43 states. From: Richmond-Crum, Malia Sent: 4 Jun 2018 08:50:14 -0400 To: Stone, Deborah Subject: Talking Points - Use these instead Attachments: Call June 5.docx Hi Deb 1 Please use this draft instead of what I sent Friday ?there was a typo that I fixed. From: Richmond-Crum, Malia Sent: Friday, June 1, 2018 4:55 PM To: Stone, Deborah Subject: RE: Question Deb ?Here are draft talking points for the call on Tuesday. They?re high-level overview of the Vital Signs data and logistics. I think there should be a way to figure out how to share with them verbally the map in the fact sheet I don?t know what that would sound like but maybe you do? Wanted to get these to you to review but I think I will tweak on Monday as well. Malia From: Stone, Deborah Sent: Friday, June 1, 2018 9:06 AM To: Richmond-Crum, Malia <"rv8 cdc. ov> Subject: RE: Question Sounds good. Thanks so much! Deb From: Richmond-Crum, Malia Sent: Friday, June 1, 2018 9:05 AM To:5tone, Deborah cdc. ov> Subject: RE: Question I?ll pull something together and share with you today. It will basically be: overview of findings, the timeline for release, that they will receive the embargoed copies and when, and what support we might be able give them to help answer questions from their SHDs, media etc. Let?s talk in person on Monday about what else we might be able to share on the phone. Malia From: Stone, Deborah Sent: Thursday, May 31, 2018 8:07 PM To: Richmond?Crum, Malia Jack, Shane P. Davis do4 cdc. ova- Subject: RE: Question Hi Malia, I'm happy to join. Would be helpful to have a general outline of what I might want to say. I can then create the talking points from there. Is that possible? Thanks Deb From: Richmond-Crum, Malia Sent: Thursday, May 31, 2018 7:38 PM To: Stone, Deborah Jack, Shane P. Davis Subject: Re: Question Hi Deb - It is still on, it's June 5 athm. do you want to join? since we won't be able to share findings in the 5th I was treating it as a partner call to prime them for the release. It would be great if you have time. It would only be the first 10-15 mind of the call. Malia From: "Stone, Deborah <2af9@cdc.gov> Sent: Thursday, May 31, 2013 5:58 PM To: "Jack, Shane P. Davis Malia Subject: Question Hi Shane and Malia, Is the call with states still on to discuss Vital Signs? Do you need me to do this? Didn?t want to lose track of this. Thanks! Deb Deb Stone, MSW, MPH Centers for Disease Control and Prevention National Center For Injury Prevention and Control Division of Violence Prevention Suicide. "(outr- Violence Ev. [Ida MaltreatmEiit Team NO 488 3942 dstoneEgEcdcgov Injury Center Preventing Injuries and Violence Through Science and Action Call -June 5 Talking points CDC will release a Vital Signs on June 7 that examines rising suicide rates across the United States. For this Vital Signs report, CDC researchers examined state-level trends in suicide rates from 1999-2016. Additionally, 2015 data from National Violent Death Reporting System. which covered 27 states, was used to look at the circumstances of suicide among people with and without known mental health problems - Nearly 45,000 lives lost to suicide in 2016. I Across the study period, rates increased in all states except for one (which had a consistently high rate throughout}. Twenty-five states had suicide rate increases of more than 30 percent. . More than half of people who died by suicide did not have a known mental health condition. The Vital Signs points to ways that states take a comprehensive public health approach to suicide prevention and address the range of factors contributing to suicide. 0 This requires coordination and cooperation among a wide variety of community partners. technical package on suicide prevention can help states as they make decisions about prevention activities and priorities. Directors will receive an embargoed copy of the Vital Signs at 9am on June 7. State Health Officers will receive this information at 9am as well. As will the media Vital Signs will be released publically at Noon on June 7 with a telebriefing hosted by Dr. Ann Schuchat, CDC Deputy Director NCIPC and DVP social media channels will be disseminating information about Vital Signs from June 7- June 19 including a Twitter Chat on June 11 at 2pm There will be a Vital Signs Town Hall on June 12 from 2-3pm, which will feature both CDC and state health department speakers From: Stone, Deborah Sent: 21 May 2018 18:01:04 +0000 To: Simon, Thomas Kristin Katherine A. Keming Asha Z. Cc: Kegler, Scott R. Alexander Subject: Reminder: Bio Form from all co-authors due Wed COB Attachments: Vital Signs Candidate CE Questions_19May2018 ds.docx, Bio Form MMWR JA2949 5.8.18.docx Importance: High Please complete the attached form by Wed COB so that we can have people obtain CE credits for our Vital Signs. Also, attaching our three CE questions. Let me know if you have any concerns or edits, Thanks! Deb From: Stone, Deborah Sent: Tuesday, May 15, 2018 6:48 PM To: Simon, Thomas Holland, Kristin Fowler, Katherine A. Yuan, Keming Crosby, Alexander Hey-Stephenson, Asha Z. Cc: Kegler, Scott R. Kurnit, Molly Regina Bruce, (CDCIOPHPRIOD) Black, Erin Bellman, Marie R. Daniel, Valerie M. :Jack, Shane P. Davis Subject: Meeting Notes and Action Item for some Importance: High Hi Everyone, I'm attaching Kristin?s notes from our meeting today. Thank you, (I?m racking up a big debt here!) Also, per our meeting, I?m forwarding the CE info below. Scott already developed two potential questions for us {Attached here. Thank you, Scott?. We need two more questions sol was thinking it would be great to have one on the analyses and one on the technical package. I will work on these unless someone has a strong desire to take this on. Regardless of whether you create a question or not, all co?authors have been asked to complete the attached bio form. I wish I could say that it doesn?t look time?consuming! Please send this to me no later than next Wednesday COB (May 23rd]. Thanks, as always let me know if you have any questions or if you have a good question in mind for or to! Deb From: Stone, Deborah Sent: Tuesday, May 15, 2018 2:17 PM To: Kegler, Scott R. Cc: Stallworth, Barbara Subject: Vital Signs - Suicide prevention - June 3, 2018 Importance: High Congratulations! Your MMWR report has been selected for the development of a continuing education (CE) activity. What we need from you. Please develop 3 CE questions and have all authors listed on the report to complete the attached bio form. Each question will need one correct answer, three incorrect answers, and an explanation. Please return to Barbara Stallworth (bysS) by COB on Friday, May 25, 2018. General Principles: 1) Continuing education (CE) is an opportunity to emphasize the key points of your report to public health and health care professionals. Think about what you want professionals to do or know after they read your report and use those key points to create CE. 2) The question, correct answer, and explanation should be identical or nearly identical to report text. Readers should not have to consult other information sources to answer MMWR CE questions. Structure of 3 CE question and answers (see attached guidance for examples): Question: the question should contain only enough information to orient the reader to the question, and use language adapted from the cleared text. Correct answer: the reader should be able to correctly answer the question using only information contained in the report. Wrong answers (3) (distractors): A good distractor should seem like a reasonable answer to someone who did n?t read the report carefully. Please do not use "none of the above? or combinations of answer "a and c? as distractors. Explanation: The explanation should be adapted from cleared text in the report and be brief (no more than 3 or 4 sentences). Trends in State Suicide Rates United States, 19994016 and Circumstances Contributing to Suicide 27 States, 2015 CE Questions Question 1. Comparing just the ?rst and last reporting periods (1999-2001 and 2014-2016) overall suicide rates (both sexes together) were seen to increase in nearly every state. When considering all six reporting periods, what was determined more generally about trends in overall suicide rates at the state level? a Due to excessive ?uctuation in rates from one period to the next, for most states nothing conclusive could be determined about general trends. Most states saw general upward trends that were further determined to be statistically significant. 0 In most states, rates tended to increase over time, but these trends were not usually found to be statistically signi?cant. Because some states experienced small numbers of suicides, it was not possible to conduct a comprehensive state-level evaluation of general trends using statistical models. Explanation: Using data for six consecutive reporting periods covering the years 1999 2016, general trends in state-level suicide rates were evaluated using statistical models. For overall suicide rates, statistically significant upward trends were identi?ed for 44 states. Question 2. What proportion of suicide decedents [in 2? states) in 2015 were known to have a mental health condition? a 54% 25% 46% 76% Explanation: According to the National Violent Death Reporting System that covered 27 states in 2015, 46% of people were known to have a known mental health condition and 54% were not known to have such a condition. Which of the following is not included as part of a comprehensive approach to suicide prevention, based on the best available evidence? a strengthening economic supports. promoting connectedness. 0 creating protective environments. public education campaigns. Explanation: The Centers for Disease Control and Prevention (CDC) published ?Preventing Suicide: A Technical Package of Policy, Programs, and Practices. A technical package is a collection of strategies that represent the best available evidence to prevent or reduce public health problems like suicide. The seven strategies in the document are as follows: 1) strengthen economic supports; 2) strengthen access and delivery of suicide care; 3) create protective environments; 4) promote connectedness; 5) teach coping and problem- solving skills; 6) identify and support people at risk; and 7) lessen harms and prevent future risk. At this time. public education campaigns have not been determined to be effective for suicide prevention. iTitle Weekly Activity JA2949 Start date 6-8.18 Division of Scientific Education and Professional Development Center for Surveillance, Epidemiology and Laboratory Services Accreditation and Compliance Team Continuing Edueation Proposal BioiDisclosure Form Information will be kept confidential. Attach additional pages, if needed. Date Submitted Role in Educational Activity {Check all that apply.) Planner FacultyIPresenterIContent Expert Section 1: Demographic Data Name, credentials, Positionititle Current Employerfaddress Centers for Disease Control and Prevention National Center for Injury Prevention and Control Atlanta, GA Phone I E?maili Section 2: Education/Expertise Describe education 5 fit: to the educational activi listed above. Degree Year Institution Describe expertise specific to the educational activity listed above. Section 3: Con?ict of interest Federal employees: For the past 12 months, I have been a federal employee and have been covered by all of the federal ethics rules, including the bribery and illegal gratuities statute (13 U.S.C. 201], the criminal conflict of interests statutes (18 U.S.C. 202?209], and the Standards of Ethical Conduct for Employees of the Executive Branch {5 C.F.R. Part 2535). Yes No Non-federal employees: Is there an actual, potential or perceived conflict of interest for yourself or spousefpartner within the last 12 months? Revised: August 2016 Page 1 of 2 lTitle luuwe Weekly Activity JA2949 Start Yes I No If yes, complete the table below for all actual, potential, or perceived conflicts of interest. Check all that apply. Cat Descri on Salary Royalty Stock Speaker?s Bureau Consultant Other *lf Planner, Skip sections 4, 5 and 6. Section 4: Unlabeled use Will your presentationls), or the content you contributed, include any discussion of unlabeled use of commercial products or products for investigational use? l:l ??35 El No If Yes, please explain your use of unlabeled products or products under investigational use. Attach additional pages, if needed. Section 5: Title of Presentation {Live} 0R Content Provided Vital Signs: Trends in State Suicide Rates United States, 1999-2016 and Circumstances Contributing to Suicide 27 States, 2015 Section 6: Best Available Knowledge Is your presentation, or the content you contributed, supported by the best available knowledge or evidence? Yes No Section 7: Statement of Understanding Completion of the line below serves as the electronic signature of the individual completing this form and attests to the accuracy of the information given above. Typed Signature: Name and Credentials (Required) Date FOR DEVELOPERS ONLY: Indicate mechanism used to resolve real or perceived conflict of interest to be documented in Disclosure Worksheet Discussion with content expert/presenter Review of content] presentation Revised: August 2018 Page 2 of 2 From: Simon, Thomas Sent: 29 May 2018 15:09:32 -0400 To: Schieber, Richard A. Cc: Stone, Deborah Subject: RE: Q5 co-release Hi Rich, Are the the same as the telebriefing script or the (1?s and A's or something different? -Tom From: Schieber, Richard A. Sent: Tuesday, May 29, 2018 12:08 PM To: Simon, Thomas Subject: Fwd: 0.5 co-release As you see below, the TPs are still under revision. Ric-h Schieber, MD MPH CAPT, USPHS Director, CDC Vital Signs Program RBS4tdicdc.gov 404 697 9666 From: Kent, Charlotte Date: May 29, 2018 at 11:19:13 AM EDT To: Schieber, Richard A. (CDCIOPHSSICSELSIDPHID1 Subject: RE: QS co-release Thanks. I talked to Dan DeNoon and is working hard on TPs for AS on this. From: Schieber, Richard A. (CDCIOPHSSICSELSIDPHIW Sent: Tuesday, May 29, 2018 11:18 AM To: Simon, Thomas (CDCXUNDIEHXNCIPC) Pea ker, Brandy Kent, Charlotte (CDCIOPHSSICSELSIDPHID) Subject: Re: (15 co-release Tom, I talked again Charlotte, expressing your points. She and i agree that We will keep the same release date established for both the VS and this QS. I suggest you write me a terse paragraph about where you want the emphasis to be in the press release and telebrie?ng (TB). I also suggest you ask her whether she would like to see any modi?cation in either the TB and/or PR, and that you will prepare a about it. I will send that note up to her. This is a better approach than surprising her know this is not the outcome you had hoped for, and I?m sorry for that. Respectfully, Rich Rich Schieber, MD MPH CAPT, USPHS Director, CDC Vital Signs Program RBS4?o1cdogoy 404 697 9666 From: Simon, Thomas (CDCXONDIEI-UNCIPC) Date: May 29, 2018 at 10:18:54 AM EDT To: Sehieber, Richard A. Peaker, Brandy {vitao aces. of} Ce: Stone, Deborah (CDCIONDIEHINCIPC) Subject: FW: Hi Rich, My concern with this Q5 coming out in the same issue as the US is that it will put the focus on youth suicides and complicate the messaging. The MMWR focuses on state trends and the range of circumstances that contribute to suicide risk among those with and without mental health conditions. This (15 could cause the media to focus on youth suicide. We know that the bulk of suicides are among middle?aged adults. The media however tends to be very interested in youth suicide. We worked with NCHS last year on a QuickStat on youth suicide trends and it ranked number 7? in the 2017 top 10 MMWR reports as measured by Altmetric. Thank you for considering this. ?Tom From: Simon, Thomas Sent: Tuesday, May 29, 2018 9:44 AM To: Schieber, Richard A. Subject: From: Stone, Deborah (CDCIONDJEHINCIPC) Sent: 18 Mar 2018 01:21:49 +0000 To: Simon, Thomas Subject: RE: Jerome That sounds encouraging {based on Jim?s experience) but just a bit confused as we seemed to have gone back to including him in the town hall vs doing the telebriefing (per Erin?s email). I don't mind the change, especially if it increases town hall meeting turnout, but will be good to finalize peoples? thoughts on this, e.g. pros and cons of both. Deb From: Simon, Thomas Sent: Saturday, March 17, 2018 11:54 AM To: Stone, Deborah Subject: FW: Jerome Hi Deb, We might not have to limit the 56?s comments to military suicide. -Tom From: Mercy, James Sent: Thursday, March 15, 2018 3:54 PM To: Black, Erin m? cdc. ov>; Simon, Thomas (t 59 cdc. ov> Subject: RE: Jerome Sounds good, although Alex and I saw him present at the Action Alliance meeting yesterday and he was great, by the way. And he spoke to suicide more generally then just vets. He didn?t dwell on that and really evoked a lot of our ideas around ACES and community work. So I wouldn't feel the need to have him focus too much on vets he is quite willing and able to address the issue from a broader perspective. From: Black, Erin Sent: Thursday, March 15, 2018 3:24 PM To: Simon, Thomas (CDCXONDIEHXNCIPC) Subject: RE: Jerome Yes, as I had mentioned Jim, we are planning to have the SG participate in the townhall. From what Leslie shared based on their experience this w0u d give us the most bang for the buck versus a written commentary from him. As Tom mentioned below, we will plan to include some vet/military stats in his talking points given his interest in vetfmilitary suicides. I talked to Leslie about the opioid joint Hall and we agree is seems to have gone well. It appeared to have garnered a larger audience (1,197 webinar lines but participation was likely much higher given many participate via group format). I think it makes sense to do a combined one to save time and effort on coordination, particularly given I am not sure a separate COCA would be as valuable given we are also doing a separate Medscape commentary (similar audience) in which Alex will mention the Vital Signs data but focus on what the physicians, nurses, pharmacists and other healthcare professionals can do specifically to prevent suicide. From: Simon, Thomas Sent: Wednesday, March 14, 2018 1:47 PM To: Mercy, James Subject: RE: Jerome Hi Jim, The V5 group is thinking that it makes the most sense to engage him in the telebriefing. Deb had suggested that we work through the policy chain to engage him and Erin is going to do that. We met last week and agreed to see how the opioid telebriefing on 3,113 went. We know that he has a particular interest in military suicide. We do provide the proportion of the suicide victims (total and those with and without known mental health problems} who ever served in the military but we don?t focus on this. I?m concerned this might not be enough for him to be involved. We could potentially develop some points for him to make about vulnerable groups, including veterans. Erin what is your take about how the opioid release went and the pros/cons of the 56?s involvement? Have you heard from the policy staff who were involved in making this happen? ?Tom From: Mercy, James Sent: Wednesday, March 14, 2018 1:27 PM To:5imon, Thomas (CDCXONDIEHINCIPC) st 59 cdc. ova- Subject: Fwd: Jerome See below. I spoke with the SG and a couple of his staff today, although not a lot about this. Anything to report yet back on 56 communications? I don?t think we should reach out about analysis suggestions. From: Houry, Debra E. Date: March 14, 2018 at 11:27:5d AM EDT To: Mercy, James Subject: RE: Jerome Good! I like him and this is why I thought we should engage him in Vital Signs Has Tom followed up with his office at all re Jerome?s suggestions on analysis or messaging? Didn?t know if it was feasible or not From: Mercy, James Sent: Wednesday, March 144, 2013 10:17 AM To: Houry, Debra E. Subject: Jerome The 56 made remarks to the Action Alliance this morning. I was very impressed. He was great - clear that many of his ideas reflect our priorities - ACEs, suicide, Overdose . He was much appreciated by the audience. From: Simon, Thomas Sent: 29 Mayr 2013 11:52:29 -0400 To: Schieber, Richard A. Brandy Charlotte Cc: Stone, Deborah Subject: RE: Q5 co-release Hi Rich, 0k, thank you for considering postponing the Q5. Idon?t think we want to work the E15 findings into the PR or TB. Thei,r focus on overall patterns now and we would like to keep that focus. Are you suggesting that write a paragraph explaining that the C15 is coming out in the same issue and make the point about most suicides being among the middle-aged group so that she is prepared and can block and bridge to the main points if the question were to be asked? Thank you, Tom From: Schieber, Richard A. Sent: Tuesday, Mat.r 29, 2018 11:18 AM To: Simon, Thomas Peaker, Brandy Kent, Charlotte Cc: Stone, Deborah Subject: Re: (15 co-release Tom, I talked again Charlotte, expressing your points. She and I agree that we will keep the same release date established for both the VS and this QS. I suggest you write me a terse paragraph about where you want the emphasis to be in the press release and telebrie?ng (TB). I also suggest you ask her whether she would like to see any modification in either the TB andIor PR, and that you will prepare a about it. I will send that note up to her. This is a better approach than surprising her know this is not the outcome you had hoped for, and I?m sorry for that. Respectfully, Rich Rich Schieber, MD MPH CAPT, USPHS Director, CDC Vital Signs Program 404 697 9666 From: Simon, Thomas (CDCIONDIEHKNCIPC) Subject: From: Stone, Deborah Sent: 7 Jun 2018 13:38:04 +0000 To: Simon, Thomas Alexander Cc: Holland, Kristin Subject: RE: Vital Signs Interview Readout Thank youl! Very appreciative. Deb From: Simon, Thomas Sent: Thursday, June 7, 2018 9:36 AM To: Crosby, Alexander (CDCIDNDIEHINCIPC) Stone, Deborah Cc: Holland, Kristin Subject: RE: Vital Signs Interview Readout Hi Deb, Kristin and I added our responses to what Alex sent. We also added some text on social media to his response for I?m encouraged by how easy it is to go from our Ci?s and A's to these responses. They will look familiar to you. See you soon. ?Tom From: Crosby, Alexander (CDCIONDIEHINCIPCI Sent: Thursday, June 7, 2018 9:25 AM To: Stone, Deborah <2an cdc. ov> Cc: Simon, Thomas Holland, Kristin Subject: RE: Vital Signs Interview Readout Greetings: I have attached some draft responses to 5 8 18. Alex {3 From: Stone, Deborah Sent: Thursday, June 7, 2018 7:20 AM To: Crosby, Alexander Simon, Thomas Holland, Kristin Subject: RE: Vital Signs Interview Readout Hi Guys, Please see attached with the list of questions below. Would you be willing to divvy up the 6 questions that we don?t really address in the Alex, if you could take questions 5818 Kristin and Tom if you can take 6,7,10, and 17vthese questions kind of go together. Thanks so much in advance! Deb From: Crosby, Alexander Sent: Wednesday, June 6, 2018 10:59 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Stone, Deborah Simon, Thomas Holland, Kristin Cc: Eschelbach, Julie Lane, Gabraelle qlgg?chogovx Black, Erin Bellman, Marie R. Daniel, Valerie M. Subject: Re: Vital Signs interview Readout Greetings: Quite an interesting list of questions. Alex From: Lenard, Courtney (CDCKONDIEHINCIPC) Qty 5 Ericdc.oov> Date: June 6, 2018 at 6:59:53 PM EDT To: Stone, Deborah Simon, Thomas Crosby, Alexander (CDCIONDIEHINCIPC) (Lace 1 Holland, Kristin (CDCKONDIEHINCIPC) Cc: Simon, Thomas Holland, Kristin Subject: RE: Vital Signs Interview Readout Greetings: I have attached some draft responses to 5 8 18. Alex From: Stone, Deborah Sent: Thursday, June 7, 2018 1:20 AM To: Crosby, Alexander Simon, Thomas (CDCIDNDIEHINCIPC) Holland, Kristin Subject: RE: Vital Signs Interview Readout Hi Guys, Please see attached with the list of questions below. Would you be willing to divvy up the 6 questions that we don?t really address in the Alex, if you could take questions 5818 Kristin and Tom if you can take 6,2,10, and 17?these questions kind of go together. Thanks so much in advance! Deb From: Crosby, Alexander Sent: Wednesday, June 6, 2018 10:59 PM To: Lenard, Courtney Stone, Deborah Simon, Thomas Holland, Kristin Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie M. (CDCIONDIEHINCIPC) Subject: Re: Vital Signs Interview Readout Greetings: Quite an interesting list of questions. Alex From: Lenard, Courtney (CDCKONDIEHINCIPC) <2vg5inicdceov> Date: June 6, 2018 at 6:59:53 PM EDT To: Stone, Deborah (CDCIONDIEHINCIPC) {zafliir?rncdo rev}, Simon, Thomas (CDCXONDIEHKNCIPC) Subject: Fw: Vital Signs Interview Readout FYI Sent from my BlackBerry 10 smartphone. From: Grusich, Katherina (Kate) nb3 cdc. ov> Sent: Wednesday, June 6, 2018 6:48 PM To: Lenard, Courtney Dorigo, Leslie Solder, Harben, Kathy Omisore, Shannon L. Burden, Bernadette Subject: Vital Signs Interview Readout Just wanted to let you know that Dr. Schuchat did phone interviews today with CNN, TIME, Washington Post, AP and NBC News [online}. I wanted to share some of the questions, as they could help with prep for the telebriefing. Overall there were a lot of questions about what is driving the increase and why it?s worse in certain statesfregions, or rising among certain groups (women, veterans, etc.) Several asked about concerns of copycat incidents following the Kate Spade news, and questioned whether today?s culture/environment play a role. The list below captures know if you have any questions. 1} What?s new here? What does this report reveal that?s not already out there? 2} Was anything in this report particularly surprising to you?CDC? 3} What is CDC trying to achieve by looking more closely at these numbers? 4} Can you explain why there has been a sustained upswing in the suicide rate in recent years? 5} Beyond these findings - what is going on in our country? is today?s culture {hate speech, social media, anxiety} driving this trend? 6} Were you surprised at the number of people who died from suicide who did not have known mental health conditions? 7} Increasing access to mental health has often been cited as key to suicide prevention. How does the ?nding that many don?t have a mental health problem complicate this strategy? 8} Clinical depression, loneliness, anxiety are all up. Are these factors contributing to the increased rates of suicide? 9} How do you define someone with mental health conditions? Do they have to be diagnosed by a mental health practitioner? 10} If many of them didn?t have a known mental health condition, how do we identify, reach and help them? 11} Can you provide more insight on why we?re seeing increases among (rural areastestern statesfwomen)? 12} Do you have more information on veterans and the burden of suicide among this group? 13} Are medically-assisted suicides included in this report? 14] Is there a reason why suicide by firearms is higher for people who didn?t have a known mental health diagnosis? 15] Can you describe what ?left a note? means in the (M MWR) table. Does that mean one-third of all people who committed suicides left a note? Is that consistent with what?s been reported before? 16) What does your prevention strategy look like? What are the main steps to getting people help early? 18] Do Kate Spade and other high profile suicides make you worry about copycats? Kate Grusich Public Affairs Specialist CBC News Media Branch lo] 770-483-3337 (C) From: Simon, Thomas Sent: 7 Jun 2018 09:35:33 0400 To: Crosby, Alexander Deborah Cc: Holland, Kristin (CDCIONDIEHINCIPCI Subject: RE: Vital Signs Interview Readout Attachments: CIA part2+AC KH and TS.docx Hi Deb, Kristin and I added our responses to what Alex sent. We also added some text on social media to his response for I?m encouraged by how easy it is to go from our [1?s and A?s to these responses. They will look familiar to you. See you soon. ?Torn From: Crosby, Alexander Sent: Thursday, June 7, 2018 9:25 AM To: Stone, Deborah Cc: Simon, Thomas Holland, Kristin Subject: RE: Vital Signs Interview Readout Greetings: I have attached some draft responses to 5 18. Alex From: Stone, Deborah Sent: Thursday, June 2018 2:20 AM To: Crosby, Alexander Simon, Thomas Holland, Kristin (CDCIONDIEHINCIPC) Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie IVI. Subject: Re: Vital Signs Interview Readout Greetings: Quite an interesting list of questions. AIEX From: Lenard, Courtney say Date: June 6, 2018 at 6:59:53 PM EDT To: Stone, Deborah (CDCIONDIEHINCIPC) size Wrtr?cdevov}, Simon, Thomas Crosby, Alexander (C DCXONDIEHINCIPC since I efilicdcgova; Holland, Kristin (CDCIONDIEHINCIPC) simh itti'cdcgov} Cc: Eschelbach, Julie (C IPC) Lane, Gabraelle {alt Black, Erin Ballman, Marie R. Sent: Wednesday, June 6, 2018 6:48 PM To: Lenard, Courtney Dorigo, Leslie Sokler, Harben, Kathy Dmisore, Shannon L. Burden, Bernadette Subject: Vital Signs Interview Readout Just wanted to let you know that Dr. Schuchat did phone interviews today with CNN, TIME, Washington Post, AP and NBC News ioniine}. I wanted to share some of the questions, as they could help with prep for the telebriefing. Overall there were a lot of questions about what is driving the increase and why it?s worse in certain statesfregions, or rising among certain groups (women, veterans, etc.) Several asked about concerns of copycat incidents following the Kate Spade news, and questioned whether today?s cultureg'environment play a role. The list below captures know if you have any questions. 1} What?s new here? What does this report reveal that?s not already out there? 2} Was anything in this report particularly surprising to you/CDC? 3] ?What is CDC trying to achieve by looking more closely at these numbers? 4} Can you explain why there has been a sustained upswing in the suicide rate in recent years? 5} Beyond these findings what is going on in our country? is today?s culture (hate speech, social media, anxiety) driving this trend? 6] Were you surprised at the number of people who died from suicide who did not have known mental health conditions? Increasing access to mental health has often been cited as key to suicide prevention. How does the finding that many don?t have a mental health problem complicate this strategy? 8] Clinical depression, loneliness, anxiety are all up. Are these factors contributing to the increased rates of suicide? 9} How do you define someone with mental health conditions? Do they have to be diagnosed by a mental health practitioner? 10] If many of them didn?t have a known mental health condition, how do we identify, reach and help them? 11] Can you provide more insight on why we?re seeing increases among (rural areas/Western statesfwomen)? 12) Do you have more information on veterans and the burden of suicide among this group? 131Are medically-assisted suicides included in this report? 14] Is there a reason why suicide by firearms is higher for people who didn?t have a known mental health diagnosis? 15] Can you describe what ?left a note" means in the (M MWR) table. Does that mean one-third of all people who committed suicides left a note? Is that consistent with what?s been reported before? 16) What does your prevention strategy look like? What are the main steps to getting people help early? 18] Do Kate Spade and other high profile suicides make you worry about copycats? Kate Grusich Public Affairs Specialist CDC News Media Branch 3?70?483?333? 404?414-7070 Gan Part What?s new here? What does this report reveal that's not already out there? This study examines state increases in suicide rates across six consecutive 3-year periods and looks at contributing factors and circumstances to suicide among people with and without a mental health condition in order to understand the broad range of factors that influence suicide. Was anything in this report particularly surprising to yoquDC? We?ve known for several years now that suicide rates have been increasing. The current study adds to our understanding by demonstrating that suicide rates increased in nearly all states; and increases of more than 30% were observed in 25 states. This study also examined the circumstances that contributed to suicide among decedents and provides new information about the contributing circumstances among those with and without known mental health conditions. What is CDC trying to achieve by looking more closely at these numbers? The purpose of this study is to understand state suicide rate increases between 1999 and 2016 and to understand the range of contributing factors and circumstances of suicide. Ultimately we want to tell the public that suicide is preventable and that it will take all of us working together to prevent it. Can you explain why there has been a sustained upswing in the suicide rate in recent years? in GM doc?questions on opioids, economy, social media, firearms and their role in increasing rates Beyond these findings what is going on in our country? Is today?s culture (hate speech, social media, anxiety} driving this trend? Suicidal behavior results from an interaction of multiple factors so there isn't any single reason. There are many current or recent influences that may be affecting suicidal behavior. These include the great recession which increased financial stressors 8: housing problems, increase in opioid abuse, stigma against help seeking for mental illness, among other changes. Changes in social media content or use patterns could also potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. Were you surprised at the number of people who died from suicide who did not have known mental health conditions? We think it is important to point out that among those who are not known to have a mental health condition, we see that they were experiencing a range of other circumstances, including substance misuse, and problems with relationships, their physical health, theirjob, or financial and legal challenges. Some of these people were also reported to be experiencing depressed mood at the time of their death. This could be related to situational stressors or an undiagnosed mental health condition. It is possible that mental health conditions could have been present and not known or reported. The results indicate the need for a comprehensive approach to suicide prevention. 7] Increasing access to mental health has often been cited as key to suicide prevention. How does the finding that many don?t have a mental health problem complicate this strategy? Access to affordable and effective mental health care is critically important and these results do not change that. Our results suggest that there are also other opportunities to intervene to address the range of circumstances that contribute to suicide risk. These are described in suicide prevention technical package. 8) Clinical depression, loneliness, anxiety are all up. Are these factors contributing to the increased rates of suicide? in document 9} How do you define someone with mental health conditions? Do they have to be diagnosed by a mental health practitioner? in doc 10) If many of them didn't have a known mental health condition, how do we identify, reach and help them? These current results underscore the importance of additional opportunities for prevention, such as 0 teaching coping and problem-solving skills to help people manage life challenges; promoting safe and supportive environments, including safe storage of medications and firearms to reduce access among people at risk for suicide; 0 providing temporary help for people struggling to make ends meet encouraging connectedness so people are less likely to feel alone or isolated. Everyone can play a role in suicide prevention. 0 Physicians and other professionals who work with vulnerable populations leg. parole officers, teachers, etc.) have an important role to playr in recognizing and appropriately responding to mental health conditions and substance use disorders but also referring people for other types of assistance related to relationship, job, or other stressors. I Schools can implement evidence-based skill building and other suicide prevention programs I Employee assistance programs can work to reduce stigma about seeking help and improving access to ca re. - Media can follow recommendations to avoid increasing suicide risk end encourage people to seek help - Everyone can learn the suicide warning signs and the steps to help someone at risk. 11) Can you provide more insight on why we?re seeing increases among (rural areastestern statesfwomen)? in (MA document 12) Do you have more information on veterans and the burden of suicide among this group? in (MA doc 13) Are medically-assisted suicides included in this report? No. Physicianmassisted suicide is not included. Only a few states have legalized this and the deaths are not classified as suicides. 14) Is there a reason why suicide by firearms is higher for people who didn?t have a known mental health diagnosis? One of the reasons why the proportion of suicides by firearm may be greater among people without a known mental health diagnosis may be because people without a diagnosis were more likely to be male and males are known to use firearms more often in suicide. However, even when controlling for sex, the difference in use of firearms still remained significant among people without a mental health diagnosis which suggests there may be other reasons. Differences in means could also potentially be due to differences in access to specific medications (specific substances are listed in Table however does not collect information on access or preference of means so it is not possible to determine how this varied across groups. 15) Can you describe what "left a note? means in the (MMWR) table. Does that mean one-third of all people who committed suicides left a note? Is that consistent with what?s been reported before? Yes this is what this means and this is consistent. 16) What does your prevention strategy look like? In 08:11. doc re technical packagefcomprehensive preventionfpublic health approach 17) What are the main steps to getting people help early? In addition to strategies addressing mental health conditions, the study identified the need for attention to the broader range of circumstances contributing to suicide, including relationship, substance use, physical health, job, financial, and legal problems. For example, we can implement upstream approaches to prevention, such as teaching coping and problem-solving skills to help people manage life challenges; help people stay connected to others for emotional and other types of support and know that other types of assistance are available. For example, employee assistance programs can help connect employees with appropriate assistance for challenges with substance misuse, finances, or relationships. We can all play a role in reducing stigma associated with getting help for mental and other challenges that many people experience throughout their lives. 18) Do Kate Spade and other high pro?le suicides make you worry about copycats? Research has shown that if high profile suicides are inappropriately covered in the media that they can lead to increases in imitation of suicidal behavior in the population. Recent examples include the suicide of Robin Williams which afterward led to a large increase in calls to the national suicide crisis hotline. Several organizations including CDC worked together to write some recommendation for how the news media could responsively report on suicides and lessen the possibility of imitation. Other questions that have come Up: Stigma question Stigma is a real concern. We all could do better to support friends, family, coworkers, and others to seek help without any fear of shame or embarrassment. Suicide is preventable and help is available, therefore seeking help is a sign of strength. We need sufficient investment and a comprehensive public health approach. CDC's technical package of comprehensive prevention strategies with the best available evidence provides a range of prevention strategies including creating protective environments so that people are encouraged to get the help they need. Would you say that suicide is an epidemic? The increase in suicide rates is undoubtedly a concerning trend that has resulted in suicide prevention being a named priority for the CDC's National Center for injury Prevention and Control. Much work needs to be done to focus strategies that have been shown to prevent suicide so that we can begin to make an impact at the population level in order to help meet the nation's goal to reduce the annual suicide rate 20 percent by year 2025. . If pushed further to specifically call suicide an epidemic, consider stating: 0 Many aspects of the definition of an epidemic are considered when the CDC identifies a health condition or outcome as an epidemic, including the magnitude of increases observed, the population at risk and the timeframe being considered. We also know that when the media and other entities use language that dramatizes suicide, it can put vulnerable people at risk of self-harm. 0 That said, we should not downplay the importance of this growing problem, which is why the CDC considers suicide prevention 3 priority. . The CDC hopes that the findings from this study will help states to understand the magnitude of the problem in their own states, and CDC offers a technical package of policy, programs, and practices with proven effectiveness for preventing suicide as a resource that can help states and communities guide their prevention efforts. From: Simon, Thomas Sent: 7 Jun 2018 09:25:38 -0400 To: Crosby, Alexander Deborah (CDCIONDIEHINCIPCI Cc: Holland, Kristin Subject: RE: Vital Signs Interview Readout Kristin and I will merge our responses in what Alex just sent. From: Crosby, Alexander Sent: Thursday, June 7, 2018 9:25 AM To: Stone, Deborah Cc: Simon, Thomas Holland, Kristin Subject: RE: Vital Signs Interview Readout Greetings: I have attached some draft responses to 5 8t 18. Alex From: Stone, Deborah Sent: Thursday, June 7, 2018 7:20 AM To: Crosby, Alexander (CDCIONDIEHINCIPC) Simon, Thomas Holland, Kristin Subject: RE: Vital Signs Interview Readout Hi Guys, Please see attached with the list of questions below. Would you be willing to divvy up the 6 questions that we don't really address in the 0.81%? Alex, if you could take questions 5818 Kristin and Tom if you can take 6,7,10, and 1??these questions kind of go together. Thanks so much in advance! Deb From: Crosby, Alexander Sent: Wednesday, June 6, 2018 10:59 PM To: Lenard, Courtney Stone, Deborah Simon, Thomas Holland, Kristin (cocronoiEH/Ndpciomhl cdc. ov} Cc: Eschelbaoh, Julie Lane, Gabraelle (CDCXONDIEHINCIPQ Black, Erin Bellman. Marie R- (CDCIONDIEHINCIPCI Daniel, Valerie M. (CDCIONDIEHINCIPCI uh8 cdc. ov> Subject: Re: Vital Signs interview Readout Greetings: Quite an interesting list of questions. Alex From: Lenard, Courtney {zy'tj?i'iiedeeov} Date: June 6, 2018 at 6:59:53 PM EDT To: Stone, Deborah (CDCIONDIEPUNCIPC) ?zaMdiedegovia, Simon, Thomas Subject: Re: Vital Signs interview Readout Greetings: Quite an interesting list of questions. Alex From: Lenard, Courtney Cc: .Esehelbaeh, Julie (CDCIONDIEHINCIPC) Lane, Gabraelle , Daniel, Valerie M. Subject: Fw: Vital Signs Interview Readout FYI Sent from my BlackBerry 10 smartphone. From: Grusich, Katherina (Kate) (CDCIODJOADC) Sent: Wednesday, June 6, 2018 6:48 PM To: Lenard, Courtney Dorigo, Leslie Solder, Harben, Kathy Omisore, Shannon L. Burden, Bernadette Subject: Vital Signs Interview Readout Just wanted to let you know that Dr. Schuchat did phone interviews today with CNN, TIME, Washington Post, AP and NBC News [online}. I wanted to share some of the questions, as they could help with prep for the telebriefing. Overall there were a lot of questions about what is driving the increase and why it?s worse in certain states/regions, or rising among certain groups (women, veterans, etc.) Several asked about concerns of copycat incidents following the Kate Spade news, and questioned whether today?s culturefenvironment play a role. The list below captures know if you have any questions. 1} What?s new here? What does this report reveal that's not already out there? 2} Was anything in this report particularly surprising to yoquDC? 3] What is CDC trying to achieve by looking more closely at these numbers? 4] Can you explain why there has been a sustained upswing in the suicide rate in recent years? 5] Beyond these findings what is going on in our country? is today?s culture [hate speech, social media, anxiety) driving this trend? 6} Were you surprised at the number of people who died from suicide who did not have known mental health conditions? 7] increasing access to mental health has often been cited as key to suicide prevention. How does the finding that many don?t have a mental health problem complicate this strategy? 8} Clinical depression, loneliness, anxiety are all up. Are these factors contributing to the increased rates of suicide? 9} How do you define someone with mental health conditions? Do they have to be diagnosed by a mental health practitioner? 10] If many of them didn?t have a known mental health condition, how do we identify, reach and help them? 11) Can you provide more insight on why we?re seeing increases among (rural areas/Western statesfwomen)? 12] Do you have more information on veterans and the burden of suicide among this group? 13] Are medically-assisted suicides included in this report? 14] Is there a reason why suicide by firearms is higher for people who didn?t have a known mental health diagnosis? 15] Can you describe what "left a note" means in the (MMWR) table. Does that mean one?third of all people who committed suicides left a note? Is that consistent with what?s been reported before? 16] What does your prevention strategy look like? 17] What are the main steps to getting people help early? 18] Do Kate Spade and other high profile suicides make you worry about copycats? Kate Grusich Public Affairs Specialist CDC News Media Branch 770-488-333? 0&9. Part What?s new here? What does this report reveal that?s not already out there? This study examines state increases in suicide rates across six consecutive 3-year periods and looks at contributing factors and circumstances to suicide among people with and without a mental health condition in order to understand the broad range of factors that influence suicide. Was anything in this report particularly surprising to youlCDC? We?ve known for several years now that suicide rates have been increasing. The current study adds to our understanding by demonstrating that suicide rates increased in nearly all states; and increases of more than 30% were observed in 25 states. This study also examined the circumstances that contributed to suicide among decedents and provides new information about the contributing circumstances among those with and without known mental health conditions. What is CDC trying to achieve by looking more closely at these numbers? The purpose of this study is to understand state suicide rate increases between 1999 and 2016 and to understand the range of contributing factors and circumstances of suicide. Ultimately we want to tell the public that suicide is preventable and that it will take all of us working together to prevent it. Can you explain why there has been a sustained upswing in the suicide rate in recent years? in GM rims-questions on opioids, economy, sociai media, firearms and their role in increasing rates Beyond these findings - what is going on in our country? Is today?s culture (hate speech, social media, anxiety) driving this trend? Suicidal behavior results from an interaction of multiple factors so there isn't any single reason. There are many current or recent influences that may be affecting suicidal behavior. These include the great recession which increased financial stressors 8: housing problems, increase in opioid abuse, stigma against help seeking for mental illness, among other changes. Were you surprised at the number of people who died from suicide who did not have known mental health conditions? Kristin and Tom Increasing access to mental health has often been cited as key to suicide prevention. How does the finding that many don?t have a mental health problem complicate this strategy? Clinical depression, loneliness, anxiety are all up. Are these factors contributing to the increased rates of suicide? in document How do you define someone with mental health conditions? Do they have to be diagnosed by a mental health practitioner? in o?oc 10) If many of them didn't have a known mental health condition, how do we identify, reach and help them? Kristin and Tom 11) Can you provide more insight on why we?re seeing increases among (rural areas/'Western statesfwomen)? in document 12) Do you have more information on veterans and the burden of suicide among this group? in doc 13) Are medically-assisted suicides included in this report? No. Physician-assisted suicide is not included. Only a few states have legalized this and the deaths are not classified as suicides. 14) Is there a reason why suicide by ?rearms is higher for people who didn?t have a known mental health diagnosis? One of the reasons why the proportion of suicides by firearm may be greater among people without a known mental health diagnosis may be because people without a diagnosis were more likely to be male and males are known to use firearms more often in suicide. However, even when controlling for sex, the difference in use of firearms still remained significant among people without a mental health diagnosis which suggests there may be other reasons. Differences in means could also potentially be due to differences in access to specific medications (specific substances are listed in Table 1), however does not collect information on access or preference of means so it is not possible to determine how this varied across groups. 15) Can you describe what "left a note? means in the (MMWR) table. Does that mean one-third of all people who committed suicides left a note? Is that consistent with what?s been reported before? Yes this is what this means and this is consistent. 16) What does your prevention strategy look like? in doc re technical package/com prehensive preventionfpublic health approach 17) What are the main steps to getting people help early? Kristin and Tom 18) Do Kate Spade and other high pro?le suicides make you worry about copycats? Research has shown that if high profile suicides are inappropriately covered in the media that they can lead to increases in imitation of suicidal behavior in the population. Recent examples include the suicide of Robin Williams which afterward led to a large increase in calls to the national suicide crisis hotline. Several organizations including CDC worked together to write some recommendation for how the news media could responsively report on suicides and lessen the possibility of imitation. Other questions that have come up: mm Stigma question Stigma is a real concern. We all could do better to support friends, family, coworkers, and others to seek help without any fear of shame or embarrassment. Suicide is preventable and help is available, therefore seeking help is a sign of strength. We need sufficient investment and a comprehensive public health approach. technical package of comprehensive prevention strategies with the best available evidence provides a range of prevention strategies including creating protective environments so that people are encouraged to get the help they need. Would you say that suicide is an epidemic? The increase in suicide rates is undoubtedly 3 concerning trend that has resulted in suicide prevention being a named priority for the National Center for injury Prevention and Control. Much work needs to be done to focus strategies that have been shown to prevent suicide so that we can begin to make an impact at the population level in order to help meet the nation's goal to reduce the annual suicide rate 20 percent by year 2025. If pushed further to specifically call suicide an epidemic, consider stating: Many aspects of the definition of an epidemic are considered when the CDC identifies a health condition or outcome as an epidemic, including the magnitude of increases observed, the population at risk and the timeframe being considered. 0 We also know that when the media and other entities use language that dramatizes suicide, it can put vulnerable people at risk of self-harm. That said, we should not downplay the importance of this growing problem, which is why the CDC considers suicide prevention a priority. I The CDC hopes that the findings from this study will help states to understand the magnitude of the problem in their own states, and CDC offers a technical package of policy, programs, and practices with proven effectiveness for preventing suicide as a resource that can help states and communities guide their prevention efforts. From: Stone, Deborah Sent: 7 Jun 2018 13:14:57 +0000 To: Simon, Thomas Alexander Kristin Subject: RE: Vital Signs Interview Readout Thanks, Tom! From: Simon, Thomas Sent: Thursday, June 7, 2018 8:56 AM To: Stone, Deborah Crosby, Alexander Holland, Kristin (CDCKONDIEHINCIPC) Subject: RE: Vital Signs Interview Readout Hi Deb. No worries. I'm looking at this now. ?Tom From: Stone, Deborah Sent: Thursday, June 7, 2018 7:20 AM To: Crosby, Alexander (CDCIONDIEHINCIPC) Simon, Thomas (CDCIDNDIEHXNCIPC) Holland, Kristin Subject: RE: Vital Signs Interview Readout Hi Guys, Please see attached with the list of questions below. Would you be willing to divvy up the 6 questions that we don't really address in the Alex, if you could take questions 5818 Kristin and Tom if you can take 6,7,10, and 17?these questions kind of go together. Thanks so much in advance! Deb From: Crosby, Alexander Sent: Wednesday, June 6, 2018 10:59 PM To: Lenard, Courtney Stone, Deborah Simon, Thomas ; Holland, Kristin cdc. ov> Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Bellman, Marie R. (CDCIDNDIEHINCIPC) Daniel, Valerie M. uh8 cdc. ov> Subject: Re: Vital Signs Interview Readout Greetings: Quite an interesting list of questions. Alex From: Lenard, Courtney (CDCIONDIEHKNCIPC) Date: June 6, 2018 at 6:59:53 PM EDT To: Stone, Deborah (CDCIONDIEHINCIPC) {zalytd'icdoeova Simon, Thomas Crosby, Alexander {see I {Ericde?ov}, Holland, Kristin , Crosby, Alexander (C {aec Holland, Kristin (CDCKONDIEHMCIPC) {imhli?rti'edovov} Cc: Eschelbach, Julie (CDCJONDIEHINCIPC) Subject: RE: Comm Review??Need your final approval to a few items RE: FOR REVIEW: Vital Signs Communications Products Hi Deb, I like these changes. Thank you for being so thoughtful about these documents. ?Tom From: Stone, Deborah Sent: Tuesday, April 24, 2018 8:38 PM To: Simon, Thomas (CDCIONDIEHINCIPC) ?it 59 cdc. ov> Subject: Comm Review?~Need your final approval to a few items RE: FOR REVIEW: Vital Signs Communications Products Importance: High Hi Tom, Are you ok with these edits to the telebriefing script (changes from original text in red) and the press release (4th item)? The second one highlighted below would mean a change to the factsheet as well. I Suggested change: People who died by suicide and who did not have a known mental health problem, were more likely than those with a mental health problem to struggle with relationship problems or loss (45% vs any life stressors (54% vs and recent or impending crises (32.9% vs However, and importantly, these circumstances were common to both groups. Original: People who died from suicides and did not have a known mental health problem, were more likely to struggle with relationship problems or loss (45.1% vs life stressors (54.2% vs and recentfimpending crises (32.9% vs however, and importantly, these circumstances were common across those with and without known mental health problems. - Rationale: Since I?ll be giving the percentages (30% vs y%l, it seemed better to let people know the group is sooner rather than later, especially since we haven?t referred to them previously at this point. The change also reduces the number of words which should make interpretation clearer. I uggested change: On a Federal level, government agencies are tracking the problem of suicide and suicide attempts to understand trends and groups at greatest risk. They are developing, implementing and evaluating suicide prevention strategies in communities and working with ihii ?1 i 0 Original: On a Federal level, government agencies are tracking the problem of suicide and suicide attempts to understand trends and groups at greatest risk. They are developing, implementing and evaluating suicide prevention strategies in communities and working with local, state, tribal and other partners to prevent suicide. I Rationale: The new version gives a nod to the National Action Alliance and it avoids having the second and third ideas (dev, impl, eval prevention, and preventing suicide) be so closely linked in meaning. It also of course mentions the national strategy which is good I think (even if we are focused on state suicide prevention}. - uggested change: The bottom line is that many factors contribute to suicide so it will take a coordinated and comprehensive response to prevent it. And everyone has a role. 0 Original: The bottom line is that it will take a coordinated and comprehensive response to prevent suicide, and everyone has a role. I Rationale: I thought we should weave back in the idea of multiple factors more directly. - Suggested change: States can use Preventing Suicide: A Technicai Package of Poiicy, Programs, and Practices t4 (b it 5} 0 Original: States can use Preventing Suicide: A Technicai Package of Poiicy, Programs, and Practices to guide actions based on what is known about keeping people safe. I Rationale: I think there?s a point of diminishing returns when it comes to plain language. Also, keeping people safe {butt} ibii 5) Press Release: Added this to the press release at the end {the part that you said was too fluffy. Note that I changed the wording a little related to the sectors. See what you think. It?s very common for the field to refer to the private sector and this way we can easily fold in the media. "Close communication and coordination of activities between the public health sector and other sectors such as health care, mental health, social services, law enforcement, education, faith, I Iis critical. To inform states and communities' decision-making about prevention priorities, the CDC released a technical package for suicide prevention that describes strategies and approaches based on the best available evidence." From: Simon, Thomas Sent: Tuesday, April 2.4, 2018 5:23 PM To: Bruce, Stone, Deborah staia?esaeaqw Cc: Ballman, Marie R. (CDCIONDIEHINCIPC) cgig?Mggog> Subject: RE: FOR REVIEW: Vital Signs Communications Products Hi have some comments in each. I discussed them with Deb and I?m ccing her on this email so that she can start working on them so that you can meet the goal of sharing these with Leslie tomorrow. I told Deb that we might have more time on the but she is going to start to answer the questions I added and pull in some more examples from existing This way we will have them if we need to send on Friday and Leslie can see them too. Thank you, Tom From: Bruce, Sent: Tuesday, April 24, 2013 8:22 AM To: Simon, Thomas Cc: Ballman, Marie R. Subject: FOR REVIEW: Vital Signs Communications Products Importance: High Hi Tom, We are moving right along with clearance of the VS communication products, and you are up next! You will see a tracker at the top, so when you have completed your review, please note it there and return them to me with your edits; I'll see that they get to the next reviewer. Each reviewer has one day. Thanks in advance! Respectfully, Bruce, MPH Health Communications Specialist Detailed to National Center of injury Prevention and Control Division of Violence Prevention, Health Communications Team Office: 770-488-5651 Mobile: 47D~249v3616 Cbruce2@cdc.gov Off alternate Fridays From: Dahlberg, Linda L. Sent: 18 Jul 2018 16:17:02 -0400 To: Holland, Kristin Deborah (CDCIUNDIEHINCIPQ Subject: RE: A few more to approach summaries to review Wonderful! I'll make that change and the ones suggested by Deb. Thank you both for your quick review!! From: Holland, Kristin Sent: Wednesday, July 18, 2018 4:14 PM To: Stone, Deborah Dahlberg, Linda L. Subject: RE: A few more to approach summaries to review These are all great. I reviewed these and the other ones, and the attached is the only one I had a small comment on, Nothing major. Everyone did a great job on these. Kristin From: Stone, Deborah (CDCIDNDIEHINCIPQ Sent: Tuesday, July 17, 2018 7:43 PM To: Dahlberg, Linda L. Holland, Kristin Subject: RE: A few more to approach summaries to review Here you go! Thanks, Linda! These all looked great! Deb From: Dahlberg, Linda L. (CDCIONDIEHINCIFC) Sent: Monday, July 16, 2018 9:15 AM To: Stone, Deborah Holland, Kristin Subject: A few more to approach summaries to review Hello Here are two more summaries to review over the next few days. For all of these, no need to do a thorough review ?just a quick scan to make sure there are no glaring mistakes or things missing that should definitely be included. Let me know if you have any questions. Thanks for your help! Linda From: Dahlberg, Linda L. Sent: Friday, July 13, 2018 3:07 PM To: Stone, Deborah Holland, Kristin Subject: For Review by COB 8/17: suicide approach summaries for the implementation guidance Hello, We are in the home stretch of completing the implementation guidance for the One component of the guidance pertains to the specific approaches in the technical packages. We are down to the last 8 summaries 7 of them are specific to the suicide TP. We put these on hold until after the Vital Signs for obvious reasons! Attached are 3 short ones for your review. Lindsey is hoping to get this last batch into clearance ASAP we are up against a contract deadline with Banyan. If you could review and send any on the three attached by Tuesday COB, l?ll incorporate your changes and get them ready for clearance. The other ones that we need to finalize include: I Postvention - Safer suicide care through system change 0 Treatment for people at risk of suicide 0 Treatment for victims/survivors (which includes content across the technical packages} Please let me know if you have any questions. Thanks in advance for your help! Linda From: Holland, Kristin Sent: 18 Jul 2018 16:14:29 -0400 To: Stone, Deborah Linda L. Subject: RE: A few more to approach summaries to review Attachments: 5U _Gatekeeper Training - for SME review ds kh.docx These are all great. I reviewed these and the other ones, and the attached is the only one I had a small comment on. Nothing major. Everyone did a great job on these. Kristin From: Stone, Deborah (CDCIONDIEHINCIPC) Sent: Tuesday, July 2018 143 PM To: Dahlberg, Linda L. Holland, Kristin Subject: RE: A few more to approach summaries to review Here you go! Thanks, Linda! These all looked great! Deb From: Dahlberg, Linda L. Sent: Monday, July 16, 2018 9:15 AM To: Stone, Deborah Holland, Kristin (CDCXONDIEHXNCIPC) (imhl cdc. ova- Subject: A few more to approach summaries to review Hello Here are two more summaries to review over the next few days. For all of these, no need to do a thorough review ?just a quick scan to make sure there are no glaring mistakes or things missing that should definitely be included. Let me know if you have any questions. Thanks for your help! Linda From: Dahlberg, Linda L. Sent: Friday, July 13,2013 3:07 PM To: Stone, Deborah Holland, Kristin (CDCXONDIEHINCIPC) Subject: For Review by C03 811?: suicide approach summaries for the implementation guidance Hello, We are in the home stretch of completing the implementation guidance for the One component of the guidance pertains to the specific approaches in the technical packages. We are down to the last 8 summaries 3? of them are specific to the suicide TP. We put these on hold until after the Vital Signs for obvious reasons! Attached are 3 short ones for your review. Lindsey is hoping to get this last batch into clearance ASAP we are up against a contract deadline with Banyan. If you could review and send any on the three attached by Tuesday COB, I?ll incorporate your changes and get them ready for clearance. The other ones that we need to finalize include: I Postvention - Safer suicide care through system change II Treatment for people at risk of suicide 0 Treatment for victims/survivors (which includes content across the technical packages] Please let me know if you have any questions. Thanks in advance for your help! Unda Gatekeeper Training This approach focuses on training individuals such as teachers, coaches, clergy, emergency responders, primary and urgent care providers, and others in the community to identify and respond effectively to people who may be at risk of suicide. By identifying people at risk ofsuicide and linking them to appropriate support and ca re, gatekeeper training can positiveiy impact suicide and risk factors for suicide such as depression and feelings of hopelessness. Strategy I Identify and Support People at Risk [Suicide] Improve ability of gatekeepers to identify and understand the warning ilgns of suicide Learn how to intervene appropriately and help people at risk of Eiuicide - I Increase knowledge of available resources and sopport Key Objectives I I implementation I Consudemlions I help gatekeepers feel comfortable with recognizing and inquiring about risk and discussion, audiovisual learning aids, presentations. role-praying] to provide opportunities to engage participants and practice skills I I the evidence supporting a specific program before selecting one to implement Public health Healthcare Education Government Community organizations Example Outcomes . Reductionsin suicide deaths suicide attempts I Engagement - I I depression feelings of hopelessness Eomparison Table of Suicide Prevention Gatekeeper Training Programs {Suicide Resources 13update.pdf Example Programs} Practice-sf Policies: Applied Suicide intervention Skills Training {Suicidal Garrett Lee Smith Suicide Prevention Program [Suicide] Programs may be implemented in a variety of settings schools, universityfcampus, healthcare. community. military} Many programs include specific guidance for the nature and sequencing of contenth_ facilitating access to support and care Programs are often delivered in groups and use a combination of methods group II I Training requirements vary depending on specific program model, ranging from a few hours to EZ-id ays Evidence of effectiveness also varies for different programs: so it is important to review r?tdditimiar Prevention Resource Center] Gatekeeper matrix Jull? I i? at the end here so it's clear the people identifying aren'tthe ones who have to .1 [Comment [Ellq]: Could add ?access careJ1 i provide care. {Comment Could drop this phrase. I It?s a little confusing. reed it's not clear. l' y' Comm-t HE :l .1 Comment Maybe say from a few If if i hours to 1 or more days? - i i i Example Programs Applied Suicide Intervention Skills Training (ASIST) (Suicide) Description: ASIST is a training program for hotline counselors, emergency workers, clergy, caregivers and others in the community. The ASIST model has three phases of caregiving: connecting, understanding and assisting. In the first phase [connecting], participants learn how to identify people who are having thoughts of suicide. In the second phase (understanding), participants learn how to recognize the caller?s invitation for help and how to listen to the caller?s reasons for dying and living. In the third phase (assisting), participants learn how to conduct a safety assessment, develop a safety plan for the person at risk, and connect the person at risk to community resources. The ASIST training program has been field tested in a variety of settings. Speci?c Populations/Settings Key Partners Considerations I Populationisl: Persons at risk of I Community organizations I 2-day training workshops are suicide I Healthcare providers required to deliver the ASIST I Emergency medical services program I Settinglsi: School, community, - Faith?based organizations I Materials and consultation support military I Government (local, state, federal] are available - School administrators and staff I Program c051 available online I Public health agencies Additional Information I ASIST Program Site - I Program Summary - skills-training asist Garrett Lee Smith IGLS) Suicide Prevention Program {Suicide} Description: Gatekeeper training is a core component of the Garrett Lee Smith [(3le Suicide Prevention Program which has been implemented in states, territories, tribal communities, and college campuses across the United States. The program is funded by the Substance Abuse and Mental Health Services Administration Individuals are trained to better recognize the risk for suicide, inquire about risk, intervene appropriately, and help the suicidal individual obtain assistance. Training rangES from a few hours to a few days. Populations.l Settings Key Partners Considerations I opulationis]: Persons at risk of I Community organizations To find the state or local GL5 grantees in suicide I School/campus administrators Your community ViSit this and staff I Schoolfcollege campuses, - State mental health agencies community I Government (local, state, federal} I Tribal communities I Public health agencies Additional Information I Garrett Lee Smith Suicide Prevention Program From: Dahlberg, Linda L. Sent: 17 Jul 2018 21:15:29 {1400 To: Stone, Deborah Kristin Subject: RE: A few more to approach summaries to review Thank you! Appreciate your quick review! From: "Stone, Deborah Sent: Tuesday, July 17, 2018 7:43 PM To: "Dahlberg, Linda L. ,"Holland, Kristin Subject: RE: A few more to approach summaries to review Here you go! Thanks, Linda! These all looked great! Deb From: Dahlberg, Linda L. Sent: Monday, July 16, 2013 9:16 AM To: Stone, Deborah Holland, Kristin (coc/onoIEHfNCIPc) Subject: A few more to approach summaries to review Hello Here are two more summaries to review over the next few days. For all of these, no need to do a thorough review -just a quick scan to make sure there are no glaring mistakes or things missing that should definitely be included. Let me know if you have any questions. Thanks for your help! Linda From: Da hiberg, Linda L. Sent: Friday, July 13, 2013 3:07 PM To: Stone, Deborah Holland, Kristin Subject: For Review by COB 8/12: suicide approach summaries for the implementation guidance Hello, We are in the home stretch of completing the implementation guidance for the One component of the guidance pertains to the specific approaches in the technical packages. We are down to the last 8 summaries 7 of them are specific to the suicide TP. We put these on hold until after the Vital Signs for obvious reasons! Attached are 3 short ones for your review. Lindsey is hoping to get this last batch into clearance ASAP - we are up against a contract deadline with Banyan. If you could review and send any on the three attached by Tuesday COB, I?ll incorporate your changes and get them ready for clearance. The other ones that we need to finalize include: I Postvention . Safer suicide care through system change 0 Treatment for people at risk of suicide - Treatment for (which includes content across the technical packages) Please let me know if you have any questions. Thanks in advance for your help! Linda From: Stone, Deborah Sent: 17 Jul 2018 23:43:25 +0000 To: Dahlberg, Linda L. Kristin (CDCIUNDIEHINCIPC) Subject: RE: A few more to approach summaries to review Attachments: 5U _Safe Reporting and Messaging About Suicide - for SME review ds.docx, SU _Postvention - for SME review ds.docx Here you go! Thanks, Linda! These all looked great! Deb From: Dahlberg, Linda L. Sent: Monday, July 16, 2018 9:16 AM To: Stone, Deborah Holland, Kristin Subject: A few more to approach summaries to review Hello Here are two more summaries to review over the next few days. For all of these, no need to do a thorough review ?just a quick scan to make sure there are no glaring mistakes or things missing that should definitely be included. Let me know if you have any questions. Thanks for your help! Linda From: Dahlberg, Linda L. Sent: Friday, July 13, 2018 3:07 PM To: Stone, Deborah Holland, Kristin Subject: For Review by CUB 81'17: suicide approach summaries for the implementation guidance Hello, We are in the home stretch of completing the implementation guidance for the One component of the guidance pertains to the specific approaches in the technical packages. We are down to the last 8 summaries of them are specific to the suicide TP. We put these on hold until after the Vital Signs for obvious reasons! Attached are 3 short ones for your review. Lindsey is hoping to get this last batch into clearance ASAP we are up against a contract deadline with Banyan. If you could review and send any on the three attached by Tuesday COB, I?ll incorporate your changes and get them ready for clearance. The other ones that we need to finalize include: . Postvention - Safer suicide care through system change In Treatment for people at risk of suicide 0 Treatment for victimslsurvivors (which includes content across the technical packages] Please let me know if you have any questions. Thanks in advance for your help! Unda Safe Reporting and Messaging About Suicide The manner in which information on a recent suicide is communicated to the public can heighten the risk of suicide among vulnerable individuals and can inadvertently contribute to suicide contagion. This approach promotes prevention messaging and reporting on suicide in a was,r that reduces the possibility of suicide contagion, encourages help?seeking, and promotes evidence?based actions that can help prevent suicide. Strategy KEV DbleatWes implementation Considerations Sector Engagem en: Examolo Outcomes Additional Resources Lessen Harms and Prevent Future Risk [Suicide] Increase awareness and adherence to guidelines for reporting on suicide Reduce the likelihood of suicide contagion Promote positive prevention messages Present accurate information about suicide rates and trends signs. and prevention Avoid sensationalizing suicide or referring to suicide as "successful" or "unsuccessful? or a ?failed attempt" Avoid conveving details around the method used in the suicide Provide information in a wav that avoids attributing suicide to a single cause Incorporate prevention messages and actions that can help prevent suicide Promote evidence?based solutions and prevention success stories Use stories of hope and resilience Encourage help-Seeking bv Incorporating information on local resources and sUpport Public health Media Education Government Communitv organizations Reductions in 0 rates of suicide contagion effects related to suicide increases in protective factors improvements in reporting following suicide] Recommendations for Reporting on Suicide htto:Hreoortineonsuicideore! Suicide Prevention Resource Center g; reporting Cement 121119]: This Seems a little circular. isn't what this whole thing is about how to improve reporting to prevent suicide? Postvention Postvention approaches are implemented after a suicide has taken place and are intended to provide bereavement support for surviving family members, friends, and other close contacts. Postvention includes debriefing sessions, counseling, support groups, and other activities to facilitate healing. People who have lost a friendg?peer, family member, co-worker or someone else close to them to suicide are at increased risk for suicide. Care and attention to the bereaved is important for helping reduce this risk. Strategy Lessen Harms and Prevent Future Risk [Suicide] KEV Dblectives I Facilitate healing and promote healthyI recovery of individuals, families, and communities bereaved by suicide Prevent suicide among surviving friends, familv, andfor community members Postvention may be delivered in a varietvr of settings schools, workplaces, communitv] Procedures for responding effectivelv to suicide and connecting survivors to communitv services and resources should be developed and in place prior to a death by suicide Implementation - Considerations - I experience surviving a suicide loss, and others involved in crisis response activities can help ensure resources are appropriately identi?ed and in place to support survivors Postvention plans should be flexible to address a variety of circumstances and take into I account both shorter- and longer-term needs Public health Education Sector I I Business and Labor I Engagement Healthcare GENE rnrne nt Community organizations Reductions in survivors' guilt, feelings of depression, and distress contagion effects related to suicide suicide attempts suicidal ideation Example - Outcomes 0 Additional I Postvention [Suicide Prevention Resource Center) - Rasources approach?postvention Postvention for College Campuses [Higher Education Mental Health Alliance) Euidepdf Postvention Guide - Alaska Suicide Preventioni?lari- Example Prugrams/Practices/Policies: - StandE-v Response Service [Suicide] 1 [23139]: This one looks ok, but here are the more usual snipects: From the Action Alliangesuwivom of Suicide Loss Task Force. (2015. April). Responding to grief, trauma, and distress after a suicide: U. S. National Guidelines 1 Washington, DC: National Action Alliance for Suicide Prevention. Retrieved from And rc.or corn rehensive- . appgoachdpostvention Example Programs StandBv Response Service {Suicide} Description: StandBv Response Service is a suicide bereavement support service. The service provides clients with face-to-face outreach and telephone support provided bv a professional crisis response team. A site coordinator then develops a customized case management plan, referring clients to other existing community services matched to their needs. The program also includes communitv education and activities with local community groups, businesses, and other organizations. Specific PopulationsISettings Kev Partners Considerations I Populationlsl: Persons I Health care I Services are available 24!? and may bereaved by a recent or past - Mental health providers be delivered in?person or by phone suicide - Community organizations Consultation and SUPPUHZ l5 0 Public health agencies available to coordinators at Standbv I Communitv RESPONSE sites 0 Program cost information is not available Additional Information I StandBv Support After Suicide Program Site From: Stone, Deborah Sent: 9 Mar 2018 21:26:14 +0000 To: Bruce, Subject: RE: Abstract for MHWG Meeting Thanks, This looks great! I added a few more goals of the Vital Signs and will add a few other talking points on the TP summary slide but I can manage that. I really appreciate your support on everything!! Have a great weekend! Deb From: Bruce, (CDCIOPHPRIDD) Sent: Friday, March 9, 2018 11:22 AM To: Stone, Deborah Subject: RE: Abstract for MHWG Meeting Hi Deb. Here?s a first draft of the presentation for the let me know your thoughts and I?m happy to revise. From: Stone, Deborah Sent: Thursday, March 8, 2018 4:45 PM To: Bruce, Subject: RE: Abstract for MHWG Meeting Thank you so much. I really appreciate the help, I will try not to bother you tomorrow on your flex dayl! Deb From: Bruce, Sent: Thursday, March 8, 2018 4:13 PM To: Stone, Deborah <2an cdc. oy> Subject: RE: Abstract for MHWG Meeting Hi Deb, l'ye tightened up the presentation to 1? slides; that gives you time to talk about VS. I don't know how much detail you want to go into. I?ll pull some high level bullets from the factsheet and let you pick and choose. Tomorrow is my flex day, but I will be online working on this (and some other critical projects), so feel free to email me after you see the draft {coming tomorrow). Thanks! From: Stone, Deborah (CDCIONDIEHINCIPCI Sent: Thursday, March 8, 2018 9:07 AM To: Bruce, :6 cdc. oy> Subject: RE: Abstract for MHWG Meeting Hi Here?s the presentation I did at APHA. It wasn?t the biennial mh sury meeting where I presented. I wonder if it would be good to put a slide in the beginning to let people know that the VS stuff is part and parcel of this presentation. Maybe even change the title to reflect that? Not sure how much we can say though so I?ll leave that up to you. I may need to trim this whole thing down but I?ll figure that out afterwards. Thanks for your help! Deb From: Bruce, (CDCIOPHPRIOD) Sent: Thursday, March 8, 2018 7:06 AM To: Stone, Deborah (CDCIONDIEHKNCIPQ Subject: RE: Abstract for MHWG Meeting Hi Deb. Thanks for sending this! The Vital Signs would fit very nicely right after his paragraph. My goal is to have a couple of slides to you this afternoon. Do you have the presentation you gave to the surveillance group? From: Stone, Deborah Sent: Wednesday, March 7, 2018 5:03 PM To: Bruce, x6 cdc. ov> Subject: FW: Abstract for MHWG Meeting Hi Hope you are doing well and have water! Just got this. Should we also insert the vital signs piece before or after the technical package? Deb From: Khalil, George M. Sent: Wednesday, March 7, 2018 8:15 AM To: Stone, Deborah (CDCJONDIEHXNCIPQ <2an cdc. 0v:- Cc: Merrick, Melissa T. (CDCIONDIEHINCIPQ (kc 7 cdc. ov>; Holbrook, Joseph Lutfy, Caitlyn Subject: Abstract for MHWG Meeting Hi Deb, I?m preparing an agenda for the MH workgroup meeting and was wondering if you would provide an abstract on what you will be presenting on 3/15. By searching the Intranet and looking at the actual technical package, ca me up with the following: I Suicide Prevention: Technical Package Dr. Deb Stone, MSW, MPH Behavioral Scientist, ONDIEH Abstract: To improve program practice across the U.S., a group of scientists led by Dr. Stone from the Division of Violence Prevention (D?v?Pl and the Division of Analysis, Research and Practice Integration (DARPH developed a technical package of policies, programs and practices for the prevention of suicide. Published in 2017, the technical package provides a core set of strategies to achieve and sustain substantial reductions in self?directed violence based upon the best available evidence. Please make revisions as you see fit. l'd like to send this out to the workgroup ASAP. Thanks! George From: Bruce, Sent: 9 Mar 2018 11:22:11 -0500 To: Stone, Deborah Subject: RE: Abstract for MHWG Meeting Attachments: MHWG Suicide Technical Package_DRAFT.pptx Hi Deb, Here?s a first draft of the presentation for the let me know your thoughts and I?m happy to revise. From: Stone, Deborah Sent: Thursday, March 8, 2018 4:45 PM To: Bruce, (CDCIOPHPRIOD) Subject: RE: Abstract for MHWG Meeting Thank you so much. I really appreciate the help, I will try not to bother you tomorrow on your flex dayll Deb From: Bruce, Sent: Thursday, March 8, 2018 4:13 PM To: Stone, Deborah Subject: RE: Abstract for MHWG Meeting Hi Deb, I've tightened up the presentation to 17 slides; that gives you time to talk about VS. I don?t know how much detail you want to go into. I'll pull some high level bullets from the factsheet and let you pick and choose. Tomorrow is my flex day, but I will be online working on this (and some other critical projects), so feel free to email me after you see the draft {coming tomorrow). Thanks! From: Stone, Deborah Sent: Thursday, March 8, 2018 9:07 AM To: Bruce, Subject: RE: Abstract for MHWG Meeting Hi Here?s the presentation I did at APHA. It wasn?t the biennial mh surv meeting where I presented. I wonder if it would be good to put a slide in the beginning to let people know that the US stuff is part and parcel of this presentation. Maybe even change the title to reflect that? Not sure how much we can say though so I?ll leave that up to you. I may need to trim this whole thing down but I?ll figure that out afterwards. Thanks for your help! Deb From: Bruce, Sent: Thursday, March 8, 2018 2:06 AM To: Stone, Deborah <2af9@cdc.gov> Subject: RE: Abstract for MHWG Meeting Hi Deb. Thanks for sending this! The Vital Signs would fit very nicely right after his paragraph. My goal is to have a couple of slides to you this afternoon. Do you have the presentation you gave to the surveillance group? From: Stone, Deborah (CDCIONDIEHINCIPC) Sent: Wednesday, March 7, 2018 6:03 PM To: Bruce, Subject: FW: Abstract for MHWG Meeting Hi Hope you are doing well and have water! Just got this. Should we also insert the vital signs piece before or after the technical package? Deb From: Khalil, George M. Sent: Wednesday, March 7, 2018 8:15 AM To: Stone, Deborah <2an cdc. ov> Cc: Merrick, Melissa T. Holbrook, Joseph ; Lutfv, Caitlvn Subject: Abstract for MHWG Meeting Hi Deb, I?m preparing an agenda for the MH workgroup meeting and was wondering if you would provide an abstract on what you will be presenting on 3/15. By searching the intranet and looking at the actual technical package, i came up with the following: II Suicide Prevention: Technical Package Dr. Deb Stone, MSW, MPH Behavioral Scientist, ONDIEH Abstract: To improve program practice across the U.S., a group of scientists led by Dr. Stone from the Division of Violence Prevention lD?v?P} and the Division of Analysis, Research and Practice Integration developed a technical package of policies, programs and practices for the prevention ofsuicide. Published in 201?, the technical package provides a core set of strategies to achieve and sustain substantial reductions in self-directed violence based upon the best available evidence. Please make revisions as you see fit. i?d like to send this out to the workgroup ASAP. Thanks! George Suicide Prevention: Technical Package New Vital CDC Vital?; Preventing Sultide: 9 N-mx? Division of Violence PreventionNational Center for Injury Prevention and ControlCenters for Disease Control and Prevention Deb Stone, MSW, MPH Serious Public Health Problem Suicide accounts for more than 44,000 deaths each yearRates of suicide are risin the lifespanHigh burden in multiple population groupsMany more people hospitalized or treated in ambulatory settings for nonfatal suicidal behavior than die Suicide is Preventable Connected to other forms of violenceShares common risk factorsRequires a comprehensive approach targeting multiple risk and protective factors across the social ecology Benefits of a Technical Package Technical packages; one of the six key components for effective public health program implementation Sharpen and focus what otherwise might be vague commitments to "action? Avoid a scattershot approach of a large number of interventions. many of which have only a small impactAchieve substantial and synergistic improvement in outcomes Suicide Technical Package Preventing Suicide: I s59. Select group of strategies based on the best available evidence to help communities and states sharpen their focus on priorities with the greatest potential to prevent suicide. Helping States and Communities Take Advantage of the Best Available Evidence inen?ng?h?dhbuse and Hegled: I TIMI Pulsar fur qur. Burn. and ngrunmmr STOP SV: A Tzdmicll Pldugi to Suual Violent! Preventing Intimate Partner untmg . - - Violence Across the Lifespan2016 2016 Three components:Strategy direction or action Approaches specific ways to advance the strategy (examples: programs; policies; practices)Evidence for each approach in preventing violence or impacting risk and protective factors Technical Package Development du Preventing Suicide: . ATerhnirai Package ofPoliry, We Programs. and Practices Stone. BM. Holiand. Bartholow. B.. Crosby, A.E.. Davis. 8., Wilkins. N. Preventing Suicide; A Technicai Package of Poiicy. Programs, and Practices. Atlanta. GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Considerations for Inclusion Example programs, policies, and practices selected based on the best available systematic reviews, rigorous evaluation studies showing impacts on suicide/suicide attempt outcomes or risk/protective factorsBeneficial effects on multiple forms of violenceSimilar outcomes with different settings/populations Feasibility of implementation in US. if evaluated in another evidence of harmful effects on specific outcomes or with subgroups Summary Table Strengthen economic supports Strengthen access and delivery of suicide care Create protective environments Promote connectedness Teach coping and problem-solving skills Identify and support people at risk Lessen harms and prevent future risk Strengthen household financial securityHousing stabilization policies Coverage of mental health conditions in health insurance policiesReduce provider shortages in underserved areasSafer suicide care through systems change Reduce access to lethal means among persons at risk of suicideOrganizational policies and cultureCornmunity-based policies to reduce excessive alcohol use Peer norm programs Community engagement activities Social-emotional learning programsParenting skill and family relationship programs Gatekeeper trainingCrisis interventionTreatment for people at risk of suicideTreatment to prevent re-attempts PostventionSafe reporting and messaging about suicide Sector Involvement Public healthEducationGovernment (local, state, federa )Socia servicesBusiness/IaborHeaIth servicesJusticeHousingMedia Military and Veteran organizationsFaith-base other non-government. organizations Monitoring and Evaluation Timely and reliable dataMonitor extent of problem evaluate. impact of prevention planning, implementation and assessment I What?s Next? Goals of the Report . Report trends in rates in the U.S. and by state and sex. Summarize suicide circumstances using the 2015 Compare suicide risk factors among people with and without mental health problems Activities Emails from CDC Director CDC Washington emails to key congressional offices promoting Vital Town Did You Know three factoids raising awareness about suicideNIH/NIMH webinar to promote Vital Signs to researchers and MH practitioners ASTHO All SHO Call to promote Vital Signs and technical package to State Health OfficersMedscape Video Commentary Questions For more information Visit page on the technical and other violence prevention Comment 18TH: I don?t understand why this was written like this. The period of the MMWR was 1999-2016 and this is 13 years not 10. JL DC Clearance: Comment 13TH: I'm requesting edits .1 ADS Clearance: DVP Policy Review: Malia Richmond~Crum, Heather Dennehy 7f26f18 {here to provide the VS results. DVP HCET Review: Erin Black, i?thiflS DVP SME Review: Deb Stone ASTHO Suicide Podcast CommentIST?: Iwouldkeepthis If I: simple and more focused on what is in i the vs. Questions for CDC guest Your Vital Signs report tracks suicide rates over an finds that suicide is on the rise. What?s happening? I Suicide is a public health Enrableni: . 0 Nearly 45,000 lives were lost to suicide in 2016, which is approximately one suicide every 12 minutes. 0 Suicide and nonfatal self?harm injuries cost more than $69 billion annually in direct medical and work loss costs. 0 Rates have increased by nearly 30% from 1999-2016 is one of lust on three leading causes of death that are on the rise. In the recent Vital Signs. we found that suicide rates increased in nearly every 0 State across the nation. 0 25 states had increases greater than 30%. Suicide and nonfatal self-harm injuries cost more than $69 billion annually in direct medical and work loss costs. While the Vital Statistics data are great for describing trends they don't tell us about the causal factors that are driving the increases. We do know that suicide is not caused by any one factor, but instead, it is typically caused by a combination of individual, relationship, community, and societal factors. To better understand the circumstances that contributed to suicide we looked at data from 17 states. We found that more than half of people who died by suicide did not have a known mental health condition. ether?factors that-contribute to suicide among those with and without a mental health condition, including: 42% relationship problems 29% crisis in the past or upcoming two weeks 28% problematic substance abuse 22% physical health problem 16%jobffinancial problem 9% legal problem 00000 4% loss of housing Several factors Sevesal?seeh?faesecsrcould be contributing to the increases: Economic conditions The role ofthe great recession in the late 2000?s and subsequent financial challenges and concerns about economic instability could have contributed to increases in suicide risk. Past research on the association between business cycles and U.S. suicide rates indicates that the overall suicide rate rises and falls in connection with the economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by parents may trickle down resulting in vulnerable youth. Opioid epidemic When there is an increased availability and misuse of prescription opioids, we may see increases in suicide rates. Substance misuse itself is an established risk factor for suicide and, therefore, opioid misuse associated with the opioid overdose epidemic could be driving the suicide rate higher. When we look at who is dying from suicide and who is dying from unintentional overdoses involving opioids, we see that there is overlap in the demographics ofthe populations most highly affected by suicide and unintended opioid overdose deaths. Social media More research is needed on the impact of social media use on suicide rates. However, changes in social media content or use patterns could potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated [Commenl 18TH: Idon?tthink you need to complicate the list with this, with social media. Rural 4 While there have been increases and decreases in suicide rates over time. research ,i shows that rates across cities and towns in the United States have been rising, with rural Ill I I areas experiencing the most increases. The increased rates may be associated with suicide risk factors that are more common in less urban areas, such as limited access to mental healthcare as well as greater social isolation. Let?s explore the factors that can play into a person's decision to take his or her own life. What are they? any known Many people think that suicide is an unexplainable act, when, in reality, factors increase These include: History of previous suicide attempts I Family history of suicide History of child abuse and neglect or other adverse childhood experiences I History of depression or other mental illness Alcohol or drug abuse Feelings of hopelessness or isolation Impulsive or aggressive tendencies Stressful life event or loss leg. relationship, job, money, criminaly?legal problems) Easy access to lethal methods Exposure to the suicidal behavior of others Isolation. lack of social connectedness The presence of any one of these factors does not mean someone is thinking about suicide or will attempt suicide. Researchers agree that suicidal behavior results from an interaction of factors and is rarely due to a single cause. How do I know if someone is at high risk of making a suicide attempt? The warning signs for suicide are: Expressing hopelessness Increased anger or rage Extreme mood swings I Sleeping too little or too much - Making plans for suicide 0 Talking andfor posting about wanting to Feeling?trapged 91in unbearable pain Increased anxiety I Securing lethal means - Increased substance use 0 Feeling like a burden - Isolation If you notice any of these signs: - Ask the question, "Are you thinking about suicide?? Asking the question won't make someone suicidal, and instead, may relieve or reduce the feeling. II If the person says yes, keep them safe. Find out ifthey have a suicide plan. Remove any lethal means in the environment, if possible, and do not leave the person alone. 0 Be there and show concern. Don't act surprised or dismiss their feelings. Take the person seriously, and do not assume they are joking. I Help them connect to resources, for example, by calling the National Suicide Prevention Lifeline (1- 300-273-TALK (8255]) or by connecting the person to someone in the community who can help, e.g. emergency department, counselor, pastor. 0 Follow up after the person is safe, follow up in the days ahead with a phone call, ask them how they are doing. See if there is anything else that you can do. You can learn more about these steps to help by going to The way society handles suicide seems almost contradictory. When a celebrity dies this way, it is all over the news. When someone in the neighborhood or at work dies by suicide, it?s the subject of unconfirmed rumor. Certainly, the survivors and family members are in pain and want privacy, but does suicide risk and the need for help for the populous at large carry a stigma that impedes life?saving treatment? In other words, should we, as a society, be talking about suicide more as a strategy to prevent these tragic losses? Talking about suicide does not cause suicide to occur or put the thought in someone?s head. 0 In fact, it can be an excellent prevention tool. Talking breaks the secrecy and shame that surrounds suicidal behavior and lets people know that help and hope are available. . By not talking about suicide, we increase the isolation and despair of individuals thinking about it and perpetuate the stigma associated with suicidal ideation and seeking helpbehavier. Everyone can play a role in suicide prevention. There are also recommendations for the media regarding how to report on suicide to raise awareness without increasing the risk of additional suicides among vulnerable populations. We know that risk can increase when the media provides details about the methods used, dramaticfgraphic headlines, or glamorize a death {see reportingonsuicideorg). We?ve talked a lot about risk and some barriers to suicide prevention like stigma, so let's turn the focus to saving lives. How can the CDC help public health professionals help their communities reduce the potential for suicide among their residents? What programs should public health professionals consider? CDC put together specific strategies for ways that the federal government, state and communities, healthcare systems, emplovers and everyone can help prevent suicide: th% Federal government is Tracking the problem to describe trends, circumstances, and populations at greatest risk (for example, I see Developing, implementing, and evaluating suicide prevention strategies. I Working with local, state, tribal, national, and other partners to provide guidance and distribute suicide prevention tools {for example, see States and communities can . Identify and support people at risk of suicide. Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 health, or other concerns. Promote safe and Supportive environments. This includes safelv storing medications and firearms to reduce access among people at risk. Offer activities that bring people together so they feel connected and not alone. ConnECt people at risk to effective and coordinated mental and phvsical healthcare. Expand options for temporary assistance for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a loved one to suicide. Health care systems can Provide high qualitv, ongoing care focused on patient safety and suicide prevention. Make sure affordable and effective mental and phvsical healthcare is available where people live Train providers in adopting proven treatments for patients at risk of suicide. Emplovers can [i i . . . professmnals consider? i suggest making 1 Comment I don?t think this long list works for Deb to respond to this question. The question is framed as what programs should public health this more focused. It is also confusing to sav CDC put together these specific strategies but then talk about the technical package later and list the strategies under ?states and communities can" again. I think some editing is needed here and below to these points about prevention. This is critical because we want Deb Hourv to feel con?dent about Lthis. Promote employee health and well-being, support employees at risk, and have plans in place to respond to people showing warning signs. Encourage employees to seek help, and provide referrals to mental health, substance use disorder, legal, or financial counseling services as needed EVEWDHE can Ask someone you are worried about ifthey?re thinking about suicide. Keep them safe. Reduce access to lethal means for those at risk. Be there with them. Listen to what they need. Help them connect with ongoing support like the Lifeline Follow up to see how they?re doing. Find out how this can save a life by visiting: And for members of the public who are listening, what can they do to protect their own families and their loved ones, or even their neighbors or colleagues? No matter what problems people deal with, we want to help them find a reason to keep living. By calling 1-800-273-TALK {8255} people will be connected to a skilled, trained counselor at a crisis center in their area, anytime 24H. There are many success stories and stories of hope where people in need have reached out and family or friends have intervened to get people help. They got the support they needed and were able to get through a crisis and go on to live productive and fulfilling lives. Given the wide range of factors that contribute to suicide, this would seem to be a problem not easily solved? - While it's true that suicide does not have one cause, this means that there are multiple opportunities for prevention. A public health approach focuses more broadly on the maportunities to reduce risk prevent?it: - - as opposed to focusing exclusively on mental health conditions. This can result in W, broader impact and reach more people at risk. There is also the issues of stigma around suicide and mental health care, which discourages people at risk for self-harm from seeking help. Suicide is preventable, but we need sufficient investment and a comprehensive public health approach. Looking at this report, and the disturbing trend the numbers illustrate, what is the outlook? Is there any reason to be optimistic about the future? Yes, the reason to be optimistic is that Suicide is preventable and we have strategies that knewwhet?works. CDC released a technical package of policies, programs, and practices to prevent suicide to help communities focus on a core set of strategies that have the best available evidence and greatest prevention potential. The technical package includes examples of programs that local implementers might tailor to fit the needs of their community. The technical package includes 1 strategies designed to work together to achieve the greatest impact possible. i. ii. iv. v. vi. vii. For example. an evidenced based suicide prevention program called Sources of Strength was developed with rural and tribal communities in North Dakota to promote connectedness between youth and caring adults. The program works to understand and respond to underlying causes of suicidal behavior and promote protective factors against suicidal behavior before the causes result in adverse butcomei Other innovative prevention strategies, such as telebehavioral or telemental health (telephone, video and web?based technologies}. are promising to increase access to health care and mental health care in rural communities. However, some rural communities may have limited access to the internet suggesting a need to increase broadband access and to identify other ways to deliver promising prevention supports Strengthen economic supports Strengthen access and delivery of suicide care Create protective environments Promote connectedness Teach coping and problem?solving skills Identify and support people at risk Lessen harms and prevent future risk where people live. If you or someone you know is thinking about suicide or needs support, help is always available. Call the National Suicide Prevention Lifeline at [8255] or visit 1 leat?il: What's the reference for this? I'd like to make sure I'm more Comment IVDI: Comes from this study referenced in the Suicide Technical package: I i . Comment I think we should be strategic about the examples used. i suggest that you carefully consider the options from the technical package that Liamiliar with this success story; will resonate the most with this audience. it would be helpful to use examples with Jesuits that you can describe. From: Stone, Deborah Sent: 2 Aug 2018 03:09:36 +0000 To: Daniel, Valerie M. Thomas Erin Subject: RE: ADS Review: ASTHO Podcast Attachments: ASTHO Suicide Podcast_v3 ds vd.docx Idon?t have much more time to work on this but I think it should be close now. Thanks! Deb From: Simon, Thomas Sent: Wednesday, August 1, 2018 5:15 PM To: Daniel, Valerie M. Stone, Deborah Cc: Black, Erin Subject: RE: ADS Review: ASTHO Podcast 0k, thank you both for clarifying and for continuing to work on this. It is already much better. From: Daniel, Valerie M. Sent: Wednesday, August 1, 2018 12:32 PM To: Stone, Deborah Simon, Thomas ?ct 59 cdc. ov> Cc: Black, Erin (e m? cdc. ova- Suhject: RE: ADS Review: ASTHO Podcast Deb and Torn, lput in some more messaging based on Deb?s last version. Deb Stone, not Houry will be speaking on the ASTHO podcast. Sorry for the confusion. Too many Deb?s As for the wording of the questions, they were provided by ASTHD who were shocked we had to clear Deb?s content in order to participate guess NCEZID or some other center who had an SME participate on a past podcast didn?t require this clearance, but I explained every Center was different) so they put together some questions for her to answer. I think it?s fine to provide edits back. Let me know what you all think of the attached. Thanks, Valerie From: Stone, Deborah Sent: Tuesday, July 31, 2018 10:56 PM To: Simon, Thomas Cc: Daniel, Valerie uh8 cdc. ov> Subject: RE: ADS Review: ASTHO Podcast Hi Tom, Thanks for your review. I?m actually doing the podcast though unless something has changed that I don?t know about {which would be fine]! Taking your comments, I went ahead and added some stuff and moved some stuff around. It?s not done yet but see what you think so far. Deb From: Simon, Thomas Sent: Tuesday, July 31, 2018 6:13 PM To: Black, Erin m7 cdc. ov> Cc: Daniel, Valerie M. Stone, Deborah Subject: RE: ADS Review: ASTHO Podcast Hi Erin and Valerie, I added some edits in the version attached. Deb Houry has not spoken much publicly about suicide prevention and I think this is a good opportunity to help her ?own? this content. We need to provide her with a strong document and there are a couple of places where the content could be improved. In particular, the results from the VS were not fully described. I added some bullets there to address this. I think the most important issue that still needs to be addressed is to tighten the prevention messages for her. I don?t think we should simply use the lists from the fact sheet and TP. I think this needs to be more conversational. I?m also concerned because the text includes the 7 strategies from the TP twice (once under ?states and communities can" and once when talking about the and doesn?t explain them in either place. I like the inclusion of some examples. I?m not sure the two selected are the best to use though. There are some that are more compelling because they have great results or will resonate with this audience. For example, the Air Force example is good because it demonstrates the value of a comprehensive approach and has effects that go beyond suicide prevention. i?m ccing Deb Stone because she likely has ideas for how to tighten the prevention points. lhopethmishek?uL ?Tom From: Black, Erin Sent: Friday, July 2018 9:20 AM To: Simon, Thomas st 59 cdc. ova Cc: Daniel, Valerie M. uh8 cdc. ova- Subject: FW: ADS Review: ASTHO Podcast Meant to copy Val! From: Black, Erin Sent: Friday, July 2018 9:19 AM To: Simon, Thomas (CDCXONDIEHXNCIPC) Subject: ADS Review: ASTHO Podcast Torn not sure if I should send this to you or Cory, let me know. Attached is the ASTHO podcast Question Val used the pre~cleared Vital Signs on suicide to pull from when preparing responses to the questions. This has been reviewed by Deb, me, and MaliaXHeather for policy. We are trying to get this cleared in time for Deb's recording of the podcast on August 6"h at 2pm. Thanks, Erin NCIPC 0C Clearance: DVP ADS Clearance: DVP Policy Review: Malia Richmond-Crum, Heather Dennehy 7f26f18 DVP HCET Review. Erin Black, 7/241/18 DVP SME Review: Deb Stone 7/231?18 ASTHO Suicide Podcast Questions for CDC guest Your Vital Signs report tracks suicide rates over an 18-year period, 1999-2016, and finds that suicide is on the rise. What's happening? I Suicide is a public health problem. Nearly 45,000 lives were lost to suicide in 2016, which is approximately one suicide every 12 minutes. Suicide and nonfatal self-harm injuries cost more than $69 billion annually in direct medical and work loss costs. Suicide is one ofjust three leading causes of death that are on the rise. We found that suicide rates increased in nearly every state across the nation. 25 states had increases greater than 30%. Do we know what is contributing to these increases? While the Vital Statistics data are great for describing trends they don?t tell us about the causal factors that are driving the increases. We do know that suicide is not caused by any one factor, but instead, it is typically caused by a combination of individual, relationship, community, and societal factors. Several factors could be contributing to the increases: Economic conditions The role of the great recession in the late 2000?s and subsequent financial challenges and concerns about economic instability could have contributed to increases in suicide risk. Past research on the association between business cycles and U.S. suicide rates indicates that the overall suicide rate rises and falls in connection with the economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by parents may trickle down resulting in vulnerable youth. Opioid epidemic When there is an increased availability and misuse of prescription opioids, we may see increases in suicide rates. Substance misuse itself is an established risk factor for suicide and, therefore, opioid misuse associated with the opioid overdose epidemic could be driving the suicide rate higher. When we look at who is dying from suicide and who is dying from unintentional overdoses involving opioids, we see that there is overlap in the demographics of the populations most highly affected by suicide and unintended opioid overdose deaths. Social media More research is needed on the impact of social media use on suicide rates. However, changes in social media content or use patterns could potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. Rural While there have been increases and decreases in suicide rates over time, research shows that rates across cities and towns in the United States have been rising, with rural areas experiencing the most increases. The increased rates may be associated with suicide risk factors that are more common in less urban areas, such as limited access to mental healthcare as well as greater social isolation. Let?s explore the factors that can play' into a person?s decision to take his or her own life. What are they? Many people think that suicide is an unexplainable act, when, in reality, many known factors increase risk. These include: 0 History of previous suicide attempts in Family history of suicide History of child abuse and neglect or other adverse childhood experiences History of depression or other mental illness Alcohol or drug abuse I Feelings of hopelessness or isolation - Impulsive or aggressive tendencies in Stressful life event or loss leg. relationship, job, money, criminalflegal problems} - Easy access to lethal methods 0 Exposure to the suicidal behavior of others I Isolation, lack of social connectedness To better understand the circumstances that contributed to suicide in our vital signs we looked at data from 27 states. We found that more than half of people who died by suicide did not have a known mental health condition and that many factors contribute to suicide among those with and without a mental health condition, including: 42% relationship problems 29% crisis in the past or upcoming two weeks 28% problematic substance abuse 22% physical health problem 16% jobffinancial problem 9% legal problem 4% loss of housing 00000 The presence of any one of these factors does not mean someone is thinking about suicide or will attempt suicide. Researchers agree that suicidal behavior results from an interaction of factors and is rarely due to a single cause. How do I know if someone is at high risk of making a suicide attempt? The warning signs for suicide are: . Expressing hopelessness 0 Increased anger or rage - Extreme mood swings - Sleeping too little or too much 0 Making plans for suicide 0 Talking andfor posting about wanting to die i Feeling trapped or in unbearable pain - Increased anxiety - Securing lethal means 0 Increased substance use I Feeling like a burden I Isolation If you notice any of these signs: I Ask the question, "Are you thinking about suicide?? Asking the question won?t make someone suicidal, and instead, may relieve or reduce the feeling. 0 If the person says yes, keep them safe. Find out if they have a suicide plan. Remove any lethal means in the environment, if possible, and do not leave the person alone. - Be there and show concern. Don?t act surprised or dismiss their feelings. Take the person seriously, and do not assume they are joking. - Help them connect to resources, for example, by calling the National Suicide Prevention Lifeline [8255]) or by connecting the person to someone in the community who can help, e.g. emergency department, counselor, pastor. 0 Follow up after the person is safe, follow up in the days ahead with a phone call, ask them how they are doing. See if there is anything else that you can do. You can learn more about these steps to help by going to The way society handles suicide seems almost contradictory. When a celebrity dies this way, it is all over the news. When someone in the neighborhood or at work dies by suicide, it?s the subject of unconfirmed rumor. Certainly, the survivors and family members are in pain and want privacy, but does suicide risk and the need for help for the populous at large carry a stigma that impedes life-saving treatment? In other words, should we, as a society, be talking about suicide more as a strategy to prevent these tragic losses? Yes. We want to talk to people who may be at risk and we want to have the conversation more broadly. People should know that talking about suicide does not cause suicide to occur or put the thought in someone?s head. I In fact, it can be an excellent prevention tool. 0 Talking breaks the secrecy and shame that surrounds suicidal behavior and lets people know that help and hope are available. a By not talking about suicide, we increase the isolation and despair of individuals thinking about it and perpetuate the stigma associated with suicidal ideation and seeking help. More broadly speaking, conversation about suicide prevention is good. However, safe messaging about suicide is imperative. For example, we should be sure to provide messages of hope and resilience and assure people that help is available and that suicide is preventable. Upstream prevention is important and can be used in messaging about? preventing risk from occurring the first place by communicating and being aware ofthe warning signs discussed previously for suicide (expressing hopelessness, sleeping too little or too much, increased anxiety, isolation] and if you notice someone acting these ways, taking action by talking to them, validating their feelings and connecting them to help. Messaging related to activities are also important. How to speak to those at increased risk and how to prevent further re?attempts. Be there for the person at risk, follow up and check on them and help connect them to suicide prevention resources or counseling. There are also recommendations for the media regarding how to report on suicide to raise awareness without increasing the risk of additional suicides among vulnerable populations. We know that risk can increase when the media provides details about the methods used, dramatic/graphic headlines, or glamorize a death (see reportingonsuicideorg). We?ve talked a lot about risk and some barriers to suicide prevention like stigma, so let?s turn the focus to saving lives. How can the CDC help public health professionals help their communities reduce the potential for suicide among their residents? What programs should public health professionals consider? I CDC suggests a public health approach to suicide prevention that focuses more broadlv on the opportunities to reduce risk as opposed to focusing exclusively on mental health conditions. This can result in a broader impact and reach more people at risk. There is also the issues of stigma around suicide and mental health care, which discourages people at risk for self-harm from seeking help. Suicide is preventable, but we need sufficient investment and a comprehensivepublic health approach. 0 Such strategies include both upstream prevention to prevent risk from occurring in the first place, such as promoting connectedness, as well as more activities responsive to the needs of people at increased risk and to prevent re?attempts through treatment interventions. In 2017 CDC released, Preventing Suicide: A technical package of policy, programs, and practices. A technical package is a core set of strategies that have the best available evidence to prevent a public health problem, like suicide. They can help improve the health and well- being of communities. I The technical package for suicideprevention includes 7 strategies designed to work together to achieve the greatest impact possible. The strategies are presented in order from those with the greatest potential toproduce broad public health impact on suicide followed bv those with potential to impact subsets of the population persons who have alreadv made a suicide attemptl. The seven strategies are: i. Strengthen economic supports ii. Strengthen access and delivery of suicide care Create protective environments iv. Promote connectedness v. Teach coping and problem?solving skills vi. ldentifv and support people at risk vii. Lessen harms and prevent future risk Together these strategies represent a comprehensive approach to suicide prevention. One example from the technical package of a successful program is The United States Air Force Suicide Prevention Program. This program, (which includes 11 policy and education initiatives designed to increase social support, social skills, and help?seeking) shifted the culture of the Air Force away from viewing suicide as an individual-oriented mental health concern to a larger, service-wide problem impacting the whole community. After the program was begun, the Air Force saw a 33% reduction in suicide as well as reductions in other related problems, such as severe family violence and homicide And for members of the public who are listening, what can they do to protect their own families and their loved ones, or even their neighbors or colleagues? No matter what problems people deal with, we want to help them find a reason to keep living. By calling 1-800-273-TALK {8255} people will be connected to a skilled, trained counselor at a crisis center in their area, anytime 24,17. There are many success stories and stories of hope where people in need have reached out and family or friends have intervened to get people help. They got the support they needed and were able to get through a crisis and go on to live productive and fulfilling lives. Given the wide range of factors that contribute to suicide, this would seem to be a problem not easily solved? - While it?s true that suicide does not have one cause, this means that there are multiple opportunities for prevention and everyone has a role. For its part The Federal government is Tracking the problem to describe trends, circumstances, and populations at greatest risk {for example, see Developing, implementing, and evaluating suicide prevention strategies. Working with local, state, tribal, national, and other partners to provide guidance and distribute suicide prevention tools (for example, see States and communities can implement the seven strategies from the technical package. Identify and support people at risk of suicide. Teach coping and problem?solving skills to help people manage challenges with relationships, jobs, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. Ekpa nd options for temporary assistance for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a loved one to suicide. Health care systems can Provide high quality, ongoing care focused on patient safety and suicide prevention. Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. Employers can Promote employee health and well-being, support employees at risk, and have plans in place to respond to people showing warning signs. Encourage employees to seek help, and provide referrals to mental health, substance use disorder, legal, or financial counseling services as needed Everyone can Ask someone you are worried about if they?re thinking about suicide. Keep them safe. Reduce access to lethal means for those at risk. Be there with them. Listen to what they need. Help them connect with ongoing support like the Lifeline (1-800-273-3255). Follow up to see how they're doing. Find out how this can save a life by visiting: Looking at this report, and the disturbing trend the numbers illustrate, what is the outlook? Is there any reason to be optimistic about the future? Yes, the reason to be optimistic is that Suicide is preven table and we have strategies that work. Implementing a comprehensive approach to suicide prevention as laid out in our technical package and with everyone playing a role, we can strive to reach our national goal which is to reduce suicide 20% by 2025. If you or someone you know is thinking about suicide or needs support, help is always available. Call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255] or visit From: fo=cdcfou=exchange administrative group Sent: 2 Aug 2018 02:32:21 +0000 To: Daniel, Valerie M. (CDCIDNDIEHINCIPQ Subject: RE: ADS Review: ASTHO Podcast Hi Val, I'm at an all day meeting tomorrow and so can?t work on this again until tomorrow night probably. From: Simon, Thomas Sent: Wednesday, August 1, 2018 5:15 PM To: Daniel, Valerie M. Stone, Deborah (CDCIONDIEHINCIPC) Cc: Black, Erin Subject: RE: ADS Review: ASTHO Podcast 0k, thank you both for clarifying and for continuing to work on this. It is already much better. From: Daniel, Valerie M. Sent: Wednesday, August 1, 2018 12:32 PM To: Stone, Deborah Simon, Thomas (t 59 cdc. ova- Cc: Black, Erin (e m? cdc. ova- Subject: RE: ADS Review: ASTHO Podcast Deb and Tom, lput in some more messaging based on Deb?s last version. Deb Stone, not Houry will be speaking on the ASTHO podcast. Sorry for the confusion. Too many Deb?s As for the wording of the questions, they were provided by ASTHO who were shocked we had to clear Deb?s content in order to participate guess NCEZID or some other center who had an SME participate on a past podcast didn?t require this clearance, but I explained every Center was different) so they put together some questions for her to answer. I think it?s fine to provide edits back. Let me know what you all think of the attached. Thanks, Valerie From: Stone, Deborah Sent: Tuesday, July 31, 2018 10:56 PM To: Simon, Thomas (CDCXONDIEHXNCIPC) Black, Erin Cc: Daniel, Valerie M. uh8 cdc. ova Subject: RE: ADS Review: ASTHO Podcast Hi Tom, Thanks for your review. I?m actually doing the podcast though unless something has changed that I don?t know about {which would be fine]! Taking your comments, I went ahead and added some stuff and moved some stuff around. It?s not done yet but see what you think so far. Deb From: Simon, Thomas Sent: Tuesday, July 31, 2018 6:13 PM To: Black, Erin Cc: Daniel, Valerie M. Stone, Deborah Subject: RE: ADS Review: ASTHO Podcast Hi Erin and Valerie, I added some edits in the version attached. Deb Houry has not spoken much publicly about suicide prevention and I think this is a good opportunity to help her ?own? this content. We need to provide her with a strong document and there are a couple of places where the content could be improved. In particular, the results from the VS were not fully described. I added some bullets there to address this. I think the most important issue that still needs to be addressed is to tighten the prevention messages for her. I don?t think we should simply use the lists from the fact sheet and TP. I think this needs to be more conversational. I'm also concerned because the text includes the 7 strategies from the TP twice (once under ?states and communities can" and once when talking about the TP) and doesn?t explain them in either place. I like the inclusion of some examples. I?m not sure the two selected are the best to use though. There are some that are more compelling because they have great results or will resonate with this audience. For example, the Air Force example is good because it demonstrates the value of a comprehensive approach and has effects that go beyond suicide prevention. I?m ccing Deb Stone because she likely has ideas for how to tighten the prevention points. I hope this is helpful. ?Tom From: Black, Erin Sent: Friday, July 27, 2018 9:20 AM To: Simon, Thomas Cc: Daniel, Valerie M. uh8 cdc. ov) Subject: FW: ADS Review: ASTHO Podcast Meant to copy 'v'al! From: Black, Erin Sent: Friday, July 2018 9:19 AM To: Simon, Thomas (CDCIONDIEHXNCIPCII ?it 59 cdc. ov> Subject: ADS Review: ASTHO Podcast Tom not sure if I should send this to you or Cory, let me know. Attached is the ASTHO podcast Question Val used the pre-cleared lvital Signs on suicide to pull from when preparing responses to the questions. This has been reviewed by Deb, me, and MaliaXHeather for policy. We are trying to get this cleared in time for Deb's recording of the podcast on August 6th at 2pm. Thanks, Erin From: Daniel, Valerie M. Sent: 1 Aug 2018 12:32:28 -0400 To: Stone, Deborah Thomas Cc: Black, Erin Subject: RE: ADS Review: ASTHO Podcast Attachments: ASTHO Suicide Podcast_v3 ds vd.docx Deb and Tom, I put in some more messaging based on Deb?s last version. Deb Stone, not Houry will be speaking on the ASTHO podcast. Sorry for the confusion. Too many Deb?s As for the wording of the questions, they were provided by ASTHO who were shocked we had to clear Deb?s content in order to participate guess NCEZID or some other center who had an SME participate on a past podcast didn't require this clearance, but I explained every Center was different) so they put together some questions for her to answer. think it?s fine to provide edits back. Let me know what you all think of the attached. Thankg Valerie From: Stone, Deborah Sent: Tuesday, July 31, 2018 10:56 PM To: Simon, Thomas Black, Erin Cc: Daniel, Valerie M. Subject: RE: ADS Review: ASTHO Podcast Hi Tom, Thanks for your review. i?m actually doing the podcast though unless something has changed that I don?t know about {which would be fine]! Taking your comments, I went ahead and added some stuff and moved some stuff around. It?s not done yet but see what you think so far. Deb From: Simon, Thomas (CDCKONDIEHINCIPC) Sent: Tuesday, July 31, 2018 6:13 PM To: Black, Erin Cc: Daniel, Valerie M. Stone, Deborah <2af9@cdc.gov> Subject: RE: ADS Review: ASTHD Podcast Hi Erin and Valerie, I added some edits in the version attached. Deb Houry has not spoken much publicly about suicide prevention and I think this is a good opportunity to help her "own? this content. We need to provide her with a strong document and there are a couple of places where the content could be improved. In particular, the results from the VS were not fully described. I added some bullets there to address this. I think the most important issue that still needs to be addressed is to tighten the prevention messages for her. I don?t think we should simply use the lists from the fact sheet and TP. I think this needs to be more conversational. I?m also concerned because the text includes the 7 strategies from the TP twice (once under "states and communities can? and once when talking about the TP) and doesn?t explain them in either place. I like the inclusion of some examples. I?m not sure the two selected are the best to use though. There are some that are more compelling because they have great results or will resonate with this audience. For example, the Air Force example is good because it demonstrates the value of a comprehensive approach and has effects that go beyond suicide prevention. I?m ccing Deb Stone because she likely has ideas for how to tighten the prevention points. I hope this is helpful. -Tom From: Black, Erin Sent: Friday, July 27, 2018 9:20 AM To: Simon, Thomas Cc: Daniel, Valerie M. Subject: FW: ADS Review: ASTHO Podcast Meant to copy Val! From: Black, Erin Sent: Friday, July 2013 9:19 AM To: Simon, Thomas (t 59 cdc. ov> Subject: ADS Review: ASTHD Podcast Tom A not sure if I should send this to you or Cory, let me know. Attached is the ASTHD podcast Question Val used the pre-cleared Vital Signs DELA on suicide to pull from when preparing responses to the questions. This has been reviewed by Deb, me, and Malia/?Heather for policy. We are trying to get this cleared in time for Deb's recording of the podcast on August 5th at 2pm. Thanks, Erin NCIPC DC Clearance: DVP ADS Clearance: DVP Policy Review: Malia Richmond?Crum, Heather Dennehy NZE-IIB DVP HCET Review: Erin Black, 7724218 DVP SME Review: Deb Stone 1723/18 ASTHO Suicide Podcast Questions for CDC guest Your Vital Signs report tracks suicide rates over an 18?year EJerioci 1999-2016, and finds that suicide is on the rise. What's happening? I Suicide is a public health brobleni. Nearly 45,000 lives were lost to suicide in 2010, which is approximately one suicide every 12 minutes. Suicide and nonfatal self?harm injuries cost more than $69 billion annually in direct medical and work loss costs. Suicide is one ofjust three leading causes of death that are on the rise. We found that suicide rates increased in nearly every state across the nation. 25 states had increases greater than 30981 Do we know what is contributing to these increases? 3 ,years not 10. Comment Tom, fine to provide Ii edits to the questions. ASTHD drafted if ,them. 1 . Comment ISTU: I?m requesting edits ,here to provide the V5 results. 1 Comment ISDU: I like these. lthinlt IComment Idon?t understand why this was written iike this. The period of the MMWR was 1999-2016 and this is 13 JL say something like, What?s happening unfortunately is that suicide is a growing public health problem. Our Signs report indicated that In 2016, 45000 people lost their lives to suicide and over the period 1999-2016 suicide increased in nearly every state. In fact rates increased by more than 30% in half of all US states. We know that suicide is just the tip of the iceberg. Many more people attempt suicide or think about suicide than actually die. In fact, suicide and self-harm injuries cost the nation more than $69 billion in 2016. Then I might wait for the question again about increases and go into the next section. Can we ask for the question to be While the Vital Statistics data are great for describing trends they don't tell US about the causal factors that are driving the increases. We do know that suicide is not caused by any one factor, but instead, it is typically caused by a combination of individual, relationship, community, and societal factors. Several factors could be contributing to the increases: Economic conditions The role of the great recession in the late 2000?s and subsequent financial challenges and concerns about economic instability could have contributed to increases in suicide risk. Past research on the association between business cycles and U.S. suicide rates indicates that the overall suicide rate rises and falls in connection with the economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by parents may trickle down resulting in vulnerable youth. Opioid epidemic kinserted here? When there is an increased availability and misuse of prescription opioids, we may see increases in suicide rates. Substance misuse itself is an established risk factor for suicide and, therefore, opioid misuse associated with the opioid overdose epidemic could be driving the suicide rate higher. When we look at who is dying from suicide and who is dying from unintentional overdoses involving opioids, we see that there is overlap in the demographics of the populations most highly affected by suicide and unintended opioid overdose deaths. Social media More research is needed on the impact of social media use on suicide rates. However, changes in social media content or use patterns could potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. Rural While there have been increases and decreases in suicide rates over time, research shows that rates across cities and towns in the United States have been rising, with rural areas experiencing the most increases. The increased rates may be associated with suicide risk factors that are more common in less urban areas, such as limited access to mental healthcare as well as greater social isolation. Let?s explore the factors that can play' into a person?s decision to take his or her own life. What are they? Many people think that suicide is an unexplainable act, when, in reality, many known factors increase risk. These include: 0 History of previous suicide attempts in Family history of suicide History of child abuse and neglect or other adverse childhood experiences History of depression or other mental illness Alcohol or drug abuse I Feelings of hopelessness or isolation - Impulsive or aggressive tendencies in Stressful life event or loss leg. relationship, job, money, criminalflegal problems} - Easy access to lethal methods 0 Exposure to the suicidal behavior of others I Isolation, lack of social connectedness To better understand the circumstances that contributed to suicide in our vital signs we looked at data from 2? states. We found that more than half of people who died by suicide did not have a known mental health condition and that manv factors contribute to suicide among those with and without a mental health condition, including 42% relationship 29% crisis in the past or upcoming two weeks 28% problematic substance abuse 22% phvsical health problem 16%jobg'financial problem 9% legal problem 4% loss of housing The presence of anv one of these factors does not mean someone is thinking about suicide or will attempt suicide. Researchers agree that suicidal behavior results from an interaction of factors and is rarelv due to a single cause. How do I know if someone is at high risk of making a suicide attempt? The warning signs for suicide are: Expressing hopelessness - Increased anger or rage - Extreme mood swings in Sleeping too little or too much . Making plans for suicide 0 Talking and/or posting about wanting to die I Feeling trapped or in unbearable pain - Increased amtiebyI - Securing lethal means Increased substance use 0 Feeling like a burden - Isolation If vou notice anv of these signs: - Ask the question, ?Are you thinking about suicide?? Asking the question won't make someone suicidal. and instead, mav relieve or reduce the feeling, - Ifthe person says ves. keep them safe. Find out ifthev have a suicide plan. Remove anv lethal means in the environment, if possible, and do not leave the person alone. I Be there and show concern. Don't act surprised or dismiss their feelings. Take the person seriouslv, and do not assume they arejoking. 0 Help them connect to resources, for example, by calling the National Suicide Prevention Lifeline (8255)} or by connecting the person to someone in the communitv who can help, e.g. emergency.r department, counselor, pastor. (Comment 1504]: Moved this here 1 Follow up after the person is safe, follow up in the days ahead with a phone call, ask them how they fFl: 5 are doing. See if there is anything else that you can do. a You can learn more about these steps to help by going to The way society handles suicide seems almost contradictory. When a celebrity dies this way, it is all over the news. When someone in the neighborhood or at work dies by suicide, it's the subject of unconfirmed rumor. Certainly, the survivors and family members are in pain and want privacy, but does suicide risk and the need for help for the populous at large carry a asking abbot whether in general as a population we should be discussing directly below buti think this question is also about messaging about Suicide and Comment Deb, I built in some 1 ommenl I thinkthis question is uicide prevention more and raising wareness etc..l can make the point making sure we are doing so safely in the media but also in our awareness activities etc.. We need to provide messages of hope. talk about helping resources. and Lhow to prevent suicide. more language about this. Feel free to stigma that impedes life?saving treatment?n other words, should we, as a society, be talking about suicide more as a strategy to prevent these tragic losses. . Yes. First off people should know that talking about suicide does not cause suicide to occur or put the thought in someone's head. In fact, it can be an excellent prevention tool. 0 Talking breaks the secrecy and shame that surrounds suicidal behavior and lets people know that help and hope are available. By not talking about suicide, we increase the isolation and despair of individuals thinking about it and perpetuate the stigma associated with suicidal ideation and seeking help. More broadly speaking, conversation about suicide prevention is good. However, safe messaging about suicide is imperative. For example, we should be sure to provide messages of hope and assure people that help is available and that suicide is preventable. Upstream prevention is important and can be used in messaging about- preventing risk from occurring the first place by communicating and being aware of the warning signs discussed previously for suicide {expressing hopelessness, sleeping too little or too much. increased anxiety, isolation} and if you notice someone acting these ways, taking action by talking to them, validating their feelings and connecting them to help. Messaging related to activities are also important. How to speak to those at increased risk and how to prevent further Be therefor the person at risk, follow up and check on them and help connect them to suicide prevention resources or counseling. There are also recommendations for the media regarding how to report on suicide to raise awareness without increasing the risk of additional suicides among vulnerable populations. We know that risk can increase when the media provides details about the methods used, dramatic/graphic headlines, or glamorize a death [see reportingonsuicide.org}. We?ve talked a lot about risk and some barriers to suicide prevention like stigma, so let?s turn the focus to saving lives. How can the CDC help public health professionals help their communities reduce the potential for suicide among their residents? What programs should public health professionals consider? tedit or tweak as needed. [lo address the full range of contributing factors to suicide. comprehensive suicide prevention activities are needed. 0 so: stretscies.ins!U.dseeth teat-event rissftercesserrins in the first place as well as more activities responswe to the needs ol people at increased risi-z and to prevent re-attempg] I EDI: suggests a public health approach to suicide prevention focuses more hroa_dly on the opportunities to reduce risk as opposed to focusing exclusively on mental health conditions. This can result in broader import and reach more people at risk. There is also the issues of stigma around suicide and mental health caret which discourages people at risk for self-harm from seeking help. Suicide is preventable. but we need sufficient investment and a comprehensive public health approach? released a technical package of policies, programs. and practices to prevent suicide to help communities focus on a core set of strategies that have the best available evidence and greatest prevention potential. The technical package includes examples of programs that local implementers migh_t n-nna-q. tailor to ?t the needs of their community. The technical package includes 1 strategies designed to work together to achieve the greatest impact possible. I. ii. iv. v. vi. vii. Strengthen economic supports Strengthen access and delivery of suicide care Create protective environments Promote connectedness Teach coping and problem?solving skills Identify and support people at risk Lessen harms and prevent future riskl Insert Air Force example And for members of the public who are listening, what can they do to protect their own families and their loved ones, or even their neighbors or colleaguesfine since Comment Might be good to provide some examples here of upstream you discuss this previously now. Comment Would Work on this a bit more. Would talk about upstream and I i [l approaches and I I Lto technical package. comprehensive prevention then transition No matter what problems people deal with, we want to help them find a reason to keep living. By calling [8255] people will be connected to a skilled, trained counselor at a crisis center in their area, anytime 24;?7. There are many success stories and stories of hope where people in need have reached out and family or friends have intervened to get people help. They got the support they needed and were able to get through a crisis and go on to live productive and fulfilling lives. {Comment Moved this here. i I i Given the wide range of factors that contribute to suicide. this would seem to be a problem If i I not easily solved? While it's true that suicide does not have one cause, this means that there are multiple I: 0 opportunities for prevention and everyone has a role. For its part The Federal governmentg Tracking the problem to describe trends, circumstances. and populations at greatest risk (for example, i see Developing, implementing, and evaluating suicide prevention strategies. Working with local. state, tribal. national. and other partners to provide guidance and distribute suicide . I prevention tools (for example, see States and communities can implement the seven strategies from the technical package. - Identifv and Support people at risk of suicide. Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, I health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. Offer activities that bring people together so thev feel connected and not alone. 0 - Conned people at risk to effEctlve and coordinated mental and phvsical healthcare. Expand options fortemporarv assistance for those struggling to make ends meet. I Prevent future risk of suicide among those who have lost a loved one to suicide. Health care systems can Provide high nualitv, ongoing care focused on patient safety and suicide prevention. Make sure affordable and effective mental and phvsical healthcare is available where people live. 0 Train providers in adopting proven treatments for patients at risk of suicide. Emplovers can Promote employee health and well?being, support employees at risk. and have plans in place to I respond to people showing warning signs. 1 Encourage employees to seek help, and provide referrals to mental health, substance use disorder, legal, or financial counseling services as needed Everyone can Ask someone you are worried about if they?re thinking about suicide. Keep them safe. Reduce access to lethal means for those at risk. Be there with them. Listen to what they need. Help them connect with ongoing support like the Lifeline (1-800-273-8255). Follow up to see how they're doing. Find out how this can save a life by visiting: Looking at this report, and the disturbing trend the numbers illustrate, what is the outlook? is there any reason to be optimistic about the future? Yes, the reason to be optimistic is that Suicide is preven table and we have strategies that work. Implementing a comprehensive approach to suicide prevention as laid out in our technical package and with everyone playing a role, we can strive to reach our national goal which is to reduce suicide 20% by 2025. If you or someone you know is thinking about suicide or needs support, help is always available. Call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255} or visit From: Stone, Deborah Sent: 1 Aug 2018 02:56:27 +0000 To: Simon, Thomas Erin Cc: Daniel, Valerie M. Subject: RE: ADS Review: ASTHO Podcast Attachments: ASTHO Suicide Podcast_v3 ds.docx Hi Tom, Thanks for your review. I?m actually doing the podcast though unless something has changed that I don?t know about {which would be fine]! Taking your comments, I went ahead and added some stuff and moved some stuff around. It?s not done yet but see what you think so far. Deb From: Simon, Thomas Sent: Tuesday, July 31, 2018 6:13 PM To: Black, Erin Cc: Daniel, Valerie M. (CDCIDNDIEHINCIPC) Stone, Deborah Subject: RE: ADS Review: ASTHO Podcast Hi Erin and Valerie, I added some edits in the version attached. Deb Houry has not spoken much publicly about suicide prevention and I think this is a good opportunity to help her ?own" this content. We need to provide her with a strong document and there are a couple of places where the content could be improved. In particular, the results from the VS were not fully described. I added some bullets there to address this. I think the most important issue that still needs to be addressed is to tighten the prevention messages for her. I don?t think we should simply use the lists from the fact sheet and TP. I think this needs to be more conversational. I?m also concerned because the text includes the 7 strategies from the TP twice (once under ?states and communities can? and once when talking about the TP) and doesn?t explain them in either place. I like the inclusion of some examples. I?m not sure the two selected are the best to use though. There are some that are more compelling because they have great results or will resonate with this audience. For example, the Air Force example is good because it demonstrates the value of a comprehensive approach and has effects that go beyond suicide prevention. I?m ccing Deb Stone because she likely has ideas for how to tighten the prevention points. I hope this is helpful. ?Tom From: Black, Erin Sent: Friday, July 27, 2018 9:20 AM To: Simon, Thomas Cc: Daniel, Valerie M. Subject: FW: ADS Review: ASTHO Podcast Meant to copy ?v?al! From: Black, Erin Sent: Friday, July 27, 2018 9:19 AM To: Simon, Thomas Subject: ADS Review: ASTHO Podcast Tom not sure ifl should send this to you or Cory, let me know. Attached is the ASTHO podcast Question Val used the pro-cleared Vital Signs on suicide to pull from when preparing responses to the questions. This has been reviewed by Deb, me, and Malia/Heather for policy. We are trying to get this cleared in time for Deb?s recording of the podoast on August 6m at 2pm. Thanks, Erin Comment iSTil: I don?t understand why this was written like this. The period of the MMWR was 1999-2015 and this is 13 years not 10. {Comment 13TH: I'm requesting edits i db. NCIPC DC Clearance: DVP ADS Clearance: ,r Policy Review: Malia Richmond~Crum, Heather Dennehy here to provide the VS results. F(Emma-mt I like these. Ithink I'd i i say something like, What?s happening It 5 unfortunately is that suicide is a growing 5 public health problem. Our Vital Signs j' Ii report indicated that In 2015, 45000 DVP HCET Review: Erin Black, DVP SME Review: Deb Stone 103/18 ASTHO Suicide Podcast people lost their lives to suicide and over g' the period 1999-2015 suicide increased in If nearly every state. In fact rates Increased by more than 30% in half of all US states. Questions for CDC guest Your Vital Signs report tracks suicide rates over an 13-yearten-yeac iseriostg?g?gqgj?Land finds that suicide is on the rise. What's happening? We know that suicide is just the tip of the I Suicide is a public health brobierrl [\learly 45,000 lives were lost to suicide in 2015, which is approximately one suicide every 12 minutes. iceberg. Many more people attempt Suicide and nonfatal self-harm injuries cost more than $69 billion annually in suicide orthink about suicide than direct medical and work less costs. actually die. In fact, suicide and selfvharm injuries cost the nation more than $69 Suicide is one of just three leading causes of death that are on the rise. Then I might wait for the question again about increases and go into the next section. Can we ask for the question billion In 2016. i i i I found that suicide rates increased in nearly every Linserted here? state across the nation. 0 25 states had increases greater than c0 3t__5_ While the Vital Statistics data are great for describing trends they don't tell us about the causal factors that are driving the increases. We do know that suicide is not caused by any one factor, but instead, it is typically caused by a combination of individual, relationship, community, and societal factors. not haeea- lenown?aaeetai- hea ith-coeditvioerM-hi ghl-ighted-ie-oos past?Vitai ?iges?seaey 28% problematic substance abuse 22% pi?rysical bearish-problem "fit-4 Comment 15m]: This might be better placed under the next question about risk factors. And instead, here, I?d go into the next set of points on the next page related to increases. Several factors SevesaLsuehaYaetosscould be contributing to the increases: Economic conditions The role of the great recession In the late 2000?s and subsequent financial challenges and concerns about economic instability could have contributed to increases in suicide risk. Past research on the association between business cycles and U.S. suicide rates indicates that the overall suicide rate rises and falls in connection with the economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by parents may trickle down resulting in vulnerable youth. Opioid epidemic When there is an increased availability and misuse of prescription opioids, we may see increases in suicide rates. Substance misuse itself is an established risk factor for suicide and, therefore, opioid misuse associated with the opioid overdose epidemic could be driving the suicide rate higher. When we look at who is dying from suicide and who is dying from unintentional overdoses involving opioids, we see that there is overlap in the demographics of the populations most highly affected by suicide and unintended opioid overdose deaths. Social media More research is needed on the impact of social media use on suicide rates. HOWever, changes in social media content or use patterns could potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections bethEn people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. Rural While there have been increases and decreases in suicide rates over time, research shows that rates across cities and towns in the United States have been rising, with rural areas experiencing the most increases. The increased rates may be associated with suicide risk factors that are more common in less urban areas, such as limited access to mental healthcare as well as greater social isolation. Let?s explore the factors that can play into a person's decision to take his or her own life. What are they? Many people think that suicide is an unexplainable act, when, in reality, many known factors increase . These include: History of previous suicide attempts Family history of suicide History of child abuse and neglect or other adverse childhood experiences History of depression or other mental illness Alcohol or drug abuse Feelings of hopelessness or isolation Impulsive or aggressive tendencies Stressful life event or loss leg. relationship, job, money, criminalg'legal problems) Easy access to lethal methods To better understand the circumstances that contributed to suicide in our vital signs we looked at data from 2? states. We feund that more than half of people who died by suicide did not have a known mental health condition and that many factors ,a'[Commenl 181??: I don?t think you need 1 I Exposure to the suicidal behavior of others Isolation, lack of social connectedness attribute LO?L?L?leem?ste msemtlaodivtthout a mental health condom. ?ovate .J 42% relationship Enroblemsl 0000000 2.9.93 "if-"ii til Elli-J. LWP 28% problematic substance abuse 16% iobi?iinantial problem 9% legal problem sagas pm guests The presence of any one of these factors does not mean someone is thinking about suicide or will attempt suicide. Researchers agree that suicidal behavior results from an interaction of factors and is rarely due to a single cause. How do i know if someone is at high risk of making a suicide attempt? The warning signs for suicide are: Expressing hopelessness Increased anger or rage Extreme mood swings Sleeping too little or too much Making plans for suicide Talking andfor posting about wanting to Feelingtgapped or in unbearable pain complicate the list with this. Comment 151]?: Moved this here i I Increased anxiety Securing lethal means Increased substance use Feeling like a burden Isolation If you notice any of these signs: Ask the question, ?Are you thinking about suicide?? Asking the question won't make someone suicidal, and instead, may relieve or reduce the feeling. It the person says yes, keep them safe. Find out if they have a suicide plan. Remove any lethal 0 means in the environment, if possible, and do not leave the person alone. Be there and show concern. Don?t act surprised or dismiss their feelings. Take the person seriously, and do not assume they arejoking. - Help them connect to resources, for example, by calling the National Suicide Prevention Lifeline l1? BDO-ETE-TALK {8255)} or by connecting the person to someone in the community who can help, e.g. emergency department, counselor, pastor. Follow up after the person is safe, follow up in the days ahead with a phone call, ask them how they are doing. See if there is anything else that you can do. You can learn more about these steps to help by going to The way society handles suicide seems almost contradictory. When a celebrity dies this way, it is all over the news. When someone in the neighborhood or at work dies by suicide, it's the subject of uncon?rmed rumor. Certainly, the survivors and family members are in pain and want privacy, but does suicide risk and the need for help for the populous at large carry a stigma that impedes life-saving treatment?n other words, should we, as a society, be talking about suicide more as a strategy to prevent these tragic lossesil to; First off pooplt should know that tlalking about suicide does not cause suicide to occur or put the thought in someone?s head. In fact, it can be an excellent prevention tool. Talking breaks the secrecy and shame that surrounds suicidal behavior and lets people know that help and hope are avaiiable. 1 Comment I think this question is asking about whether in general as a population we should be discussing suicide prevention more and raising awareness etc..l can make the point directly below butl think this question is also about messaging about Suicide and making sure we are doing so safely in the media but also in our awareness activities etc.. We need to provide messages of hope, talk about helping resources. and khow to prevent suicidenot talking about suicide, we increase the isolation and despair of individuals thinking 0 about it and perpetuate the stigma associated with suicidal ideation and seeking helpbehavios. More broadlesEeaking, conversation about suicide p_revention is good. However,_sale messaging about suicide is imperative. For example, we should be sure to provide messages of hope and assure people that help is available and that suicide is oreventabie. are else-recommendations for the media regarding how to report on suicide to raise awareness without increasing the risk of additional suicides among vulnerabie populations. We know that risk can increase when the media provides details about the methods used, dramatic/graphic headlines, or giamorize a Comment Would work on this a death {see reportingonsuicideorg]. bit more. Would talk about upstream and approaches and comprehensive prevention then transition to technical acka e. We?ve talked a lot about risk and some barriers to suicide prevention like stigma, so let?s turn the focus to saving lives. How can the CDC help public health professionals help their communities reduce the potential for suicide among their residents? What programs should public health professionals consider? EIDC suggests a public health approach to suicide prevention that focuses more broadly on the opportunities to reduce risk as opposed to focusing exclusively on men col health conditions. This can result in a broader impact and reach more people at risk. There Is also the issues of stigma around suicrde and mental health care. which discourages people at risk for self?harm from Seeking help. Suicide is preventable, but we need sufficient investment and a comprehensive public health approach] EDC released a technical package of policies, programs, and practices to prevent suicide to help communities focus on a core set of strategies that have the best available evidence and greatest prevention potential. The technical package includes examples of programs that local implementers might tailor to fit the needs of their community. The technical package includes 3' strategies designed to work together to achieve the greatest impact possible. i. Strengthen economlsuppfq?s ii. Strengthen access and deiiverv of suicide care iv. Promote connectedness v. Teach copingand problem-solving skills vi. ldentifv and support people at risk vii. Lesson harms and prevent futu_r_e_r_i_s_l51 Insert Ac Fete: example And for members of the public who are listening, what can they do to protect their own families and their loved ones, or even their neighbors or colleagues? No matter what problems people deal with, we want to help them find a reason to keep living. Bv calling [82551 people will be connected to a skilled, trained counselor at a crisis center in their area, anytime 24/71 There are manv success stories and stories of hope where people in need have reached out and familv or friends have intervened to get people help. They got the support they needed and were able to get through a crisis and go on to live productive and fulfilling lives. Given the wide range of factors that contribute to suicide, this would seem to he a problem For its part The Federal governmentg Tracking the problem to describe trends, circumstances, and populations at greatest risk (for example, not easily solved? While it?s true that suicide does not have one cause, this means that there are multiple opportunitLes for prevention and evervone has a role. hreadlyon-the-eppertunities to?teduce?rislt?t?he reseaeeh?tells werk?te?pseveet?it: -. tefewsmexdusWeW?WEMM impact alsethe issues oi stigma -arou-nd?seicideand mentalrheelth care; which?diseaoregespeepleatrisk? ioeself?harm fronrseeking?helo -Seieide?is J[Imminent [Sill]: Moved this heresee rs). Developing, implementing, and evaluating suicide prevention strategies. Working with local, state, tribal, national, and other partners to provide guidance and distribute suicide prevention tools {for example, see States and communities can implement the seven strategies from the technical package. Identifv and support people at risk of suicide. Teach coping and problem?solving skills to help people manage challenges with relationships, jobs, health, or other concerns. Promote safe and supportive environments. This includes safelyr storing medications and firearms to reduce access among people at risk. Offer activities that bring people together so they feel commuted and not alone. I Connect people at risk to effective and coordinated mental and phvsical healthcare. Expand options for temporary assistance for those struggling to make ends meet. Prevent future risk ofsuicide among those who have lost a loved one to suicide. Health care systems can Provide high quality, ongoing care focused on patient safety and suicide prevention. 0 Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. Employers can Promote employee health and well-being, support employees at risk, and have plans in place to respond to people showing warning signs. Encourage employees to seek help, and provide referrals to mental health, substance use disorder, legal, or financial counseling services as needed Everyone can I- Ask someone you are worried about if they?re thinking about suicide. - Keep them safe. Reduce access to lethal means for those at risk. 0 Be there with them. Listen to what they need. 0 Help them connect with ongoing support like the Lifeline 0 Follow up to see how they?re doing. I Find out how this can save a life by visiting: Looking at this report, and the disturbing trend the numbers illustrate, what is the outlook? Is there any reason to be optimistic about the future? Yes, the reason to be optimistic is that Suicide is preventable and we have strategies MWwarA-s. Implementing a comprehensive approach to suicide prevention as laid out in our technical package and with everyone playing a role, we can strive to reach our national goal which is to reduce suicide 20% by 2025. If you or someone you know is thinking about suicide or needs support, help is always available. Call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255} or visit From: fo=cdcfou=exchange administrative group rysearchmailb Sent: 1 Aug 2018 01:51:45 +0000 To: Simon, Thomas Erin Cc: Daniel, Valerie M. Subject: RE: ADS Review: ASTHO Podcast Hi Tom, Thanks for your review. I?m actually doing the podcast though unless something has changed that I don?t know about {which would be fine]! I made some additional comments in the document. I didn?t have time to add as much as Iwanted because I have to go to bed. Mostly ljust moved some things around. I agree that the air force program is good to highlight. From: Simon, Thomas Sent: Tuesday, July 31, 2018 6:13 PM To: Black, Erin Cc: Daniel, Valerie M. (CDCIONDIEHINCIPC) Stone, Deborah Subject: RE: ADS Review: ASTHO Podcast Hi Erin and Valerie, I added some edits in the version attached. Deb Houry has not spoken much publicly about suicide prevention and I think this is a good opportunity to help her ?own" this content. We need to provide her with a strong document and there are a couple of places where the content could be improved. In particular, the results from the VS were not fully described. I added some bullets there to address this. I think the most important issue that still needs to be addressed is to tighten the prevention messages for her. I don?t think we should simply use the lists from the fact sheet and TP. I think this needs to be more conversational. I?m also concerned because the text includes the 7 strategies from the TR twice (once under ?states and communities can? and once when talking about the TP) and doesn?t explain them in either place. I like the inclusion of some examples. I?m not sure the two selected are the best to use though. There are some that are more compelling because they have great results or will resonate with this audience. For example, the Air Force example is good because it demonstrates the value of a comprehensive approach and has effects that go beyond suicide prevention. I?m ccing Deb Stone because she likely has ideas for how to tighten the prevention points. I hope this is helpful. ?Tom From: Black, Erin Sent: Friday, July 27, 2018 9:20 AM To: Simon, Thomas Cc: Daniel, Valerie M. Subject: FW: ADS Review: ASTHO Podcast Meant to copy ?v?al! From: Black, Erin Sent: Friday, July 27, 2018 9:19 AM To: Simon, Thomas Subject: ADS Review: ASTHO Podcast Torn not sure ifl should send this to you or Cory, let me know. Attached is the ASTHO podcast Question Val used the ore-cleared Vital Signs on suicide to pull from when preparing responses to the questions. This has been reviewed by Deb, me, and Malia/Heather for policy. We are trying to get this cleared in time for Deb?s recording of the podoast on August 6m at 2pm. Thanks, Erin From: fo=cdcfou=exchange administrative group rysearchmailb Sent: 31 Jul 2018 23:37:20 +0000 To: Simon, Thomas Erin Cc: Daniel, Valerie lvl. Subject: RE: A05 Review: ASTHO Podcast Hi Tom, I'm actually doing the podcast, not Deb Houry! I can work on fixing this up but From: Simon, Thomas Sent: Tuesday, July 31, 2018 6:13 PM To: Black, Erin Cc: Daniel, Valerie M. Stone, Deborah Subject: RE: ADS Review: ASTHO Podcast Hi Erin and Valerie, I added some edits in the version attached. Deb Houry has not spoken much publicly about suicide prevention and I think this is a good opportunity to help her ?own" this content. We need to provide her with a strong document and there are a couple of places where the content could be improved. In particular, the results from the VS were not fully described. I added some bullets there to address this. I think the most important issue that still needs to be addressed is to tighten the prevention messages for her. I don?t think we should simply use the lists from the fact sheet and TP. I think this needs to be more conversational. I?m also concerned because the text includes the 7 strategies from the TP twice (once under "states and communities can? and once when talking about the TP) and doesn't explain them in either place. I like the inclusion of some examples. I?m not sure the two selected are the best to use though. There are some that are more compelling because they have great results or will resonate with this audience. For example, the Air Force example is good because it demonstrates the value of a comprehensive approach and has effects that go beyond suicide prevention. I?m ccing Deb Stone because she likely has ideas for how to tighten the prevention points. I hope this is helpful. ?Tom From: Black, Erin Sent: Friday, July 2018 9:20 AM To: Simon, Thomas (CDCIONDIEHINCIPCJ Cc: Daniel, Valerie M. c: uh8 cdc. ov> Subject: FW: ADS Review: ASTHO Podcast Meant to copy Val! From: Black, Erin Sent: Friday, July 27, 2018 9:19 AM To: Simon, Thomas Subject: ADS Review: ASTHO Podcast Tom not sure ifl should send this to you or Cory, let me know. Attached is the ASTHO podcast Question 0.3111. Val used the ore-cleared Vital Signs (MA on suicide to pull from when preparing responses to the questions. This has been reviewed by Deb, me, and Malia/Heather for policy. We are trying to get this cleared in time for Deb?s recording of the podcast on August 6th at 2pm. Thanks, Erin From: Stone, Deborah Sent: 4 Apr 2018 13:11:02 +0000 To: Caine, Eric Subject: RE: AJPH Opinion Editorial Hi Eric, Sorry I missed your call yesterday. I had a half day meeting and then somehow missed that I had a call when I finally did get back to my office. Ok, I?m glad you are able to edit it down. My heartache has lessened. Thanks for sending when you're done. Deb From: Caine, Eric Sent: Tuesday, April 3, 2018 8:09 PM To: Stone, Deborah Subject: Re: AJPH Opinion Editorial Deb?Heartache? What?s happened? I have comments back and have begun to edit, with an to 1200 words. I will send to Alex and to you. 1 left a phone message at work today. . .but I guess you are not in the of?ce. Eric Eric D. Caine. MD. University of Rochester Medical Ctr. 300 Crittenden Blvd. Rochester. NY, USA [4642-8409 +1 585.746.3574 From: Deborah Stone <2an @cdc.goy> Date: Tuesday, April 3, 2018 at 7:37 PM To: "Caine, Eric" Subject: FW: AJPH Opinion Editorial Hi Eric, Thanks for sending along the editorial. have some comments but what's giving me heartache at the moment is that I just realized this is not in the 1200 word limit (highlighted below}. Did you think it was 1800 words? Would you still be able to revise?? Also, I'd like to have Alex review. Please let me know what you think. Deb From: Caine, Eric Sent: Tuesday, February 27, 2018 9:33 AM To: Stone, Deborah (CDCIONDIEHXNCIPQ iarrod.hindman@state.co.us; Reed, Jerry Subject: Re: AJPH Opinion Editorial Glad to, too! Eric D. Caine. MD. University of Rochester Medical Ctr. 300 Crittenden Bivd. Rochester. NY, USA 14642-8409 +1 585.746.3574 From: Deborah Stone Date: Monday, February 26, 2018 at 5:34 PM To: "Caine, Eric" Subject: AJPH Opinion Editorial Hi Guys, As you may have heard from me? others? CDC is releasing a Vital Signs on Suicide on June 5th. This is a really high profilefhigh impact publication. it includes a website, MMWR, Fact Sheet, Social Media messages, press release, telebriefing by Acting CDC Director and a Town Hall Meeting [We already have on record that the Surgeon General may participate in the telebriefing]. Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? i know you are probably tired of being singled out for all of your great work and but would the three of you or some combination of you do us the honor of writing an opinion editorial (1200 words, 7 references, )for us in AJPH about comprehensive suicide prevention and CD efforts [we can refine later but for purposes here, this is the topic]? I?m happy to set up a call to discuss but in the meantime, please see attached Vital Signs description with preliminary results [Please do not distribute or otherwise use or I?ll probably be fired). Also see recent Vital Signs {on opioids] and the companion commentary. Also, editorial is due to AJPH April So it?s coming right up. By. Look forward to hearing of your interest and thoughts. Deb Duh Stone, SCI), MSW, :?o??lPH Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers l?oir Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research 8: Evaluation Branch 4??0 Buford Highway, MS F-64 Atlanta, GA 30341 deten?@cdcaes From: Stone, Deborah Sent: 28 Feb 2018 00:08:34 +0000 To: Hindman - CDPHE, Jarrod;Reed, Jerry Cc: Caine, Eric;Betz, Marian Subject: RE: AJPH Opinion Editorial Hi Jarrod, Emmy was on the invite. If you want me to just call in to your line I?m ha py to do that and can revise the invite. Is this the number, 888.330.3581; access codeleEP Deb From: Hindman - CDPHE, Jarrod Sent: Tuesday, February 27, 2018 7:05 PM To: Reed, Jerry Cc: Stone, Deborah (CDCIONDIEHINCIPQ Caine, Eric; Betz, Marian Subject: Re: AJPH Opinion Editorial Sorry. Just saw Deb's appointment. Disregard my suggestion on the call-in. Deb - can you add Emmy to the appointment you sent? Thanks. jarrod On Tue, Feb 27, 2018 at 5:02 PM, Hindman - CDPHE, Jarrod wrote: Adding Emmy to the conversation in case she is available after our already scheduled call. We will be using the ICRC-S call for our 1 pm EDT call, so I?m wondering if we can just stay on the line and Deb can join us at 2pm Erie - does that work? jarrod On Tue, Feb 27, 2018 at 3:13 PM, Reed, Jerry rijreedgdl?edoorgra wrote: Do we have a call in it? Jerry Jerry Reed, MSW Senior iulice President for Practice Leadership Suicide, Violence 8i Injury Prevention Portfolio Lead National Action Alliance for Suicide Prevention Executive Committee Member jreed@edc.org I 202-572-3221 202-294?81321Ml I 202-223-4059 (F) Education Develo merit Center Inc. Education Development Center From: Stone, Deborah [mailto1zaf9@cdc.govl Sent: Tuesday, February 27, 2018 4:27 PM To: Reed, Jerry Hindman - CDPHE, Jarrod Ce: Caine, Erie ?Erie Caine?urmo.rochester.edu> Subject: RE: AJPH Opinion Editorial I have another call that ends two late if that's ok. But agree with hard stop at 3. Deb From: Reed, Jerry Sent: Tuesday, February 27, 2018 3:13 PM To: Stone, Deborah Hindman - CDPH E, Jarrod Cc: Caine, Eric Subject: RE: AJPH Opinion Editorial I could do Friday at 2PM. Hard stop at 3. And Had start at 2. Best, Jerry Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide, Violence 8t Injury Prevention Portfolio Lead National Action Alliance for Suicide Preyention Esecutiye Committee Member jreed@edc.org 202-5?2-3??1 I 202-294-8132 202-223-4059 duration Develo ment Center Inc. Education EDC Development Center From: Stone, Deborah (CDCIONDIEHKNCIPQ Sent: Tuesday, February 27, 2018 2:53 PM To: Hindman CDPHE, Jarrod Cc: Caine, Erie Cc: Caine, Eric Subject: Re: AJPH Opinion Editorial EIGlad to, too! Eric D. Caine, MD. University of Rochester Medical Ctr. 300 Crittenden Blvd. Rocltester. NY. USA 14642-8409 +1 585.746.35?4 From: Deborah Stone Date: Monday, February 26, 2018 at 5:34 PM To: "Caine, Eric" wrote: Do we have a call in Jerry Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide, Violence at Injury Prevention Portfolio Lead National Action Alliance For Suicide Prevention Exeeuliue Committee Member 2(l2-294-8l32 2(12-223-4059 Education Development Center, Inc. Educanon Development Center From: Stone, Deborah Sent: Tuesday, February 27, 2018 4:27 PM To: Reed, Jerry Hindrnan - CDPHE, Jarrod Ce: Caine, Eric Subject: RE: PH Opinion Editorial 1 have another call that ends two late if that?s ok. But agree with hard stop at 3. Deb From: Reed, Jerry Sent: Tuesday, February 27, 2018 3: 3 PM To: Stone, Deborah Hindman - CDPHE, Jarrod state.co.ns> Cc: Caine, Eric Cc: Caine, Erie wrote: Fabulous! Assuming Jarrod is on board as well. until I hear differently! Do any ofthese times work (all EST) to meet this week? Also. wanted to discuss some CDC Foundation stuff as well. I had a follow-up call with them today after our last CNC meetingThurs [0 am 1 pm I Friday anytime except pm Deb From: Caine, Eric [mailto:Erie Cainefd?JURMC.Roehester.edu] Sent: Tuesday, February 27, 2018 9:33 AM To: Stone, Deborah <2an diode. I0v}; jarred.hindman@state.eo.us; Reed, Jerry <'reed diedeor 3* Subject: Re: AJPH Opinion Editorial ?flGlad to, too! Eric D. Caine, MD. University of Rochester Medical Ctr. 300 Crittenden Blvd. Rochester, NY, USA 14642-8409 +1 535.146.3574 From: Deborah Stone <2an (Dede. ov> Date: Monday, February 26, 2018 at 5:34 PM To: "Caine, Eric? Subject: PH Opinion Editorial Hi Guys, As you may have heard from me? others? CDC is releasing a Vital Signs on Suicide on June This is a really high pro?lefhigh impact publication. It includes a website, MMWR, Fact Sheet. Social Media messages, press release. telebrie?ng by Acting CDC Director and a Town Hall Meeting (We already have on record that the Surgeon General may participate in the telebrie?ng). Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? I know you are probably tired of being singled out for all of your great work and perspectives. . .(sorry!) but would the three of you or some combination of you do us the honor of writing an opinion editorial (1200 words. 7 references. for us in AJ PH about comprehensive suicide prevention and CO efforts [we can re?ne later but for purposes here, this is the topic]? I?m happy to set up a call to discuss but in the meantime, please see attached Vital Signs description with preliminary results (Please do not distribute or otherwise use or I?ll probably be ?red). Also see recent Vital Signs (on opioids) and the companion commentary. Also. editorial is due to AJPH April So it?s coming right up. Oy. Look forward to hearing of your interest and thoughts. Deb Deb Stone, MSW, MPH Behavioral Scientist Suicide. 1Youth Violence. and Elder Mallreabnenl Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research Evaluation Branch 4770 Buford Highway, MS F-64 Atlanta, GA 3034] ??0.488.3942 dstone3 {Elicde gov Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch 303.692.2539 303.691.7901 4300 Cherrv Creek Drive South, Denver CO 30246 Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch El 303.692.2539 303.691.7901 4300 Cherry Creek Drive South. Denver CO 80246 iarrod.hindmana?stateeous Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention?Mental Health Promotion Branch El 303.692.2539 IF 303.691.7901 4300 Cheny Creek Drive South, Denver CO 80246 iarrod.hindman@state.co.us From: Betz, Marian Sent: 23 Feb 2018 00:04:06 +0000 To: Reed, Jerrv,?Hindman - CDPHE, Jarrod Cc: Stone, Deborah Eric Subject: Re: AJPH Opinion Editorial Works for me. but with hard stop 245 for me {3pm meeting elsewhere) Get Outlook for Android From: Hindman - CDPHE, Jarrod Sent: Tuesday, February 27, 5:02 PM Subject: Re: AJPH Opinion Editorial To: Reed, Jerry Cc: Stone, Deborah (CDCIONDIEHINCIPC), Caine, Eric, Betz, Marian Adding Emmyr to the conversation in case she is available after our already scheduled call. We will be using the ICRC-S call for our 1pm EDT call, so I?m wondering if we can just stay on the line and Deb can join us at 2pm Eric - does that work? jarrod On Tue, Feb 27, 2018 at 3:13 PM, Reed, Jerry wrote: Do we have a call in Jerry Jerry Reed. MSW Senior Vice President for Practice Leadership Suicide, Violence Injury Prevention Portfolio Lead National Action Alliance for Suicide Prevention Executive Committee Member ireedt?ledcorq 202-572-3??1 (0) 202-294-8132 (M) 202-223-4059 (F) Education Development Center, Inc. From: Stone, Deborah (CDCIONDIEHINCIPC) Sent: Tuesday. February 2018 4:2? PM To: Reed, Jerry Hindman - CDPHE, Jarrod Cc: Caine, Eric Subject: RE: AJPH Opinion Editorial have another call that ends two late if that?s ok. But agree with hard stop at 3. Deb From: Reed, Jerry Sent: Tuesday, February 27, 2018 3:13 PM To: Stone, Deborah Hindman - CDPHE, Jarrod siarrod.hindman@state.co.us> Cc: Caine, Eric Subject: RE: AJPH Opinion Editorial I could do Friday at 2PM. Hard stop at 3. And Had start at 2. Best, Jerry Jerry Reed. MSW Senior Vice President for Practice Leadership Suicide, Violence Injury Prevention Portfolio Lead National Action Alliance for Suicide Prevention Executive Committee Member ireed@edc.oro 202-572-3?T?i (D) 202-294-8132 (M) 202-223-4059 (F) Education Development Center, Inc. EDC Development Center From: Stone, Deborah (CDCIONDIEHINCIPC) Sent: Tuesday, February 27, 2018 2:53 PM To: Hindman - CDPHE, Jarrod Cc: Caine. Eric Subject: RE: AJPH Opinion Editorial Great, thanks Jarrod! i can do Friday at 2 if everyone else is free. Deb From: Hindman - CDPHE, Jarrod Sent: Tuesday. February 27. 2018 2:35 PM To: Stone, Deborah (CDCIONDIEHINCIPC) <2an cdc. ov> Cc: Caine, Eric Subject: Re: AJPH Opinion Editorial I'm in, sorry for my late reply. Of the times you noted for a callThurs at 1pm - Friday at 2pm Deb - Jerry, Eric, Emmy and I already have a call on the books for Friday at 1, so perhaps 2pm might work well? Would be great to include Emmy as well if possible. Jarrod On Tue. Feb 2018 at 9:41 AM, Stone, Deborah wrote: Fabulous! Assuming Jarrod is on board as well, until I hear differently! Do any of these times work (all EST) to meet this week? Also, wanted to discuss some CDC Foundation stuff as well. I had a follow-up call with them today after our last CNC meetingThurs 10 am Thurs 1 pm - Friday anytime except 1-2 pm Deb From: Caine, Eric [mailto:Eric Caine@URMC.Roohesteredul Sent: Tuesday, February 2018 9:33 AM To: Stone, Deborah (CDCIONDIEHINCIPQ <2an ads. or); iarrod.hindman@state.co.us; Reed, Jerry Date: Monday, February 26, 2018 at 5:34 PM To: "Caine, Erio" Subject: AJ PH Opinion Editorial Hi Guys, As you may have heard from me? others? CDC is releasing a Vital Signs on Suicide on June This is a really high pro?lefhigh impact publication. It includes a website, MMWR, Fact Sheet, Social Media messages, press release, telebriefing by Acting CDC Director and a Town Hall Meeting (We already have on record that the Surgeon General may participate in the telebrie?ng). Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? I know you are probably tired of being singled out for all of your great work and but would the three of you or some combination of you do us the honor of writing an opinion editorial (1200 words, 7" references. )for us in AJPH about comprehensive suicide prevention and CO efforts [we can refine later but for purposes here, this is the topic]? I'm happy to set up a call to discuss but in the meantime. please see attached Vital Signs description with preliminary results (Please do not distribute or othenivise use or I'll probably be fired). Also see recent Vital Signs (on opioids) and the companion commentam. Also, editorial is due to AJPH April 5th!! So it's coming right up. 0y. Look fonivard to hearing of your interest and thoughts. Deb Deb Stone, MSW, MPH Behavioral Scientist Suicide. Youth Violence. and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research ti Evaluation Branch 4770 Buford Highway, MS F-64 Atlanta, GA 30341 dstone3@cdc.gov Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch 303.692.2539 303.691.?901 4300 Cherrv Creek Drive South. Denver CO 80246 iarrod.hindman@state.oo.us Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch 303.692.2539 303.691.7901 4300 Cherry Creek Drive South, Denver CO 30246 iarrod.hindman@state.co.us From: Hindman - CDPHE, Jarrod Sent: 27 Feb 2018 17:02:14 0700 To: Reed, Jerry Cc: Stone, Deborah Erie;Betz, Marian Subject: Re: AJPH Opinion Editorial Adding Emmy to the conversation in ease she is available after our already scheduled call. We will be using the ICRC-S call for our lpin EDT call, so I?m wondering if we can just stay on the line and Deb can join us at 2pm Erie does that work? jarred On Tue, Feb 27, 2018 at 3: 13 PM, Reed, Jerry wrote: Do we have a call in it? Jerry Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide, Violence ti Injury Prevention Portfolio Lead National Action Alliance for Suicide Prevention Executive Committee Member ireed?edenre 202-571-3??1 202-294-3132 202-223-4059 Education Development Center. inc. Educauon Development Center From: Stone, Deborah Sent: Tuesday, February 27, 2018 4:27 PM To: Reed, erry Hindrnan CDPHE, Jarrod aiarrod.liindman@state.eo.us> Ce: Caine, Eric Ce: Caine, Eric {Erie Subject: RE: AJPH Opinion Editorial I could do Friday at 2PM. Hard stop at 3. And [-lad start at 2. Best, Jerry Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide, Violence Injury Prevention Portfolio Lead National Action Alliance for Suicide Prevention Executive Committee Member iread?u-edcere 202-294-3132 (M: 202-223-4059 Education Develo mentCenter lne. Education Development enter From: Stone, Deborah [mailtozzatgf?gcdegov'l Sent: Tuesday, February 2018 2:53 PM To: Hindrnan - Jarrod {iarrodJiindman@state.co.us> Ce: Caine, Eric {Eric Cainegilunneroehester.edu}; Reed, Jerry <"reed nae-door Subject: RE: AJPH Opinion Editorial Great, thanks Jarrod! 1 can do Friday at 2 if everyone else is free. Deb From: Hindman - CDPHE, Jarrod Sent: Tuesday, February 27. 2018 2:35 PM To: Stone, Deborah (CDCIONDIEHFNCIPC) Subject: RE: AJPH Opinion Editorial I could do Friday at 2PM. Hard stop at 3. And Had start at 2. Best, Jerry Jerryr Reed, MSW Senior Vice President for Practice Leadership Suicide. Violence 8: injury Prevention Portfolio Lead National Action Alliance for Suicide Prevention Executive Committee Member 202-5'2-377'1 (O) 202-294-8132 (M) Education lleveln menl Center. Inc. Education Development Center From: Stone, Deborah [1nailtozzat9if?edeeov] Sent: Tuesday, February 27, 2018 2:53 PM To: Hindman - CDPHE, Jarrod efiarrod.hindmanr?lstatecous} Cc: Caine, Eric Cc: Caine, Eric Reed, Jerry Subject: Re: Opinion Editorial I?m in, sorry for my late reply. Of the times you noted for a callThurs at 1pm Friday at 2pm Deb Jerry, Eric, Emmy and I already have a call on the books for Friday at 1, so perhaps 2pm might work well? Would be great to include Emmy as well if possible. Jarrod On Tue, Feb 27, 2018 at 9:41 AM, Stone, Deborah <2an diode. row} wrote: Fabulous! Assuming is on board as well, until I hear differently! Do any ofthese times work (all EST) to meet this week? Also. wanted to discuss some CDC Foundation stuffas well. 1 had a follow-up call with them today after our last CNC meetingThurs 10 am IThurs 1 pm 0 Friday anytime except 1-2 pm Deb From: Caine, Eric [mailtozErie Caine?c?URMCRochesteLedu] Sent: Tuesday, February 27, 2018 9:33 AM To: Stone, Deborah <12an ticdc. ov>; iarrod.hindman@state.co.us; Reed, Jerry edcorg> Subject: Re: AJPH Opinion Editorial Glad to, too! Eric D. Caine, MD. University of Rochester Medical Ctr. 300 Crittenden Blvd. Rochester. NY, USA 14642-8409 From: Deborah Stone <2an diode. ov> Date: Monday, February 26, 2018 at 5:34 PM To: "Caine, Erie" Jarrod Hindman Jerry Reed {'reed oiledcor Subject: AJPH Opinion Editorial Hi Guys, As you may have heard from me? others? CDC is releasing a Vital Signs on Suicide on June 51". This is a really high pro?lefhigh impact publication. It includes a website, MMWR, act Sheet, Social Media messages, press release, telebrie?ng by Acting CDC Director and a Town Hall Meeting (We already have on record that the Surgeon General may participate in the telebrie?ng). Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? I know you are probably tired of being singled out for all of your great work and perspectives. . .(sorryl) but would the three of you or some combination of you do us the honor of writing an opinion editorial (1200 words, 7 references, for us in AJPH about comprehensive suicide prevention and CO efforts [we can refine later but for purposes here, this is the topic]? I'm happy to set up a call to discuss but in the meantime, please see attached Vital Signs description with preliminary results (Please do not distribute or otherwise use or I?ll probably be fired). Also see recent Vital Signs [on opioids) and the companion commentary. Also, editorial. is due to AJPH April 5th? So it?s coming right up. 0y. Look forward to hearing of your interest and thoughts. Deb Deb Stone, MSW, MPH Behavioral Scientist Suicide. Violence, and Elder Maltreatmenl Team Centers for Disease Control and Prevenlion National Center for Injury Prevention and Control Division ofViolencc Prevention Research 8: Evaluation Branch Buford Highway. MS F-t'icl Atlanta, GA 7Tll.48?d.3942 dstone3 ratedc. gov Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch 303.692.2539 i 303.69l .7901 4300 Cherry Creek Drive South, Denver CO 80246 iarrod.hindmandigstateeous From: Reed, Jerry Sent: 2? Feb 2018 20:12:46 +0000 To: Stone, Deborah - CDPHE, Jarrod Cc: Caine, Eric Subject: RE: AJPH Opinion Editorial I could do Friday at 2PM. Hard stop at 3. And Had start at 2. Best. Jerry Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide. Vioienee Injury Prevention Portfolio Lead National Action Alliance for Suicide Prevention ExeCutiye Committee Member (O) 202494-8132. (M) I 202-223?4059 (F) Education Des-elo menl Center. Inc. Education Development Center From: Stone, Deborah (CDCIONDIEWNCIPC) Sent: Tuesday, February 27, 2018 2:53 PM To: Hindrnan - CDPHE, Jarrod Cc: Caine, Erie Reed, Jerry Subject: RE: AJPH Opinion Editorial Great, thanks Jarrod! i can do Friday at 2 if everyone else is free. Deb From: Hindman - CDPHE, Jarrod Sent: Tuesday, February 27, 2018 2:35 PM To: Stone, Deborah Ce: Caine, Erie wrote: Fabulous! Assuming Jarrod is on board as well, until I hear differently! Do any of these times work (all EST) to meet this week? Also, wanted to discuss some CDC Foundation stuff as well. I had a follow?up call with them today after our last CNC meetingpin IT'hurs 10 am 1 pm 0 Friday anytime except 1-2 pm Deb From: Caine, Eric [mailto:Eric CaineG?URMC.Rochester.edu] Sent: Tuesday, February 27, 2018 9:33 AM To: Stone, Deborah (CDCJONDIEHINCIPC) <3an jarrod.hindman@state.co.us; Reed, Jerry Subject: Re: AJPH Opinion Editorial Glad to, too! Eric D. Caine, MD. University of Rochester Medical Ctr. 300 Crittenden Blvd. Rochester, NY, USA l4642-84(19 +1 535.746.3574 From: Deborah Stone <2an Eri'edc. ov> Date: Monday, February 26, 2018 at 5:34 PM To: ?Caine, Eric" wrote: Fabulous! Assuming Jarrod is on board as well. until i hear differently! Do any of these times work (all EST) to meet this week? Also, wanted to discuss some CDC Foundation stuffas well. i had a follow-up call with them today after our last meetingThurs 10 am IThurs 1 pm I Friday anytime except 1-2 pm Deb From: Caine, Eric [mailto:Erie CaiueQEURMCRoehesteredul Sent: Tuesday, February 27', 2018 9:33 AM To: Stone, Deborah {zafg?edegoyx iarrod.hindman??stateeous; Reed, Jerry Subject: Re: AJPH Opinion Editorial ClGlad to, too! Erie D. Caine, MD. University of Rochester Medical Ctr. 300 Critlenden Blvd. Rochester. NY. USA 14642-8409 From: Deborah Stone Date: Monday, February 26, 2018 at 5:34 PM To: ?Caine, Eric" , Jerry Reed {reed tiledcor Subject: AJPH Opinion Editorial Hi Guys, As you may have heard from me? others? CDC is releasing a Vital Signs on Suicide on June 5th . This is a really high pro?lefhigh impact publication. It includes a website, MMWR, Fact Sheet, Social Media messages, press release, telebrie?ng by Acting CDC Director and a Town Hall Meeting (We already have on record that the Surgeon General may participate in the telebrie?ng). Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? I know you are probably tired of being singled out for all of your great work and perspectives. . .(sorryl) but would the three of you or some combination of you do us the honor of writing an opinion editorial (1200 words, 7 references, for us in AJPH about comprehensive suicide prevention and CO efforts [we can re?ne later but for purposes here, this is the topic]? I?m happy to set up a call to discuss but in the meantime, please see attached Vital Signs description with preliminary results (Please do not distribute or otherwise use or I?ll probably be fired). Also see recent Vital Signs {on opioidsi and the companion commentary. Also, editorial is due to AJPH April 5th?! So it?s coming right up. 0y. Look forward to hearing of your interest and thoughts. Deb Deb Stone. Sci), MSW, MPH Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research 8: Evaluation Branch 47m Buford Highway, MS F-64 Atlanta, GA 30341 dston93@cdc.gov Jarrod Hindman, MS Deputy Chief Violence and injury Prevention-Mental Health Promotion Branch 303.692.2539 303.691.7901 4300 Cherry Creek Drive South, Denver CO 80246 jarred.hindman@state.ce.us From: Hindman - CDPHE, Jarrod Sent: 6 Mar 2018 12:18:39 -0700 To: Stone, Deborah Subject: Re: AJPH Opinion Editorial Sounds good. Thanks Deb. On Tue, Mar 6, 2018 at 12:01 PM, Stone, Deborah (CDCKONDIEHINCIPC) wrote: Hi Jarrod, Yeah at some point over the weekend I realized that too. If I can touch base with any combo of you for like 10 mins that would be helpful. Deb From: Hindman - CDPHE, Jarrod Sent: Monday, March 5, 2018 12:42 PM To: Reed, Jerry {ireedgc?edeorg} Cc: Betz, Marian Eric Cainet?iURMC.Roc11ester.edu; Stone, Deborah Subject: Re: AJ PH Opinion Editorial Thanks for the kind words Jerry. Always enjoy working with this team. 011 re?ection, we never got around to talking about the CDC Foundation process or any follow-up related to the conversation Deb had with Rob. Deb - I'm going to include an agenda item for our Wed call, but de?nitely let me know if there is anything we need to discuss andfor agree on prior to Wed's call. Thanks. Jarrod On Sat, Mar 3, 2018 at 10:34 AM, Reed, Jerry wrote: Dear Colleagues, As I catch up on this day, just want to say that I really value our open, candid, (oftentimes humorous) discussions. Truly, I love working with people 1 really enjoy to be around. Thanks for what turned out to be a great part of my day. Best, Jerry Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide. Violence is}; Injury Prevention Portfolio Lead National Action Alliance tor Suicide Prevention Executive Committee Member 202-572-37?1 (0i 202-294-8132 (M) 202-223-4059 (F) Education Derelo mentfenter Inc. Education Dc Development Center From: Betz, Marian Sent: Friday, March 02, 2018 5:02 PM To: Eric Caine@URMC.Rochester.edu; iarrod.hindman@state.co.us; Reed, Jerry Stone, Deborah Sent: Friday, March 02, 2018 3:00 PM To: Betz, Marian Thank you for a productive (and entertaining call). But seriously, I do so appreciate your willingness to write this editorial to accompany the Vital Signs. This is going to be a great product (collectively). Attaching drafts ofeverything so far so you can get the full effect of what we're going for. Based on the titles and watermarks and PDF file type I think you?ll ?gure out not to share. The draft of the MMWR hasn't been reviewed yet so take it with a grain of salt. especially the discussion which needs lots 0 work. Also, please do review these two links to see an example of how the vital signs and the editorial link together. Vital Signs on opioids) and the companion commenta! Let me know if you have any questions about anything. Dates to keep in mind: Week of March lZm?Outline to Deb March 23- Copy of article to share with CDC for soft edits April Article due to AJPH Thankful for this partnership? {now but in general) Happy Friday. Deb From: Stone, Deborah Sent: Monday, February 26, 2018 5:31 PM To: Caine, Eric (Eric Caine@URMC.Rochesteredu) wrote: Hi Jarrod, Yeah at some point over the weekend I realized that too. If I can touch base with any combo of you for like 10 mins that would be helpful. Deb From: Hindman - CDPHE, Jarrod Sent: Monday, March 5, 2018 12:42 PM To: Reed, Jerry c'reed edc.or Cc: Betz, Marian Eric Caine@URMC.Rochester.edu; Stone, Deborah Subject: Re: AJPH Opinion Editorial Thanks for the kind words Jerry. Always enjoy working with this team. On reflection, we never got around to talking about the CDC Foundation process or any follow-up related to the conversation Deb had with Rob. Deb I'm going to include an agenda item for our Wed call, but de?nitely let me know if there is anything we need to discuss andfor agree on prior to Wed?s call. Thanks. Jarrod On Sat, Mar 3, 2018 at 10:34 AM, Reed, Jerry wrote: Dear Colleagues, As I catch up on this day, just want to say that I really value our open, candid, (oftentimes humorous) discussions. Truly. I love working with people I really enjoy to be around. Thanks 't'or what turned out to be a great part of my day. Best, .ieny Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide, Violence Injury Prevenlinn Portfolio Lead National Action Alliance For Suicide Prevention Executive C'oinmincc Member 202-572-377l I 203?294-8l32 202?323-4059 Education Dereli'nmlem Center. Inc. Ed ucatian EDC Devetopment Center From: Betz, Marian Sent: Friday, March 02, 2018 5:02 PM To: Eric CaineGiJURMCRochesteredu; Reed, Jerry Stone, Deborah Subject: RE: AJPH Opinion Editorial Hi all, Just switching to my work email from gmail for this email chain please use this address for responses. Great talking to you all, and Eric let me know howiwhen I can help out with the paper. Emmy Marian (Emmy) Beta, MD, MPH Associate Frofessorj Department of Emergency Medicine University of Colorado School of Medicine Core Faculty Program for Injury Prevention, Education and Research Colorado School of Public Health Mail Step 13-215 Leprino Of?ce Building, 7?3" Floor, 1240] a. 17th Avenue Aurora._ co 80045 Phone: 720.848.6770 1 Cell: 303.550.5669 Twitter: @EmmyBetz Department of Emergency Medicine mamxoruemm Wow 0" norm ?I'm Con?dentiality Notice: This email message, including any attachments, is for the sole use of the intended recipientts] and may contain con?dential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. lfyou are not the intended recipient, please contact the sender by reply email and destroy all copies ofthe original message. From: Emmy Betz Sent: Friday, March 02, 2018 3:00 PM To: Betz, Marian Subject: Fwd: AI PH Opinion Editorial Forwarded message From: Stone, Deborah (CDCIONDIEHINCIPC) <2af9?a>cdegov> Date: Fri, Mar 2, 2018 at 1:47 PM Subject: RE: AJPH Opinion Editorial To: ?Caine, Eric (Eric {Eric "Reed, Jerry" Emmy Betz ; iarrod.hindmanatlstatecous; Reed, Jerry Subject: AJPH Opinion Editorial Hi Guys, As you may have heard from me? others? CDC is releasing a Vital Signs on Suicide on 5th June . This is a really high profilefhigh impact publication. It includes a website, MMWR, Fact Sheet, Social Media messages, press release, telebrieflng by Acting CDC Director and a Town. Hall Meeting (We already have on record that the Surgeon General may: participate in the telebrie?ng). Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? I know you are probably tired of being singled out for all of your great work and perspectives. . .(sorry!) but would the three of you or some combination of you do us the honor of writing an opinion editorial [1200 words, references, for us in AJPH about comprehensive suicide prevention and CO efforts [we can re?ne later but for purposes here, this is the topic]? I?m happy to set up a call to discuss but in the meantime, please see attached Vital Signs description with preliminary results (Please do not distribute or otherwise use or I?ll probably be ?red). Also see recent Vital Signs on opioids) and the companion commentall Also, editorial is due to AJ PH April So it?s coming right up. Oy. Look forward to hearing of your interest and thoughts. Deb Deb Stone, MSW, MPH Behavioral Scientist Suicide. Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research 3. Evaluation Branch 4?70 Buford Highway, MS F-64 Atlanta, GA 30341 Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch 303.692.2539 303.691.7901 4300 Cherry Creek Drive South, Denver CO 30246 iarrod.hindman@state.co.us Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch El 303.692.2539 303.691.7901 4300 Cherry Creek Drive South, Denver CO 80246 iarrod.hindman@state.co.us From: Hindman - CDPHE, Jarrod Sent: 6 Mar 2018 11:59:18 -D700 To: Stone, Deborah Cc: Reed, Jerry;Betz, Subject: Re: AJPH Opinion Editorial Hey Deb. I'm pretty much booked the rest of this afternoon, other than the next hour. If we can?t touch base, is it feasible to update the group on the call tomorrow morning? Or, do we need to save the conversation update for later? Jarrod On Mon, Mar 5, 2018 at 11:] 1 AM, Stone, Deborah (CDCIONDIEHENCIPC) gov> wrote: Hi Jarrod, Yeah at some point over the weekend I realized that too. if i can touch base with any combo of you for like 10 mins that would be helpful. Deb From: Hindman - CDPHE, Jarrod Sent: Monday, March 5, 2018 12:42 PM To: Reed, Jerry <"reed cuedeor Cc: Betz, Marian Eric Cainetti'JURMC.Rochester.edu; Stone, Deborah <2af9?alcdogov> Subject: Re: AJPH Opinion Editorial Thanks for the kind words Jerry. Always enjoy working with this team. On reflection, we never got around to talking about the CDC Foundation process or any follow-up related to the conversation Deb had with Rob. Deb - I'm going to include an agenda item for our Wed call, but de?nitely let me know if there is anything we need to discuss andfor agree on prior to Wed?s call. Thanks. Jarrod On Sat, Mar 3, 2018 at 10:34 AM, Reed, Jerry wrote: Dear Colleagues. As I catch up on this day. just want to say that I really value our open, candid, (oftentimes humorous) discussions. Truly, I love working with people 1 really enjoy to be around. Thanks for what turned out to be a great part of my day. Jerry Reed. MSW Senior Vice President for Practice Leadership Suicide. Violence Injury.r Prevention Portfolio Lent] National Action Alliance For Suicide Prevention Executive Committee Member Il?CCtlIIiCdC?l'g 202-572?157? {01 202%23-4059 [Fl Educalilm C?L'nlcr, Education Dc Development Center From: Betz, Marian Sent: Friday, March 02, 2018 5:02 PM To: Eric Caine?rQURMC.Rochesteredu; iarrod.hindman@state.co.us; Reed, Jerry ; Stone, Deborah (CDCJONDIEHINCIPC) <2af9?wcdegov> Subject: RE: AJPH Opinion Editorial Hi all, Just switching to my work email from gmail for this email chain please use this address for responses. Great talking to you all, and Eric let me know howlwhen I can help But with the papen Emmy Marian (Emmy) Betz, MD, MPH Associate Professori Deparuncnt of Emergency( Medicine University of Colorado School of Medicine Core Faculty Program for Inj ury Prevention, Education and Research (PIPER) Colorado School of Public Health Mail Stop 13-215 Leprino Of?ce Building, Floor, 12401 E. Wm Avenue lAurora, CO 80045 Phone: 720.848.6770 1 Marian.Betzf?Jucdenveredu Cell: 303.550.5669 Twitter: @EmmyBetz Department of Emergency Medicine If IIBIOHE Con?dentiality Notice: This email message. including any attachments, is for the sole use of the intended rccipientts) and may contain con?dential and privileged information. Any unauthorized review. use. disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message. From: Emmy Betz Sent: Friday, March 02, 2018 3:00 PM To: Betz, Marian Subject: Fwd: Opinion Editorial Forwarded message From: Stone, Deborah Thank you for a productive (and entertaining call). But seriously, I do so appreciate your willingness to write this editorial to accompany the Vital Signs. This is going to be a great product (collectively). Attaching drafts of everything so far so you can get the full effect of what we?re going for. Based on the titles and watermarks and PDF file type I think you?ll ?gure out not to share. The draft of the MMWR hasn't been reviewed yet so take it with a grain of salt. especially the discussion which needs lots 0 work. Also, please do review these two links to see an Example of how the vital signs and the editorial link together. Vital Signs on opioids) and the companion commentary. Let me know if you have any questions about anything. Dates to keep in mind: Week of March l2m-Outline to Deb March 23- Copy of article to share with CDC for soft edits April 5th?Article due to AJPH Thankful for this partnershipll (now but in general) Happy Friday. Deb From: Stone, Deborah (CDCIONDIEHKNCIPC) Sent: Monday, February 26, 2018 5:31 PM To: Caine, Eric (Eric Cainet?ri?iURMC.Rochesteredu) Subject: AJPH Opinion Editorial Hi Guys. As you may have heard from me? others? CDC is releasing a Vital Signs on Suicide on June This is a really high pro?lefhigh impact publication. It includes a website, MMWR, Fact Sheet, Social Media messages, press release, telebrie?ng by Acting CDC Director and a Town Hall Meeting (We already have on record that the Surgeon General may participate in the telebrie?ng). Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? I know you are probably tired of being singled out for all of your great work and perspectives. . .(sorry!) but would the three of you or some combination of you do us the honor ofwriting an opinion editorial (1200 words, 7 references, for us in AJPH about comprehensive suicide prevention and efforts [we can refine later but for purposes here, this is the topic]? I?m happy to set up a call to discuss but in the meantime, please see attached Vital Signs description with preliminary results (Please do not distribute or otherwise use or I?ll probably be fired). Also see recent Vital Signs on opioids) and the companion commentary. Also, editorial is due to AJPH April So it?s coming right up. 0y. Look forward to hearing of your interest and thoughts. Deb Deb Stone. Sel}. MSW, MPH Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of?v?iolenee Prevention Research Evaluation Branch 4??0 Buford Highway, MS [3-64 Atlanta, GA 3034 ?0.435.394? d510ne3?f?edegov Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch 303.692.2539 303.691.7901 4300 Cherry Creek Drive South, Denver CO 80246 iarrod.hindman?lstatecous Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention?Mental Health Promotion Branch El 303.692.2539 303.691.7901 4300 Cherry Creek Drive South. Denver CO 80246 iarrod.hindmanc?r?statecous From: Stone, Deborah Sent: 5 Mar 2018 18:11:14 +0000 To: Hindman - CDPHE, Jarrod;Reed, Jerry Cc: Betz, Subject: RE: AJPH Opinion Editorial Hi Jarrod, Yeah at some point over the weekend I realized that too. If I can touch base with any combo of you for like 10 mins that would be helpful. Deb From: Hindman - CDPHE, Jarrod Sent: Monday, March 5, 2018 12:42 PM To: Reed, Jerry Cc: Betz, Marian Stone, Deborah (CDCIONDIEHINCIPCJ Subject: Re: AJPH Opinion Editorial Thanks for the kind words Jerry. Always enjoy working with this team. On re?ection, we never got around to talking about the CDC Foundation process or any follow?up related to the conversation Deb had with Rob. Deb - I'm going to include an agenda item for our Wed call, but de?nitely let me know if there is anything we need to discuss andfor agree on prior to Wed?s call. Thanks. Jarrod On Sat, Mar 3, 2018 at 10:34 AM, Reed, Jerry wrote: Dear Colleagues, As I catch up on this day, just want to say that I really value our open, candid, (oftentimes humorous) discussions. Truly, i love working with people I really enjoy to be around. Thanks for what turned out to be a great part of my day. Best, Jerry Jerry Reed, MSW Senior Vice President For I?racticc Leadership Suicide. Violence Injury Prevention Portfolio Lend National Action Alliance for Suicide Prevention Executive Committee Member ireedtn?iedcorg 202-294-8132 202-223-40591F: Education {It-veto Center. Inc. Education Development Center From: Betz, Marian Sent: Friday, March 02, 2018 5:02 PM To: Eric CaineQE-URMC.Rochester.edu; iarrod.hindman?tstatecous; Reed, Jerry Stone, Deborah (CDCKONDIEHJNCIPC) <2af9 diode. ova- Subject: RE: AJPH Opinion Editorial Hi all, Just switching to my work email from gmail for this email chain please use this address for responses. Great talking to you all, and Eric let me know howtwhen I can help out with the paper. Emmy Marian (Emmy) Betz, MD, MPH Associate Professorl Department of Emergency Medicine 1 University of Colorado School of Medicine Core Faculty Program for Injury Prevention, Education and Research (PIPER) I Colorado School of Public Health Mail Stop 3215 Leprino Of?ce Building, 7th Floor, 12401 E. 17'Lh Avenue lAurora, CO 80045 Phone: T20.848.677fl Marian.Betz@ucdenver.edu Cell: 303.550.5669 Twitter: @EmmyBetz Department of Emergency Medicine WUKDIM OF COLORADO women Con?dentiality Notice: This email message. including any attachments, is for the sole use ot?the intended reelpien?s] and may contain con?dential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message. From: Emmy Betz Sent: Friday, March 02, 2018 3:00 PM To: Betz, Marian Subject: Fwd: AJPH Opinion Editorial Forwarded message From: Stone, Deborah Date: Fri, Mar 2, 2018 at 1:4? PM Subject: RE: AJPH Opinion Editorial To: "Caine, Eric (Eric CainetrilURMC.Rochester.edu)" Thank you for a productive (and entertaining call). But seriously, 1 do so appreciate your willingness to write this editorial to accompany the Vital Signs. This is going to be a great product (collectively). Attaching drafts of everything so far so you can get the full effect of what we?re going for. Based on the titles and watermarks and PDF file type 1 think you?ll figure out not to share. The draft of the MMWR hasn?t been reviewed yet so take it with a grain of salt, especially the discussion which needs lots 0 work. Also, please do review these two links to see an example of how the vital signs and the editorial link together. Vital Signs {on opioids) and the companion commentary. Let me know if you have any questions about anything. Dates to [seen in mind: Week of March 12*? Outline to Deb March 23- Copy of article to share with CDC for soft edits April Sm?Article due to Al PH Thankful for this partnershipl! (now but in general) Happy Friday. Deb From: Stone, Deborah (CDCHONDIEHWCIPC) Sent: Monday, February 26, 2018 5:31 PM To: Caine, Eric {Eric iarrod.hindman@state.co.us; Reed, Jerry <1jreedgrbedc.org> Subject: MPH Opinion Editorial Hi Guys, As you may have heard from me?? others? CDC is releasing a Vita! Signs on Suicide on June 51". This is a really high pro?le/high impact publication. It includes a website, MMWR, Fact Sheet, Social Media messages, press release, telebrie?ng by Acting CDC Director and a Town Hall Meeting (We already have on record that the Surgeon General may participate in the telebrie?ng). Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? I know you are probably tired of being singled out for all of your great work and perspectives. . .(sorryl) but would the three of you or some combination of you do us the honor of writing an opinion editorial (1200 words, 7 references, for us in AJPH about comprehensive suicide prevention and CO efforts [we can re?ne later but for purposes here, this is the topic]? I?m happy to set up a call to discuss but in the meantime, please see attached Vital Signs description with preliminary results Please do not distribute or otherwise use or I?ll probably be ?red). Also see recent Vital Signs [on opioids) and the companion commentary. Also, editorial is due to AJPH April So it?s coming right up. 0y. Look forward to hearing of your interest and thoughts. Deb Deb Stone. MPII Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research 3; Evaluation Branch 4770 Buford Highway. MS F-64 Atlanta. GA 30341 770.488.3942 dstone3@cdc.gov Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch 303.692.2539 303.691.7901 4300 Cherry Creek Drive South, Denver CO 80246 iarrod.hindman@state.co.us From: Hindman - CDPHE, Jarrod Sent: 5 Mar 2018 10:42:22 -0700 To: Reed, Jerry Cc: Betz, Deborah Subiect: Re: AJPH Opinion Editorial Thanks for the kind words Jerry. Always enjoy working with this team. On re?ection, we never got around to talking about the CDC Foundation process or any follow?up related to the conversation Deb had with Rob. Deb - I'm going to include an agenda item for our Wed call, but de?nitely let me know if there is anything we need to discuss andi?or agree on prior to Wed?s call. Thanks. arrod On Sat, Mar 3, 2018 at 10:34 AM, Reed, Jerry edcorga wrote: Dear Colleagues, As I catch up on this day, just want to say that I really value our open, candid, (oftentimes humorous} discussions. Truly, I love working with people I really enjoy to be around. Thanks for what turned out to be a great part of my day. Best, Jerry Jerry Reed, Senior President for Practice Leadership Suicide. Violence at Injury Prevention Portfolio Lead National Action Alliance Eiir Suicide Prevention Executive Committee Member ireeclfn'rtienre 202-522-37? (M) 202-223-4059 Education Development Center, Inc. Education Development Center From: Betz, Marian Sent: Friday, March 02, 2018 5:02 PM To: Eric Caine(ci3.URMC.Roehester.edu; iarrod.hindmanfc?stateeous; Reed, Jerry ; Stone, Deborah Subject: RE: Opinion Editorial Hi all, Just switching to my work email from gmail for this email chain please use this address for responses. Great talking to you all, and Eric let me know howfwhen I can help out with the paper. Emmy Marian (Emmy) Beta, MD, MPH Associate Professor Department of Emergency Medicine 1 University of Colorado School of Medicine Core Faculty Program for Injury Prevention, Education and Research (PIPER) Colorado School of Public Health Mail Stop 3-215 1 Leprino Of?ce Building, Floor, 12401 E. 17?h Avenue lAurora, CO 80045 Phone: 720.848.6770 Marian.Betztdiucdenveredu Cell: 303.550.5669 Twitter: @EmmyBetz Department of Emergency Medicine sewn [7 DEDICNE mum Cf cameo mm Con?dentiality Notice: This email message, including any attachments, is for the sole use of the intended reeipientts} and may contain con?dential and privileged attenuation. Any unauthorized review. use. disclosure or distribution is prohibited. 11' you are not the intended recipient. please contact the sender by reply email and destroy all copies of the original message. From: Emmy Betz Subject: Fwd: AJPH Opinion Editorial Forwarded message From: Stone, Deborah (CDCIONDIEHINCIPC) Date: Fri, Mar 2, 2018 at 1:4? PM Subject: RE: AJPH Opinion Editorial To: "Caine, Eric (Eric {Eric "iarrodliindman?silstateco.us" "Reed, Jerry" {Creed ciledccr Emmy Betz {mebetz?lgmailcom}: Thank you for a productive (and entertaining call}. But seriously. 1 do so appreciate your willingness to write this editorial to accompany the Vital Signs. This is going to be a great product {collectively}. Attaching drafts of" everything so far so you can get the full effect of what we?re going for. Based on the titles and watermarks and file type I think you'll ?gure out not to share. The draft of the MMWR hasn?t been reviewed yet so take it with a grain o't?salt. especially the discussion which needs lots 0 work. Also, please do review these two links to see an example of how the vital signs and the editorial link together. Vital Signs on opioids) and the companion commentary. Let me know if you have any questions about anything. Dates to keep in mind: Week of March lZ?h?Outline to Deb March 23? Copy of' article to share with CDC for soft edits April Sill?Article due to AJPH Thankful for this partnershipll (now but in general) Happy Friday. Deb From: Stone, Deborah (CDCIONDIEHINCIPC) Sent: Monday, February 26, 2018 5:31 PM To: Caine, Eric (Erie Caine?lURMCRochesteredu) iarrod.hindman@state.co.us; Reed, Jerry Subject: AJPH Opinion Editorial Hi Guys, As you may have heard from me? others? CDC is releasing a Vital Signs on Suicide on June This is a really high pro?le/high impact publication. It includes a website, MWR, Fact Sheet, Social Media messages, press release, telebriefing by Acting CDC Director and a Town Hall Meeting (We already have on record that the Surgeon General may participate in the telebrie?ng). Vital Signs sometimes also include an accompanying commentary in a peer reviewed journal. What does this have to do with you? I know you are probably tired of being singled out for all of your great work and perspectives. . .(sorry!) but would the three of you or some combination of you do us the honor of writing an opinion editorial (1200 words, 7 references, for us in AJPH abOut comprehensive suicide prevention and CO efforts [we can re?ne later but for purposes here, this is the topic]? I?m happy to set up a call to discuss but in the meantime, please see attached Vital Signs description with preliminary results (Please do not distribute or otherwise use or I?ll probably be ?red). Also see recent Vital Signs {on opioids) and the companion commentarv. Also, editorial is due to AJPH April So it?s coming right up. 0y. Look forward to hearing of your interest and thoughts. Deb Deb Stone, MSW, MPH Behavioral Scientist Suicide. Youth Tv?iolencc. and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of 'v'iolence Prevention Research 3.: Evaluation Branch 47?71} Buford Highway, MS F-M Atlanta. GA 3034] 77(14883942 dston e3trticde. gov Jarrod Hindman. MS Deputy Chief Violence. and Injury Prevention-Mental Health Promotion Branch IEI 303.692.2539 303.691.?901 4300 Cherry Creek Drive South, Denver CO 80246 iarrod.hindman@state.co.us From: Reed, Jerry Sent: 3 Mar 2018 17:34:30 +0000 To: Betz, Deborah Subject: RE: AJPH Opinion Editorial Dear Colleagues, As I catch up on this day, just want to say that I really value our open, candid, (oftentimes humorous) discussions. Truly, I love working with people I really enjoy to be around. Thanks for what turned out to be a great part of my day. Best Jerry Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide, Violence 31 Injury Prevention Portfolio Lead NatiOnal Action Alliance for Suicide Prevention Executive Committee Member 202?522?3771 2022943132 (M) I 202223-4059 {Fl Education Develo ment Center Inc. Educahon Development Center From: Betz, Marian Sent: Friday, March 02, 2018 5:02 PM To: jarrod.hindman@state.co.us; Reed, Jerry; Stone, Deborah Subject: RE: AJPH Opinion Editorial Hi all, Just switching to my work email from gmail for this email chain please use this address for responses. Great talking to you all, and Eric let me know how/when i can help out with the paper. Emmy Marian (Emmy) Beta, MD, MPH Associate Professorl Department of Emergency Medicine University of Colorado School of Medicine Core Faculty Program for Injury Prevention, Education and Research (PIPER) Colorado School of Public Health Mail Stop 3215 Leprino Office Building, 7th Floor, 12401 E. 17th Avenue IAurora, CO 80045 Phone: 720.848.6770 Marian.Betz@UCdenver.edu Cell: 303.550.5669 Twitter: @EmmyBetz Department of Emergency Medicine CF 080?:th mazes-rm GIF <30me mom mu. Confidentiality Notice: This email message, including any attachments, is for the sole use of the intended recipientls} and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply email and destroy all copies of the original message. From: Emmy Betz smebetz Sent: Friday, March 02, 2018 3:00 PM To: Betz, Marian Subject: Fwd: AJPH Opinion Editorial Forwarded message From: Stone, Deborah <2af9@cdc.gov> Date: Fri, Mar 2, 2018 at 1:47 PM Subject: RE: AJPH Opinion Editorial To: "Caine, Eric (Eric Thank you for a productive (and entertaining call]. But seriously, I do so appreciate your willingness to write this editorial to accompany the Vital Signs. This is going to be a great product (collectively). Attaching drafts of everything so far so you can get the full effect of what we?re going for. Based on the titles and watermarks and PDF file type I think you?ll figure out not to share. ,1 The draft of the MMWR hasn?t been reviewed yet so take it with a grain of salt, especially the discussion which needs lots 0 work. Also, please do review these two links to see an example of how the vital signs and the editorial link together. Vital Signs (on opioidsl and the companion commentary. Let me know if you have any questions about anything. Dates to keep in mind: Week of March nth?Outline to Deb March 23? Copy of article to share with CDC for soft edits April Elm?Article due to AJPH Thankful for this partnershipll (now but in general) Happy Friday. Deb From: Stone, Deborah Sent: Monday, February 26, 2018 5:31 PM To: Caine, Eric (Eric Caine@URMC.Rochester.edul Date: Fri, Mar 2, 2018 at 1:47 PM Subject: RE: AJPH Opinion Editorial To: "Caine, Eric {Eric Caine@URMC.Rochester.edul" Thank you for a productive {and entertaining call]. But seriously, I do so appreciate your willingness to write this editorial to accompany the Vital Signs. This is going to be a great product (collectively). Attaching drafts of everything so far so you can get the full effect of what we're going for. Based on the titles and watermarks and PDF file type I think you?ll figure out not to share. :1 The draft of the MMWR hasn?t been reviewed yet so take it with a grain of salt, especially the discussion which needs lots 0 work. Also, please do review these two links to see an example of how the vital signs and the editorial link together. Vital Signs [on opioidsl and the companion commentary. Let me know if you have any questions about anything. Dates to keep in mind: Week of March 12th?Dutline to Deb March 23- Copy of article to share with CDC for soft edits April sth?Article due to AJPH Thankful for this partnership!! {now but in general] Happy Friday. Deb From: Stone, Deborah Sent: Monday, February 26, 2018 5:31 PM To: Caine, Eric (Eric Caine@URMC.Rochester.edu] (Eric jarrod.hindman@state.co.us; Reed, Jerry wrote: Hi Jarrod, (lb-M6." f- Emmy was on the invite. If you want me to just call in to your line, I'm happy to can revise the invite. Is this the number. 888.330.3158 1; access code '8 Deb From: Hindman - CDPHE, Jarrod Sent: Tuesday, February 27, 2018 7:05 PM To: Reed, Jerry {ireedgaiedeorgir Ce: Stone, Deborah Caine, Erie {Erie Betz, Marian wrote: Adding Emmy to the conversation in ease she is available after our already scheduled call. We will be using the ICRC-S call for our 1pm EDT call, so I'm wondering if we can just stay on the line and Deb can join us at 2pm Erie - does that work? jarred On Tue, Feb 27, 2018 at 3: 3 PM. Reed, Jerry wrote: Do we have a call in ii? Jerry Jerry Reed, MSW Senior Vice President for Practice Leadership Suicide1 Violence Injury Prevention Portfolio National Action Alliance for Suicide Prevention Executive Committee Member ii'eeilr'n edcorn 202?572-3771 202-294-8132 (M) 202?223-4059 (F) Education Development Center. Inc. Education DC Development Center From: Stone, Deborah Sent: Tuesday, February 27, 2018 4:27 PM To: Reed, Jerry ?Hindman - CDPHE, Jarrod Cc: Cains, Eric Ce: Cains, Erie wrote: Fabulous! Assuming Jarrod is on board as well, until I hear differently! Do any ofthese times work (all EST) to meet this week? Also. wanted to discuss some CDC Foundation stut?fas well. I had a follow-up call with them today after our last CNC meeting. IThurs [0 am IThurs I pm 0 Friday anytime except 1-2 pm Deb From: Caine, Eric [mailto:Eric Caine@URMC.Rochesteredu] Sent: Tuesday, February 27, 2018 9:33 AM To: Stone, Deborah (CDCKONDIEHINCIPC) Sent: Thursday, February 15, 2018 5:57 PM To: Cc: Subject: CDC Commentary for a June Vital Signs on Suicide Dear Dr. Morabia, My name is Deb Stone. I?m a behavioral scientist at CDC in the Division of Violence Prevention. I am leading the publication of a CDC Vital Signs focused on suicide to be released June 5, 2018. Vito! Signs, as you may know, began in 2010 and is a high profile CDC publication widely distributed to highlight important public health threats and what can be done to prevent them. The release always includes a web page, an MMWR article, a translation piece fact sheet), science clips, and a telebriefing by the CDC Director with the media. It also often includes a companion commentary piece in a top tierjournai, linked on our CDC Vital Signs web site and referenced in the other materials. i am writing to inquire whether AJPH may be interested in coiioboroting with us to pubiish such commentary. The commentary intends to integrate our study findings and the work of one state that is pioneering the first-ever comprehensive community?based public health approach to suicide prevention. I believe that both the Vital Signs article and the journal companion piece will attract a great deal of attention. This is the debut feature on suicide in a Vital Signs and the results are highly compelling and relevant to a wide public health audience (see description below) including states, prevention practitioners, and providers. In addition, the U.S. Surgeon General has also expressed interest in conducting a town hall meeting as part of the wider release. BRIEF DESCRIPTION: Suicide rates have increased nearly 30% between 1999 and 2016. To address this serious and growing problem, the proposed Vito! Signs will use data from the Notionoi' Vital Statistics System (NVSS, 1999-2016) and National Vioient Death Reporting System 2015). The trends in suicide rates in the U5. overall and by store and set, will be reported for the first time. Changes in state rankings over time will also be included. To help the reader fully understand and appreciate the multiple factors influencing suicide risk, the report will also compare the many social and environmental circumstances preceding suicide among people with and without known mental health problems. Preventive solutions will be offered that focus on a comprehensive population-based approach using the best available evidence as described in the CDC's Suicide Prevention Technical Package. We have selected AJPH as ourjournal of choice for this commentary as we believe its reputation for high quality science and public health prevention most closely aligns with our message and our target audience. We hope that you will partner with us as we forge this exciting territory. For your convenience, here is an example of a relatively recent Vital Signs {on opioidsl and the companion commentary. I look forward to your reply and the opportunity to provide additional information. Sincerely, Deb Stone Deb Stone. Scl), MSW. MPH Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research Evaluation Branch Buford Highway, MS Atlanta, GA 30341 T70.488.3942 cistone3@cdc.gov American Journal of Public Health Now is the time Public Health, Comprehensive, Integrated Approach to Manuscript Number: Article Type: Keywords: Corresponding Author: First Author: Order of Authors: Full Title: Manuscript Classi?cations: Author Comments: Additional Information: Question Please list the Abstract word count for this document. This count is forwarded to the Editors and Reviewers as part of the evaluation process. Please list the main text word count for this document. This count excludes the abstract. ?gures and tables. and references and is forwarded to the Editors and Reviewers as part of the evaluation process. Please list the number of references in this document. This count is forwarded to the Editors and Reviewers as part of the evaluation process. Preventing Suicide Draft-- Editorial suicide prevention; public health; comprehensive Eric Caine, MD. University of Rochester Medical Center Rochester, NY UNITED STATES Eric Cains, MD. Eric Caine. MD. Now is the time Public Health. Comprehensive. Integrated Approach to Preventing Suicide 12: Community Health; 34: Health Professionals; 45: Injuryr?Ernergency CareNioience; 51: Mental Health; 55: Prevention; 56: Public Health Practice This editorial is submitted in the context of a forthcoming MMWR report (due for publication 5 June 2028) from the Division of Violence Prevention. National Center of Injury Prevention and Control, CDC. The authors of that report asked if we would be willing to prepare an editorial for AJPH timed to coincide with the release of the MMWR piece. We also were given an advanced copy of what is being prepared. We stipulated that whatever we would write would be our own opinions. While we welcomed the advanced copy. we also that indicated anything we prepared would NOT be subject to approval by CDC personnel or administration. Once that was agreed to, we prepared this manuscript for your review. I did let CDC personnel look at the near-final draft yesterday to let them know what we would be submitting. Aside from some grammatical 'stuff' thatl and my colleagues missed, and a suggestion to add a date for my comment a comparing the number of overdose and suicide deaths (which I had already), there were no changes to ideas, comments. points of view. etc. Thank you for considering what my co-authors and I consider to be an important and timety submission. Yours truly, Eric Caine Response 0 1260 6 Powered by Editorr'ar? Manager? ano? Proo?UXr'on Manager@ from Aries Systems Corporation Please list the number of Tables and Figures and Supplemental Tables and Figures in this document. This count is forwarded to the Editors and Reviewers as part of the evaluation process. Please report counts as follows: Figures: Tables: Supplemental Tables: Supplemental Figures: {where represents the actual count of submitted Tables and Figures). Af?liations Statement Acknowledgments and Disclosure Human Participant Protection statement 0 Eric D. Caine, MD Injury Control Research Center for Suicide Prevention Department of University of Rochester Medical Center Rochester. NY Jarrod Hindman. MS Colorado Department of Public Health and Environment Violence and Injury Prevention-Mental Health Promotion Branch Denver. Colorado Jerry Reed. MSW Injury Control Research Center for Suicide Prevention Education Deveiopment Center Washington. DC Marian E. Beta. MD, MPH Department of Emergency Medicine University of Coiorado School of Medicine Denver, Colorado Drs. Caine and Reed are supported, in part, by grant R49 CEDUZOQS (ED. Caine, PI) from the Centers for Disease Control. All opinions expressed are those of the authors and not of CDC. NIP. Powered by Editorial Managerf?i and ProduXion Menagerie) from Aries Systems Corporation Cover Letter SCHOOL 01? MEDICINE 8: Departmental? Eric D. Caine. MD. Professor oi Director, injury Control Research Center for Suicide Prevention MEDICINE 5 Apr1l2013 Alfredo Morabia, MD, Editor American Journal of Public Health Dear Dr. Morabia: This editorial is submitted on behalf of my colleagues and me in the context of a forthcoming MMWR report (due for publication 5 June 2023) from the Division of Violence Prevention, National Center of Injury Prevention and Control, CDC. The authors of that report asked if we would be willing to prepare an editorial for AJPH timed to coincide with the release of their MMWR piece. We also were given an advanced draft of what is being prepared. In our initial discussion, we stipulated that whatever we would write would be our own opinions. While we welcomed the advanced copy, we also that indicated anything we prepared would go; be subject to approval by CDC personnel or administration. Once that was agreed to, we prepared this manuscript for your review. I did let CDC personnel look at the near-final draft yesterday to let them know what we would be submitting to you. Aside from some grammatical 'stuff' that I and my colleagues missed, a couple of word clarifications, and a suggestion to add a date for my comment comparing the number of overdose and suicide deaths (which I had in hand already}, there were no changes to ideas, comments, points of view, etc. We very much appreciate your time and consideration! Yours truly, Eric D. Caine, M.D. 3m) Crittenden Boulevard Box - Rochester, NY 14642 +1-585-746-3574 a Manuscript Click here to download Manuscript Suicide Editoriai_related to 06.05.18 Now is the time Public Health, Comprehensive, Integrated Approach to Preventing Suicide The rapidly rising tide of suicides and risk-related drug overdose deaths (collectively, ?self - injury mortality;" SIM) has contributed substantially to decreasing U.S. life expectancy.[1] This national crisis reflects fraying social fabric as well as individual vulnerabilities: Indeed, these deaths serve simultaneously as measures of community health and indicators of individual They potentially signal greater trouble ahead for our nation and its states and communities. This week?s MMWR, from Division of Violence Prevention, underscores the extraordinary burden of lives lost to suicides, deaths whose effects ramify widely throughout families and communities. The U.S. crude suicide rate in 2000 was 10.40 per 100,000 lives, rising by 2016 to 13.92, an overall increase of with an uneven impact across states. Moreover, this likely is an under-estimate, due to mounting fatal opioid overdoses, many of which are codified as ?accidents? by medical examiners and coroners in the absence of definitive evidence of intent to die.[3] Antecedent family, and social factors that contribute to suicides, as identified in the MMWR report, also are common to deaths from drug overdoses.[1] The cumulative national burden of SIM now equals or exceeds that of diabetes?albeit, rendering many more years of life lost because the bulk of these deaths occur before age 55.[4] We bring to this discussion perspectives represented by the Colorado National Collaborative This collective of local, state and national partners is working to design, implement and rigorously evaluate a coherent set of initiatives to save lives by preventing suicides, and SIM more generally, reaching persons of all ages living in urban and rural communities across Colorado. Efforts to roll back this rising tide largely have depended on interceding when individuals are in-crisis or have survived a suicide attempt. While these are essential emergency interventions, a fundamental reduction in rates will require aggressively addressing ?upstream' factors to steer individuals away from lethal life trajectories as well as access to needed clinical services. In an analogous fashion, mortality reductions from cardiac-vascular disorders followed promotion of positive health habits, smoking cessation, and increasing exercise; screening for antecedent indicators of future clinical disorders; and fostering cultural transformation among health care providers and health systems to identify treatable ?risk factors" rather than awaiting later adverse events. Lasting reductions in suicides and related adverse outcomes will depend on highly integrated, comprehensive public health programs?upstream and programs as well as crisis services?implemented with the committed involvement of local communities. It is best that we define what we mean by public health, comprehensive, and integrated. Each term connotes implicates that may not be considered when facing the complex social, policy, and health challenges that are inherent to preventing suicides. Public health must embrace the challenge of reducing stigma. Suicide, and frequently linked mental health and substance use disorders as well as fraught social, economic, and family issues, have been an intensely private, closely-held matters shrouded by shame and silence. How many people would accept such issues as public (health) concerns? IIOI Comparable silence once shrouded issues such as breast cancer and HIWAIDS. However, champions of social change and fighters of stigma made it acceptable to seek support, advocate for lasting cultural transformation, and make demands for policy change and research funding.[5] Opioid deaths now are grabbing national attention and new funding. Suicides exceeded all overdose fatalities until 2016,[2] but they never generated a sense of public urgency. Some clinicians, researchers, and policy makers considered suicide as a relatively rare outcome specific to high-risk persons rather than a result, in part, of societal forces. Broadly applied prevention efforts will not be effective until there is a collective imperative to save lives otherwise lost, not simply focusing on uniquely vulnerable individuals, many of whom were viewed previously as weak or defective and reSponsible for their own fate. Comprehensive requires an appreciation of where in communities it is possible to engage potentially vulnerable populations long before individual members become suicidal. It requires an understanding of those social factors and policies that promote well-being, while seeking to mitigate those that degrade families and communities, however inadvertent or intentional they may be. Systemic, strategic, and encompassing, it requires the development of programs based on data about overall burden as well as death rates. it means binding together community organizations and committed individuals that already are involved while recruiting new ones, as well as reducing structural and fiscal barriers between health systems and communities. Comprehensive also requires changing values in the general population?to bring full meaning to public health?by building and reinforcing a shared culture of safety and caring. Firearms are the method used in half of U.S. suicides.[2] A recent study showed that only one-third of gun-owning households stored firearms unloaded and locked; there was no difference between families with a youth who had risks for self-harm versus other homes.[6] Broadly supported discussions to promote safe homes?whether involving guns, poisons or medications, or slippery rugs that are hazards for elders?should be the purview of a society that cares about its citizens. Working with firearm retailers and owners, pharmacies, and poison control experts will be essential for creating an atmosphere of culturally-attuned respect and common purpose, and safer homes. Similarly, comprehensive must include more effective use of social media to promote mental health and caring communities, especially in the current Wild West of the Internet. The latter too often serves as a platform for sharing of suicide-tinged themes, bullying, and social discourse promoting shame and humiliation, especially among teens and young adults. There remains insufficient understanding of how to instigate the type of exchanges and virtual communities that diminish vulnerabilities, promote a helping-society, and foster public health. integrated is especially challenging in our country, which has no central health authority, unlike countries that have successfully implemented their national strategies. There has been substantial progress uniting national level activities through the National Action Alliance for Suicide Prevention (a public-private partnership}, together with CDC, NIMH, SAMHSA, VA, and However, it has been challenging to forge state and local coalitions that have the collective moral and statutory authority, as well as the necessary resources, to conduct effective, persisting efforts. The U.S. is too large and too diverse to launch and sustain local actions that ?reach the ground? based on Federal activities alone. At the same time, national level efforts have provided many of the tools essential to building effective, lasting local partnerships, and already have offered inspiration, guidance, and support. These include the 2012 National Strategy for Suicide Prevention prevention/index.html] and the consistent record of funding through the Garrett Lee Smith Memorial Act since 2005, which serves youth between the ages of 10-24 years. Recently, grants from NSSP, SAMHSA (Zero Suicide), and CDC have focused on adults. This past year the National Action Alliance released its report, Transforming Communities (http: i helping to facilitate the development of effective local?state partnerships. Division of Violence Prevention of published, Preventing Suicide: A Technical Package of Policy, Programs, and Practices The latter offers a review of evidence-based tools, complementing materials from the SAMHSA-funded Suicide Prevention Resource Center These tools provide valuable assistance for building evidence-based programs that depend on measuring outcomes and defining what works in an accountable fashion. Ultimately, the development of an effective, sustained, comprehensive set of integrated public health programs will depend on the commitment?the political and social will?of states, cities, and diverse communities (both geographically defined and reflecting common interests) to build structures that reach far and wide. Federal leadership and scientific knowledge are necessary but not sufficient. Local determination can make the difference. 1. Case, A., Deaton, A, Mortality and morbidity in the 21st century, in Brookings Panel on Economic Activity, March 23-24, 201?. 2017, Brookings Institute. 2. WISQARS, Fatal injury Reports, National and Regional, 1999 - 2016, National Center for Injury Prevention and Control. Accessed March 26, 2018, Centers for Disease Control and Prevention. 3. Rockett, et al., Discerning suicide in drug intoxication deaths: Paucity and primacy of suicide notes and history. PLUS ONE, 2018. 13(1): p. e0190200. 4. Rockett, et al., Self-injury mortality in the united states in the early 21st century: A comparison with proximally ranked diseases. JAMA 2016. 73110): p. 1072-1081. 5. Lytle, M.C., v.3. Silenzio, and ED. Caine, Are there still too few suicides to generate public outrage? JAMA 2016. 73(10): p. 1003-1004. 6. Scott, J., D. Azrael, and M. Miller, Firearm Storage in Homes With Children With Self- Harm Risk Factors. Pediatrics, 2018. 141(3). From: Stone, Deborah Sent: 29 Mar 2018 23:08:43 +0000 To: American Journal of Public Health Editor Subject: RE: CDC Commentary for a June Vital Signs on Suicide Dear Dr. Morabia, Per the email correspondence below, Dr. Eric Caine will be submitting an opinion editorial to you by April 5th. Is there is a special way to submit this so that it can be flagged for publication a few days after June 5th or does it get submitted in the typical way via the editorial manager? Also, I wanted to ask if there?s any way the op-ed can come out on June 5th in line with our vital signs release? If not, as you indicate a few days after June 51th will be fine. Thank you so much. Sincerely, Deb Stone From: American Journal of Public Health Editor Sent: Monday, February 19, 2018 2:55 PM To: Stone, Deborah Subject: Re: CDC Commentary for a June Vital Signs on Suicide Dear Deb Stone, I am happy to offer an opinion editorial in AJPH to accompany the Vital Signs. If I get it by April 5 it could appear online a few days after June 5 2018. Sincerely, Alfredo Morabia, MD, Editor-in-Chief, AJPH 18888.! ISJEH From: Morabia, Alfredo Sent: Thursday, February 15, 2018 11:41 PM To: American Journal of Public Health Editor Subject: Fw: CDC Commentary for a June Vital Signs on Suicide From: Stone, Deborah (CDCIONDIEHINCIPC) <2an cdc. Dy:- Sent: Thursday, February 15, 2018 5:57 PM To: am52@columbia.edu Cc: Subject: CDC Commentary for a June Vital Signs on Suicide Dear Dr. Morabia, My name is Deb Stone. I?m a behavioral scientist at CDC in the Division of Violence Prevention. am leading the publication of a CDC Vital Signs focused on suicide to be released June 5, 2018. Vito! Signs, as you may know, began in 2010 and is a high profile CDC publication widely distributed to highlight important public health threats and what can be done to prevent them. The release always includes a web page, an MMWR article, a translation piece (Le. fact sheet), science clips, and a telebriefing by the CDC Director with the media. It also often includes a companion commentary piece in a top tierjournal, linked on our CDC Vital Signs web site and referenced in the other materials. i am writing to inquire whether AJPH may be interested in coiioboroting with us to pubiish such commentary. The commentary intends to integrate our study findings and the work of one state that is pioneering the first-ever comprehensive community?based public health approach to suicide prevention. I believe that both the Vital Signs article and the journal companion piece will attract a great deal of attention. This is the debut feature on suicide in a Vital Signs and the results are highly compelling and relevant to a wide public health audience (see description below) including states, prevention practitioners, and providers. In addition, the U.S. Surgeon General has also expressed interest in conducting a town hall meeting as part of the wider release. BRIEF DESCRIPTION: Suicide rates have increased nearly 30% between 1999 and 2016. To address this serious and growing problem, the proposed Vito! Signs will use data from the Notionoi' Vital Statistics System (NVSS, 1999-2016) and National Vioient Death Reporting System 2015). The trends in suicide rates in the U5. overall and by store and set, will be reported for the first time. Changes in state rankings over time will also be included. To help the reader fully understand and appreciate the multiple factors influencing suicide risk, the report will also compare the many social and environmental circumstances preceding suicide among people with and without known mental health problems. Preventive solutions will be offered that focus on a comprehensive population-based approach using the best available evidence as described in the CDC's Suicide Prevention Technical Package. We have selected AJPH as ourjournal of choice for this commentary as we believe its reputation for high quality science and public health prevention most closely aligns with our message and our target audience. We hope that you will partner with us as we forge this exciting territory. For your convenience, here is an example of a relatively recent Vital Signs {on opioidsl and the companion commentary. I look forward to your reply and the opportunity to provide additional information. Sincerely, Deb Stone Deb Stone. Scl), MSW. MPH Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research Evaluation Branch Buford Highway, MS Atlanta, GA 30341 T70.488.3942 cistone3@cdc.gov From: Stone, Deborah Sent: 20 Feb 2018 16:55:50 +0000 To: Simon, Thomas James Subject: RE: CDC Commentary for a June Vital Signs on Suicide Thanks Tom and Jim, I'll reach out to CD and thank you for clarifying that the MMWR doesn?t need to be cleared {or cross- cleared] to make the editorial happen. That?s a relief! Deb From: Simon, Thomas Sent: Tuesday, February 20, 2018 10:23 AM To: Mercy, James (CDCIDNDJEHINCIPC) Stone, Deborah Subject: RE: CDC Commentary for a June Vital Signs on Suicide Hi Deb, I?m so glad that AJPH is open to this. I think we should start reaching out to colleagues in C0 who might be interested in writing this. I think they could simply use the increasing rates in the MMWR as a starting point for the broader discussion about what comprehensive suicide prevention looks like in a state, the role of technical package, how they are making prevention happen, how they will monitor and sustain it etc. Our MMWR does not need to be cleared first. We could provide our colleagues who are writing this commentary with a brief description of the key findings and that should be sufficient to get them started. I don?t think Cross?clearance will be needed if we keep the focus described above. We won?t need to cross?clear with NCHS since we are not presenting new data from Vital Stats in the commentary. ?Tom From: Mercy, James Sent: Tuesday, February 20, 2018 6:41 AM To: Stone, Deborah Simon, Thomas (CDCJONDIEHXNCIPQ ctg59@cdc.gov> Subject: RE: CDC Commentary for a June Vital Signs on Suicide This is great Deb. I think this could be worked out. As I understand it this ?editorial? would have to parallel and not duplicate the VS MMWR, although you clearly will have to link the two. So need to think of an interesting and captivating way to sort of simultaneously link to the MMWR, but elevate the issue in a different way. Maybe use the editorial to talk about comprehensive suicide prevention or primary directions we should be heading comprehensive, social media, etc). I don?t see why the MMWR has to necessarily be cleared first. Why would we need cross clearance on the ?editorial?? Let me know if there is anything I can do to help. Thanks, Jim From: Stone, Deborah Sent: Monday, February 19, 2018 4:45 PM To: Simon, Thomas Cc: Mercy, James Subject: FW: CDC Commentary for a June Vital Signs on Suicide Hi Tom, The good news is that we got the green light to submit an Opinion Editorial to AJPH (similar format to JAMA Viewpoint). The bad news is that we need to do so by April 5th. I think we should go forward with this but wouldn?t we need a cleared MMWR first? i think we could manage Center clearance but cross?clearance?? Will need to talk this Deb Opinion Editorials may be commissioned or reformatted as editorials from submitted papers. They are 1200 words of text with subheadings, 1 small table or figure, and no more than 7? references. From: American Journal of Public Health Editor Sent: Monday, February 19, 2018 2:56 PM To: Stone, Deborah (CDCIONDIEHKNCIPCJ Subject: Re: CDC Commentary for a June Vital Signs on Suicide Dear Deb Stone, I am happy to offer an opinion editorial in AJPH to accompany the Vital Signs. If I get it by April 5 it could appear online a few days after June 5 2018. Sincerely, Alfredo Morabia, MD, Editor-in-Chief, AJPH Twitter AJPH From: Morabia, Alfredo Sent: Thursday, February 15, 2018 11:41 PM To: American Journal of Public Health Editor Subject: Fw: CDC Commentary for a June Vital Signs on Suicide From: Stone, Deborah (CDCIONDIEHJNCIPC) <2af9 cdc. ova-? Sent: Thursday, February 15, 2018 5:57 PM To: am52@columbia.edu Cc: Subject: CDC Commentary for a June Vital Signs on Suicide Dear Dr. Morabia, My name is Deb Stone. I?m a behavioral scientist at CDC in the Division of Violence Prevention. I am leading the publication of a CDC Vital Signs focused on suicide to be released June 5, 2018. Vita! Signs, as you may know, began in 2010 and is a high profile CDC publication widely distributed to highlight important public health threats and what can be done to prevent them. The release always includes a web page, an MMWR article, a translation piece fact sheet), science clips, and a telebriefing by the CDC Director with the media. It also often includes a companion commentary piece in a top tierjournal, linked on our CDC Vital Signs web site and referenced in the other materials. i am writing to inquire whether AJPH may be interested in collaborating with us to pabiish such a commentary. The commentary intends to integrate our study findings and the work of one state that is pioneering the first-ever comprehensive community-based public health approach to suicide prevention. I believe that both the Vital Signs article and the journal companion piece will attract a great deal of attention. This is the debut feature on suicide in a Vital Signs and the results are highly compelling and relevant to a wide public health audience (see description below) including states, prevention practitioners, and providers. In addition, the US Surgeon General has also expressed interest in conducting a town hall meeting as part of the wider release. BRIEF DESCRIPTION: Suicide rates have increased nearly 30% between 1999 and 2016. To address this serious and growing problem, the proposed Vito! Signs will use data from the National Vital Statistics System (NVSS, 1999-2016) and National Violent Death Reporting System 2015). The trends in suicide rates in the U.S. overall and by store and sex, will be reported for the first time. Changes in state rankings over time will also be included. To help the reader fully understand and appreciate the multiple factors influencing suicide risk, the report will also compare the many social and environmental circumstances preceding suicide among people with and without known mental health problems. Preventive solutions will be offered that focus on a comprehensive population-based approach using the best available evidence as described in the Suicide Prevention Technical Package. We have selected AJPH as ourjournal of choice for this commentary as we believe its reputation for high quality science and public health prevention most closely aligns with our message and our target audience. We hope that you will partner with us as we forge this exciting territory. For your convenience, here is an example of a relatively recent Vital Signs {on opioids] and the companion commentary. I look forward to your reply and the opportunity to provide additional information. Sincerely, Deb Stone Deb Stone. Set), MPH Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research 8: Evaluation Branch 4WD Buford Highway. MS F-E4 Atlanta. GA 30341 detone3@cdc.gov From: Holland, Kristin Sent: 15 May 2018 14:30:24 -0400 To: Stone, Deborah Subject: RE: CDC Data Release - County-Level Trends in Suicide Rates at Upcoming MMWG Call {5:31} Attachments: Suicide VSWG Meeting Notes S.1S.18.docx Ack? I?m sorry I missed this. I went straight to 2 other meetings after our VS meeting. Here?s the most recent verison. From: Stone, Deborah Sent: Tuesday, May 15, 2018 1:19 PM To: Holland, Kristin Subject: RE: CDC Data Release - County-Level Trends in Suicide Rates 8t Upcoming MMWG Call {5.131) Can you send me the most recent (18:15? have until 2:00 to review them. Ugh. Deb From: Holland, Kristin Sent: Tuesday, May 15, 2018 11:59 AM To: Simon, Thomas st 59 cdc. ova- Cc: Stone, Deborah cdc. ov> Subject: RE: CDC Data Release County-Level Trends in Suicide Rates 8t Upcoming MMWG Call {5331) Added this to the ?recent CDC research" section of the QA doc: In mid-May, the National Center for Health Statistics released a stud),J describing county-level trends in US. suicide rates from 2005-2015. I This study, published in the American Journal of' Preventive Medicine, documents that county-level suicide rates increased by more than l0% from 2005 to 20l5 in 99% of counties in the 87% of counties showed an increase of greater than 20% . States and communities can use these data in combination with the results from the present study to obtain more granular level detail about suicide rates within their states and to help focus prevention efforts. From: Simon, Thomas Sent: Tuesday, May 15, 2018 9:54 AM To: Holland, Kristin simhl cdc. ov> Cc: Stone, Deborah <2af9@cdc.gov> Subject: RE: CDC Data Release - County-Level Trends in Suicide Rates Upcoming MMWG Call Hi Kristin, Yes, they had mentioned this a while ago and that it was in the pipeline with AJPM. We asked and they confirmed that there were no state-specific rates and there would not be a press release. We were not so concerned given that. Tom From: Holland, Kristin Sent: Tuesday, May 15, 2018 9:37 AM To: Simon, Thomas (CDCIONDIEHXNCIPC) st 59 cdc. ov> Cc: Stone, Deborah Subject: FW: CDC Data Release - County-Level Trends in Suicide Rates Upcoming MMWG Call {5f31} Importance: High Hi Tom, I'm not sure if you received the email below. Deb and were both surprised to see that this analysis of county-level trends in suicide rates was released online yesterday. The first author is someone from NCHS, who i don?t believe any of us has worked with, but Holly and Margy are also coauthors, so I would have expected to hear about this in our meetings with NCHS. I don?t recall them mentioning it in any of our recent meetings, as I think we would have expressed concern over the timing ofthe release with respect to the VS. Kristin P.S. We have a media messaging meeting with this WG scheduled for Thursday where we can let them know the social media post they proposed below is not accurate: Data released by featured in PrevMed shows county-level trends in suicide rates in the US I CDC Injury is not the group that released this data it?s NCHS. From: Torguson, Kimberly Sent: Monday, May 14, 2018 6:55 PM Subject: CDC Data Release - County-Level Trends in Suicide Rates Upcoming MMWG Call {531) Importance: High Hello Media Messaging Work Group, We wanted to call to your attention to a just-released article published in the American Journoi of Preventive Medicine that looks at county-specific estimates of suicide rates. The paper titled "County- level Trends in Suicide Rates in the U.S., 2005?2015? was written by our Partner, CDC {authors include: Lauren M. Rossen, Holly Hedegaard, Diba Khan and Margaret Warner from Key findings include: I Posterior predicted mean county-level suicide rates increased by >10% from 2005 to 2015 for 99% of counties in the U.5., with 87% of counties showing increases of Iv Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.5., with the exception of southern California and parts of Washington. It Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the U5. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement (written in collaboration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please find below some tailorable social media posts to help further promote the data: a Data released by featured in @AmJPrevMed shows county-level trends in suicide rates in the US I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts http:/fbitiy/ZIHthk - Trends about suicide, like geographic patterns, helps us develop more targeted community?based #suicideprevention strategies so we can reduce annual suicide rate 20% by 2025 - Rural counties in the 0.5. had the highest estimated suicide rates from 2005?2015 according to just?released @AmJPrevMed I Tracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts I Together we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community?level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: I @Action Alliance - West I @afspnational I @CDCIniury I I @DeptofDefense I @DeptVetAffairs I @EDCTweets NIH I I @samhsagov I @SAVEvoicesofedu - I @TrevorProiect I Some resources that you may also find helpful as you promote the data include: I Action Alliance's Transforming Communities: Key Eiements for the impiementation of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. I CDC's Preventing Suicide: A Technicai Package of Poiicv, Programs, and Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this larger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Piease join us for a pianning ca" on Thursday, May 31 at 2:00 am. ET to pian ahead for re?ective stgtement about CDC data. We will send you a calendar invite (containing call~in information) to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC for giving us the heads up about the data. Thank you. Kimberly Torguson Associate Director for Communications National Action Alliance for Suicide Prevention Email: kto_rgu_s_on@edcorg Phone: 202-572-373? Follow us: Twitter Facebook NATIONAL ACTION ALLIANCE FOR SUICIDE PREVENTION SUICIDE VITAL SIGNS WORK GROUP MEETING MAY 15, 2018 ibi(6) 1? .1 - 12 noon 1:00 ?iaglafgl?sgi?awr Note taker: Kristin i Agenda 23; Set up welcome (Deb; 5?10 mins) 3e Monday?s curve ball >3 Change from "mental health problems" to "mental health conditions" 3; Comms products, FS, and MMWR have all been updated with this language I Social media, telebriefing script, press release I Did You Know items will be pulled from the F5 1* Recap from last week?s pre-brief new updates, next steps Pre?brief debrief (Attendees 8L Deb; 10 mins) Next steps (see attached table] MMWR status (Deb; 5 mins] 1r Next steps (what's on the horizon} I Deb rec?d first proof on Friday II Revisions were due 8am on Monday complete I Deb rec?d additional reviewer comments from first proof on Monday I Revisions submitted on Monday spoke with Theresa on the phone I Deb rec?d second proofs yesterday late in the day 0 Revisions due by 1:00 today Will review the tables again because of concern over double set of proofs I A few changes had been made to indentations and holding of overarching categories I mental health conditions need to be indented I Kristin will help with this review I Should receive third set of proofs tomorrow - Tables need to be reviewed by Friday Err- Fact Sheet (Deb; 5 mins) 3% Next steps I Changes to ?everyone can? section I Changes to page 3 consistent with best practices for media I Graphic design elements 0 will coordinate with Molly I Tom will take first pass and forward to Deb and Kristin Next version due back to VS team 5?316 C013 3. Communication products Kristin 5 mins] Next steps I Press release with VS team I Critical contacts, dear colleague letter? with VS team Social media II Pulled directly from F5, but social media team came back with changes 0 Substance abuse - change to "substance use? Will send those to Tom I with Kristin; will send to Deb to review - Needs to be submitted to V5 team by C03 today Telebriefing introduction wording is ?Suicide: More than just a MH condition" Script talking points received from Surgeon General yesterday afternoon - Need to review will send to the group 0 will put these TPs into the overall script and send the script back out Outstanding pieces: script, media advisory Policy/Partnerships (Erin; 5 mins) Next steps I Town Hall June 12 - Need to identify state examples 0 Colorado should be one Malia can reach out to Ellie at SPRC to get another example 0 Malia will formulate email forJarrod and Deb will send it I The ask will be to do a presentation - need to pull together talking points and slides we need them by June 1 0 Second state suggestions: NC, MA, TX . State health dept seems to be involved Who does this involve? Deb has 8 mins to present, state speakers 0 We can all call in at 2:00 on this day I Malia has list of partners on board - ASTHO CEO will participate in Twitter chat It Will take part in call to give them a heads up I Will talk to DARPI about how to prime grantees - Congressional plan hill alerts to every congressional office 0 Hill visits June Will do some other Hill visits in September I AFSP Policy Summit ?June 11 Will be there for that briefing (Alex) I Erin working with NGA webinar for policy health advisors in July I Blog post for national Conference of State Legislators . Template language for all of our partners? newsletter blurb, customized emails from Jim and Deb for them to send on June Iinking V5 to priorities June 7 press briefing? Deb will be there with Dr. Schuchat 3% Other items (Deblevervone; 15-20 mins Town hall 3} Continuing education Science clips p? Next stepsfmeetinngrap-up (Deb; 5 mins) Next VS Due Dates: 0 To be provided in updates above What we need to get moving on I Town Hall - Need to nail down participant list by end of the week Continuing education - candidate questions so people can get CEUs From: Chris Maxwell Sent: 7 Jun 2018 13:38:43 +0000 To: Richmond-Crum, Malia Cc: Stone, Deborah Subject: Re: CDC Report Hi Malia, I greatly appreciate you sending these over and I totally understand about the strict limits put on sensitive information. Thanks again and I hope you have a wonderful rest of the week. Take care, Chris Maxwell Communications Coordinator American Association of Suicidologv 5221 Wisconsin Ave, NW Washington, DC 20015 Office: 202-23?-2280 ext. 306 Cell: 913-?75-2293 AAS is a membership organization for off those invoived in suicide pro vention and intervention, or touched by suicide. AAS is a tender in the advancement of scienti?c and programmatic efforts in suicide prevention through research, education and training, the deveiopment of standards and resources, and survivor support services. On Jun 7, 20l8, at 8:36 AM, Richmond-Crum, Malia wrote: Chris, Thank you very much for reaching out. Deb shared your email with me as I?m helping with outreach related to the Vital Signs launch. Embargoed copies of the report and associated materials are attached. Please do not share this information with your networks until the embargo lifts at 1pm today. Some additional information is below on events ~te ebriefing for media, social media tools and Town Hall teleconference next week. I?m so sorryr we weren?t able to share these materials with you sooner so that it would have helped with media inquiries. We were under a strict embargo and are only allowed to share even embargoed copies beginning at this morning. Please let me know if I can answer anv questions or help in anvwav moving forward. Best, Malia The CDC VitoiSigns series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortality Weekly Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7,2018, at 1:00 pm (EST) following a media telebriefing at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: I In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Web page to ?nd the MMWR article, fact sheet, and other materials. Take advantage of CD05 scolal media tools, such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Malia Richmond-Crum. MPH Team Lead, Policy and Partnerships Division of Violence Prevention National Center for Injury Control and Prevention Centers for Disease Control and Prevention Office: 770-488-0526 Ce lz 60-11-3016135 igriclimojgcium?chcgov From: Chris Maxwell Sent: Thursday, June ?,2018 9:27 AM To: Stone, Deborah Subject: CDC Report Hi Deb hope you?re doing well! We?ve been contacted by some members of the press over the past couple of days due to the recent and unfortunate celebrity suicide and a few of them have been referencing the vet-to-be-released report coming out today regarding suicide and data. Would it be possible for our Executive Director and President to receive drafts or embargoed advance copies of these types of reports so they can be better prepared to answer the questions from the media? This could go a long way in helping both our membership and the general public be more prepared to handle inquiries from the media, especially when the media has been provided advance notice or data. If we need to contact someone else over there, please let us know who we should get in touch with. Thanks and looking forward to hearing from you! Chris Maxwell Communications Coordinator American Association of Suicidologv 5221 Wisconsin Ave, NW Washington, DC 20015 Office: 202-23?-2280 ext. 306 Cell: 913-775-2293 AAS is a membership organization for those invoived in suicide prevention and intervention. or touched by suicide. AAS is a ieader in the advancement of scienti?c and programmatic e?orts in suicide prevention through research, education and training, the deveiopment of standards and resources. and survivor support services. From: Hindman - CDPHE, Jarrod Sent: 4 Jun 2018 14:52:58 -0600 To: Richmond-Crum, Malia Cc: Stone, Deborah Subject: Re: CDC Suicide Vital Signs Town Hall: Request for bio, photo and PPT slides Attachments: 2018-06-12-CDC-Hindman.pptx See attached. Happy to update the data, but am not totally sure what the Vital Signs will have us ranked at. I'm fine changing the talking point to something like, ?2014-2016 - highest rate in nation according to Vital Signs report". deleted slide #2 rather than combining ll and 12. JH On Mon, Jun 4, 2018 at 2:22 PM, Richmond-Cram, Malia wrote: Thanks Jarrod. A couple of edits: Slide 3 I The in Laws should be capitalized to be consistent with the rest ofthe table I Data point about Colorado rate being in the nation is inconsistent with the state data which will be reported through Vital Signs because that combines multiple years (2014-2016) and results in a different ranking. You could keep as is, but I just want you to be aware it may look a little off so you may have to address in talking points. Slide 8: type in home-base Slide 11 and 12 is it possible to combine these? We're kept to a strict slide limit of 12 and your last slide should include your contact info so we?ll need a new Slide l2 that has that info. Malia From: Hindman CDPHE, Jarrod Sent: Monday. June 4, 2018 2:57 PM To: Richmond-Crum, Malia wrote: Hi Jarrod I hope your conference went well last week. We?re looking for to receiving your slides this morning. Please let me know if you have any questions or need anything today. Also we would like to schedule a run through with you and Neetha on the phone on Friday we?re free anytime after Noon ET on Friday works for us. Please let me know your availability that day and I will send a meeting invite. Best, Malia From: Richmond-Grunt, Malia Sent: Friday. June I, 2018 3:16 PM To: Stone, Deborah Hindman - CDPHE. Jarrod Ce: Bruce, (CDCIOPHPRIOD) Subject: RE: CDC Suicide Vital Signs Town Hall: Request for bio. photo and PPT slides Jarrod I hope your conference went well. Ijust wanted to share the attached FAQs for Town Hall speakers in case this is helpful as you ?nalize your slides and send to us on Monday morning. Have a good weekend. Malia From: Stone, Deborah (CDCKONDIEHKNCIPC) Sent: Wednesday. May 30, 2018 12:57 PM To: Hindman - CDPHE, Jarrod Richmond-Crum, Malia (CDCHON Ce: Bruce, (CDCIOPHPRIOD) <5 x6 Eacdc. 'rov> Subject: RE: CDC Suicide Vital Signs Town Hall: Request for bio, photo and PPT slides Hi Jarrod, I think what you mention is great. Ifyou want me to check out the slidea ?rst to verify, happy to do so! Deb From: Hindman - CDPHE. Jarrod wrote: Hi Jarrod Would you be able to send your slides to us no later than Monday morning (June We really can?t push it back any more than that I?m afraid. I?m hoping this is not too big an ask and that you might already have slides from previous presentations that eover?s Colorado?s comprehensive approach to suicide prevention though I. totally understand when your travel, presenting at conferences etc. it can be hard to get other work done. Malia From: Hindman CDPHE, Jarrod Sent: Friday, May 25, 2018 5:39 PM To: Richmond-Crum, Malia (CDCFONDIEHINCIPC) <'rv8 f?cdc, ov> Ce: Mony, Nectha (DOH) Subject: Re: CDC Suicide Vital Signs Town Hall: Request for bio. photo and PPT slides Hi Malia - Photo and bio attached. Unfoltunately, I am completely booked on Tuesday, which is my only day in the office next week. I'll be at a conference Wed through Fri, which also means it will be very difficult for me to get you slides by next Wed. [5 there any flexibility? Sorry for the wrench and certainly let me know if that impacts my participation. Jarrod On Thu, May 24, 2018 at 3:44 PM, Richmond-Crum, Malia <1irv8g$cdcgovir wrote: Neetha and Jarrod, Thank you again for agree to participate in the June 12 Vital Signs Town Hall - Suicide Rates RisfngAcross the US. We?re very excited to have you participate and showcase the wonderful prevention work you?re doing in Washington and Colorado respectively. I have a couple of requests: 1. Would you please send a short (1-2 paragraph) bio and photo to me by COB Friday? a. This info will be posted on CDC "s website (see 2. I would like to schedule a 30 minute conference call. with you both to discuss the Town Hall logistics. Here are some dates/times, please let me know your availability. oFriday May 24 (tomorrow): 12-4:30prn ET oTuesday May 29: [2:00-4:30pm ET Wednesday, May 30: 12:00?4z30pm ET 1. Lastly, I would like to request your Powerpoint slides be sent me no later than Wednesday, May 30. I apologize for the tight timeline and asking for them so far in advance of the Town Hall. Please let me know if the May 30 deadline is a problem. a. You?ll be speaking for 10 minutes and your PowerPoint presentation should be no more than 8 to 12 slides(slide limits are strictly enforced). I First slide should be a title slide with the name of presentation, presenter name, credentials, organization, and position. I Last slide should include presenter contact information All of acronyms are spelled out at the ?rst instance. I Slides should be material that is ready to be public facing Thank you again! Best, Malia Malia Richmond-Cram, MPH Team Lead. Policy and Partnerships Dixision of Violence Prevention Vationnl ("enter for Injury Control and Prevention ("enters for Disease (?nntrol and Prevention 7704834526 4ll4~?ll7?? gov Preventing Injuries and Violence Through Scuence and Action Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch El 303.692.25391F 303.691.7901 4300 Chem: Creek Drive South, Denver CO 80246 Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch El 303.692.2539 303.691.7901 4300 Cherrv Creek Drive South. Denver CO 80246 iarrod.hindman@state.co.us Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch IE1 303.692.2539 303.691.7901 4300 ?Cherrvr Creek Drive South. Denver CO 80246 Erodhindman?s?stateco.us Jarrod Hindmau, MS Deputy Chief Violence and Injury Prevention-Mental Health Promotion Branch El 303.692.2539 303.691.7901 4300 Cherrv Creek Drive South. Denver CO 80246 iarrod.hindman@state.eo.us Jarrod Hindman, MS Deputy Chief Violence and Injury Prevention?Mental Health Promotion Branch El 303.692.2539 303.691.7901 4300 Cherry Creek Drive South, Denver CO 80246 Jarrod Hindman, MS: Violence and injury Prevention Mental Health Promotion, Colorado Dept of Public Health Environment Identifying the Starting Point: State Readiness Significant Burden Evidence High enough burden to demonstrate effectiveness of successful intervention2016 - 1,156 deaths; 20.87 per 100,000 resident52016 - 5th in the nation Political Will Senior political support governor state legislature)Recently passed legislation in support of suicide prevention Key Infrastructure Senior Executive State lnfrastructureSuicide Prevention CommissionSupport across federal, county, community behavioral health centers Firearm Laws Preferred state with less restricted rural/urban firearm ownership laws Agreement on Approach Respect for both Upstream Approaches (Public Health Mental Health) Establishing Priorities: An Interactive Data Dashboard Home=no#8 Suicides in Colorado: An Overview ll: il', 1' v? '1 i'-l ?r'io 4; Hum 5 hall)?: Lull- 155 12.5 F. II it? 415 Orr: Tl ?pol-{11 ?may; W14 ?qua [nil-uh Mir-Ml! I Plrlenl km: 1 UI-itm-I COLORADO 10303 Establishing Priorities: Health Care Priority Systems:Mental Health Behavioral ted CareEmergency DepartmentsHospitalsPrimary Care priority for older adults) VA DoDDepartment of Corrections Establishing Priorities: Youth Priority Populations and Systems:Schools (including parents) Community programs and resources serving youthDepartment of Youth CorrectionsCourts, foster care, child welfareMilitary familiesEarly childhood programs and systemsHispanic/Latino TQ youthFaith communities Establishing Priorities: Adults Priority Populations and Systems:Veterans, particularly non- VHA veteransHigh risk industriesCourts and criminal justice systemsFinancial services systems (unemployment, bankruptcy, etc.) Establishing Priorities: Older Adults Priority Systems and Services:Social services agenciesSeniors centersAssisted living facilitiesActive living servicesDeath and dying servicesFaith communityVietnam era veteransPublic service providers (transportation, meals on wheels, store clerks, etc.)Falls preventionHome- based care and servicesPain management Environmental Scan A mapping of existing efforts to prevent self-injury mortality. Participants include health systems, prison systems, government agencies, community-based organizations engaged in prevention efforts. Which Suicide-related Activities Are Happening? 00 Who do you serve? In what setting? How are your prevention efforts funded? How long do you (6 expect your funding to continue? Do you collaborate with other prevention agencies? Who are your important collaborators? Evaluation Intervention Packages ProgramsProcess and outcome designs to measure baseline and impact of all intervention strategies, programs, and/or policiesAction Research I Systems LevelTracking and measuring the processEnsuring that successes can be accounted for and replicated in additional communitiesNational partners Ensure that strategy can be replicated in other statesConstant Evolutionlterative Design Local Partners Priorities 1) Environmental Scan of Counties w/ Highest BurdenEnhance Build Local PartnershipsTarget Focal Populations: Youth, Adults, Older Adults: Criminal Justice, Veterans outside of VA, High-risk Industries 1) Steering teamEvaluation teamExpert guidance and cap?al From: Stone, Deborah Sent: 31 May 2018 17:45:05 +0000 To: Bruce, Subject: RE: CDC Vital Signs Telebriefing June 7th Hi Sorry for delay. Yes, that?s the last one I have too. Will respond to your other email shortly. Deb From: Bruce, Sent: Thursday, May 31, 2018 11:31 AM To: Stone, Deborah Subject: FW: CDC Vital Signs Telebriefing June 7th Deb, I think you were the last person working on the telebriefing script {correct me if I?m wrong}. I don?t want to send the wrong version to Dr. Schuchat office. Here?s what I?m sending, unless you have a later From: Dorigo, Leslie Sent: Thursday, May 31, 2018 11:02 AM To: Stone, Deborah Simon, Thomas Bruce, Black, Erin (e m? cdc. ova; Ballman, Marie R. Cc: Middlebrooks, Jennifer Subject: RE: CDC Vital Signs Telebriefing June 7th F?r?l, just heard from that we need the revised telebriefing script by 10AM tomorrow to send to Dr. Schuchat. Let me know status of 56 as soon as you're able. From: Dorigo, Leslie (CDCIDNDIEHJNCIPC) Sent: Wednesday, May 30, 2018 6:40 PM To: Stone, Deborah Simon, Thomas Bruce, x6 cdc. ov>; Black, Erin Ballman, Marie R. Cc: Middlebrooks, Jennifer <'od5 cdc. ov> Subject: Re: CDC Vital Signs Telebriefing June 7th Dr. Schuchat?s preference is to do the telebriefing solo but to give the 56?s office some content etc.) to promote via social media or other messaging oftheir choice on their own schedule. If this is ok with you all, think we?re ok to communicate this back to the 56?s office. From: Stone, Deborah <2af9@cdc.gov> Sent: Wednesday, May 30, 2018 5:20 PM Subject: RE: RE: CDC Vital Signs Telebriefing June 7th To: Dorigo, Leslie Simon, Thomas Bruce, Black, Erin Ballman, Marie R. Cc: Middlebrooks, Jennifer Thanks for looping in Deb H, Leslie. Will wait to hear back. If the SG doesn?t work out, suggested he could put out a written statement, just FYI. Deb From: Dorigo, Leslie Sent: Wednesday, May 30, 2018 4:12 PM To: Simon, Thomas Bruce, Stone, Deborah (CDCIDNDIEHXNCIPC) Black, Erin Ballman, Marie R. Cc: Middlebrooks, Jennifer Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Got it. Will keep you posted! From: Simon, Thomas Sent: Wednesday, May 30, 2018 4:11 PM To: Dorigo, Leslie Bruce, Stone, Deborah Black, Erin Ballman, Marie R. Cc: Middlebrooks, Jennifer Subject: RE: RE: CDC Vital Signs Telebriefing June 7th share that concern about the ASH. There could be a risk in bringing that office in at this point. From: Dorigo, Leslie Sent: Wednesday, May 30, 2018 4:09 PM To: Simon, Thomas (CDCIONDIEHINCIPC) Bruce, (igx??cdcgovb; Stone, Deborah (CDCIONDIEHINCIPC) Black, Erin Ballman, Marie R. Cc: Middlebrooks, Jennifer s'odS cdc. ov> Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Chatted with Deb. She's open to the SG doing a statement or even the ASH doing a brief call topper. We?re both a little worried about the ASH focusing more on the HHS priority angle of severe mental illness vs. our ?more than mental illness? approach though. She?s going to email Dr. Schuchat this evening and see if she wants to weigh in. From: Simon, Thomas Sent: Wednesday, May 30, 2018 4:00 PM To: Bruce, (CDCIOPHPRIOD) Dorigo, Leslie Stone, Deborah Black, Erin ; Ballman, Marie R. Cc: Middlebrooks, Jennifer <'od5 cdc. ov> Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Hi Leslie, Thank you for sharing your perspective this is very helpful. I welcome Deb H?s thoughts on this. I think a supportive message from the 36 about the urgency of the issue and the need for a public health approach will be very helpful even if it is recorded or a media statement. Him making the time to do this sends a message too. lfthat won?t work then I agree just Dr. Schuchat at the briefing. ?Tom From: Bruce, Sent: Wednesday, May 30, 2018 3:54 PM To: Dorigo, Leslie Stone, Deborah Black, Erin Ballman, Marie R. (CDCIONDIEHXNCIPC) Simon, Thomas Cc: Middlebrooks, Jennifer Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Got it! Thanks for your guidance!! From: Dorigo, Leslie Sent: Wednesday, May 30, 2018 3:52 PM To: Bruce, (CDCIOPHPRIDD) Stone, Deborah Black, Erin Ballman, Marie R. Simon, Thomas Cc: Middlebrooks, Jennifer Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Adding Tom back in because I accidentally deleted him. I checked in with on how to come to a decision on this. She recommended we make a rec and then loop in Dr. Schuchat since HHS leadership is involved. (I can get Deb?s thoughts too on recommended Deb email Schuchat with our rec. From: Bruce, Sent: Wednesday, May 30, 2018 3:51 PM To: Dorigo, Leslie Stone, Deborah Black, Erin Ballman, Marie R. cdc. ov> Cc: Middlebrooks, Jennifer <'od5 cdc. ova- Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Thanks Leslie, these are very good points! At what point to we say to the 56?s office "Thanks but, we've got this." I know they are trying to find a way for him to participate, but logistically it?s just not working out. When do we make the call and who does that? From: Dorigo, Leslie Sent: Wednesday, May 30, 2018 3:45 PM To: Bruce, Subject: RE: RE: CDC Vital Signs Telebriefing June 7th I'm just including NCIPC folks on this email (deleting VS folks). My two cents is that if the 36 cannot do it, then perhaps we could suggest he could put out a supportive media statement or something? I thinkjournalists would find a recorded message on a live telebriefing quite atypical. I also think involving the ASH at this point will be probably difficult. Deb, Schuchat, and OPP have been working closely with him on the opioid issue and he has high demands for information, quick turnaround asks, is very exacting in his questions/comments?all completely within his purview? but Ijust think it chuld be hard to manage this in the final stretch of a US and I worry that he would shift our messaging potentially. (Plus, media visibility-wise, the 56 has more pull than the ASH, so I don?t know that swapping them out is really as appealing for a journalist.) If we keep it to Dr. Schuchat, I think it?s easier for us to stay on message and have better control over the 'quote?worthy? points. From: Simon, Thomas Sent: Wednesday, May 30, 2018 3:02 PM To: Solder, Bruce, (CDCIOPHPRIOD) Stone, Deborah (CDCIONDIEHINCIPQ Schieber, Richard A. Black, Erin (CDCIONDIEHXNCIPQ Ballman, Marie R. ; Ballman, Marie R. Cc: Sokler, Omisore, Shannon L. Dorigo, cdc. ov> Subject: RE: RE: CDC Vital Signs Telebriefing June 7th We?ve never done that with a speaker. Since this is an audio telebriefing, it might not sound real, since Anne will be ?live?. We also pre-brief 20-mins before, which he would miss. Is there a conflict? From: Bruce, Sent: Wednesday, May 30, 2018 11:21 AM To: Simon, Thomas Stone, Deborah (CDCIDNDIEHKNCIPC) Schieber, Richard A. Sokler, Black, Erin (e m7 cdc. ov>; Ballman, Marie R. Subject: FW: RE: CDC Vital Signs Telebriefing June Any thoughts? I'm headed to a meeting; happy to discuss From: Migliaccio-Grabill, Kate Sent: Wednesday, May 30, 2018 11:17 AM To: Bruce, Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Hi, Is it possible to tape the 86?s remarks? Kate Migliaccio Grabill, MPH CDR, USPHS Press Secretary From: Bruce, Sent: Tuesday, May 29, 2018 11:01 AM To: Migliaccio-Grabill, Kate (HHSIOASH) Cc: Stone, Deborah Black, Erin Bellman, Marie R. Richmond-(2mm, Malia Peaker, Brandy Simon, Thomas Subject: RE: RE: CDC Vital Signs Telebrie?ng June 2th Hi Kate, We are so glad to hear that! Having Dr. Adams on the call will be an important part of the telebreifing. From: Migliaccio-Grabill, Kate (HHSIOASH) Sent: Tuesday, May 29, 2018 10:57 AM To: Bruce, Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Hi Actually, I think we can make this work. Kate Migliaccio Grabill, MPH CDR, USPHS Press SECretary From: Migliaccio-Grabill, Kate (HHSIOASH) Sent: Tuesday, May 29, 2018 10:12 AM To: Bruce, (CDCIOPHPRIOD) Subject: Re: RE: CDC Vital Signs Telebrie?ng June ?th Hi, We have a quick question for you. Is it possible to change the date? If not, would you be up for having the ASH stand in? It?s going to be really hard to have the 3G take this from the airport. He?s ?ying back that day from Dallas. On: 24 May 20181539, "Bruce, wrote: Hi Kate, Thanks for the update on the talking points! Our Vital Signs office says the airport call will be fine. We will look for comments on the talking points from Dr. Adams as soon as he can get to them. We appreciate you working with us on Respectfully, Bruce, MPH Health Communications Specialist Detailed to National Center of Injury Prevention and Control Division of Violence Prevention, Health Communications Team Office: 77048845651 Mobile: 470?249?3616 llibruce2@ctlc.g0tf Off alternate Fridays From: Dorigo, Leslie Sent: 31 May 2018 11:18:12 -O4OO To: Black, Erin Cc: Middlebrooks, Jennifer Deborah Thomas Marie R. Subject: RE: CDC Vital Signs Telebriefing June 7th Thanks, yeah, we need a final decision today. More than happy to provide them with content so he could support via a media statement or social media promo. From: Black, Erin (CDCIONDIEHINCIPQ Sent: Thursday, May 31, 2018 11:15 AM To: Bruce, (CDCIOPHPRIOD) Cc: Middlebrooks, Jennifer Dorigo, Leslie Stone, Deborah Simon, Thomas Ballman, Marie R. Subject: RE: CDC Vital Signs Telebriefing June 7th I just talked to Leslie and she asked that you please follow-up with the 50?s office and let them know we are unable to reschedule or tape Dr. Adam?s comments and thus Anne will proceed with hosting the vital signs release. From: Bruce, Sent: Thursday, May 31, 2018 11:07 AM To: Dorigo, Leslie Stone, Deborah Simon, Thomas Black, Erin Ballman, Marie R. Subject: RE: CDC Vital Signs Telebriefing June 7th you recommend I reach back out to Kate at the 36?s office? The last word i had was that she would circle back to me today when she had more details. How pushy should I be? From: Dorigo, Leslie (CDCIONDIEHINCIPCJ Sent: Thursday, May 31, 2018 11:02 AM To: Stone, Deborah Simon, Thomas Bruce, Black, Erin (CDCIONDIEHINCIPCJ Ballman, Marie R. Cc: Middlebrooks, Jennifer Cc: Middlebrooks, Jennifer Subject: Re: CDC Vital Signs Telebriefing June 7th Dr. Schuchat?s preference is to do the telebriefing solo but to give the 56?s office some content (TPs, etc.) to promote via social media or other messaging of their choice on their own schedule. If this is ok with you all, I think we?re ok to communicate this back to the 56?s office. From: Stone, Deborah Sent: Wednesday, May 30, 2018 5:20 PM Subject: RE: RE: CDC Vital Signs Telebriefing June 7th To: Dorigo, Leslie Simon, Thomas Bruce, (CDCIOPHPRIOD) Black, Erin Ballman, Marie R. Cc: Middlebrooks, Jennifer Thanks for looping in Deb H, Leslie. Will wait to hear back. If the 56 doesn?t work out, suggested he could put out a written statement, just FYI. Deb From: Dorigo, Leslie Sent: Wednesday, May 30, 2018 4:12 PM To: Simon, Thomas (CDCIONDIEHINCIPC) Bruce, Stone, Deborah Black, Erin Ballman, Marie R. Cc: Middlebrooks, Jennifer Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Chatted with Deb. She?s open to the SG doing a statement or even the ASH doing a brief call topper. We're both a little worried about the ASH focusing more on the HHS priority angle of severe mental illness ys. our ?more than mental illness' approach though. She?s going to email Dr. Schuchat this evening and see if she wants to weigh in. From: Simon, Thomas Sent: Wednesday, May 30, 2018 4:00 PM To: Bruce, Dorigo, Leslie Stone, Deborah Black, Erin Ballman, Marie R. Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Hi Leslie, Thank you for sharing your perspective this is very helpful. I welcome Deb H?s thoughts on this. I think a supportive message from the 56 about the urgency of the issue and the need for a public health approach will be very helpful even if it is recorded or a media statement. Him making the time to do this sends a message too. If that won?t work then I agree just Dr. uchat at the briefing. -Tom From: Bruce, Sent: Wednesday, May 30, 2018 3:54 PM To: Dorigo, Leslie Stone, Deborah Black, Erin Ballman, Marie R. Simon, Thomas Cc: Middlebrooks, Jennifer Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Got it! Thanks for your guidancell From: Dorigo, Leslie Sent: Wednesday, May 30, 2018 3:52 PM To: Bruce, Stone, Deborah Black, Erin sepmi?chcgow; Ballman, Marie R. (CDCIONDIEHINCIPC) Cc: Middlebrooks, Jennifer Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Adding Tom back in because I accidentally deleted him. I checked in with on how to come to a decision on this. She recommended we make a rec and then loop in Dr. Schuchat since HHS leadership is involved. (I can get Deb?s thoughts too on recommended Deb email Schuchat with our rec. From: Bruce, Sent: Wednesday, May 30, 2018 3:51 PM To: Dorigo, Leslie Stone, Deborah Black, Erin Ballman, Marie R. Cc: Middlebrooks, Jennifer Subject: RE: RE: CDC Vital Signs Telebriefing June 7th I?m just including NCIPC folks on this email (deleting VS folks]. My two cents is that if the 56 cannot do it, then perhaps we could suggest he could put out a supportive media statement or something? I thinkjournalists would find a recorded message on a live telebriefing quite atypical. I also think involving the ASH at this point will be probably difficult. Deb, Schuchat, and OPP have been working closely with him on the opioid issue and he has high demands for information, quick turnaround asks, is very exacting in his questionsg?comments?all completely within his purview? but I just think it would be hard to manage this in the final stretch of a V5 and I worry that he would shift our messaging potentially. (Plus, media Visibility-wise, the 56 has more pull than the ASH, so i don?t know that swapping them out is really as appealing for a journalist.) If we keep it to Dr. Schuchat, I think it?s easier for us to stay on message and have better control over the ?quote-worthy? points. From: Simon, Thomas Sent: Wednesday, May 30, 2018 3:02 PM To: Sokler, Bruce, (CDCIOPHPRIOD) Stone, Deborah Schieber, Richard A. Black, Erin Cc: Omisore, Shannon L. Dorigo, Leslie Subject: RE: RE: CDC Vital Signs Telebriefing June 7th One thing to consider is that the 56 has spoken on suicide and does a great job. Reporters might appreciate having some quotes from him that they can use even from a recorded message. It could help raise the profile of the release. From: Sokler, Sent: Wednesday, May 30, 2018 11:31 AM To: Bruce, Simon, Thomas Stone, Deborah Schieber, Richard A. Black, Erin Ballman, Marie R. (CDCIDNDIEHINCIPC) Cc: Sokler, Omisore, Shannon L. Dorigo, Leslie Subject: RE: RE: CDC Vital Signs Telebriefing June 7th Hi Actually, think we can make this work. Kate Migliaccio Grabill, MPH CDR, USPHS Press Secretary From: Migliaccio-Grabill, Kate Sent: Tuesday, May 29, 2018 10:12 AM To: Bruce, Subject: Re: RE: CDC Vital Signs Telehriefing June 2th Hi, We have a quick question for you. Is it possible to change the date? If not, would you be up for having the ASH stand in? It?s going to be really hard to have the SG take this from the airport. He?s ?ying back that day from Dallas. On: 24 May 2018 15:39, "Bruce, <'ux6 wrote: Hi Kate, Thanks for the update on the talking points! Our Vital Signs office says the airport call will be fine. We will look for comments on the talking points from Dr. Adams as soon as he can get to them. We appreciate you working with us on Respectfully, Bruce, MPH Health Communications Specialist Detailed to National Center of injury Prevention and Control Division of Violence Prevention, Health Communications Team Office. 270-488-5651 Mobile: 470-249-3616 Cbruce2@cdc.goy Off oiternote Fridays From: Pea ker, Brandy Sent: 27 Jun 2013 10:32:58 0400 To: Rebecca Ray Cc: Walt Hadikin,?Simon, Thomas Deborah Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Rebecca 1) ?between? is fine for first bullet 2) We?re ok with following your style guide re: abbreviations. Looking forward to the posting. As always we are so appreciative of your help in spreading VS important messages. In partnership, Brandy From: Rebecca Ray Sent: Tuesday, June 26, 2018 7:04 PM To: Peaker, Brandy Cc: Walt Hadikin Simon, Thomas Stone, Deborah Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, Thank you for checking with the subject matter experts. We are happy to use the phrase ?Data from 27 states? to make the sentence more accurate, as well as a shortened version of the first bullet. However, in the first bullet, we think it would be better to say between providersfsettings," vs. in providersfsettings,? since people generally say that transitions occur between two different entities. I understand your concern about the abbreviations?especially since l?rn not a clinician myself. if we change ?incr? to ?increase," we can still stick to the SUD?character limit. However, we have to preserve the rest of the abbreviations, since spelling them out would put us over the limit. Also, the abbreviations have been part of our company?s unique style since its inception, and we use them throughout our Rx content, as well as in every DocAlert message that would otherwise run too long, so most of our readers are familiar with them. We will send you the screenshots of the message once it is published. Rebecca Ray Senior Associate Content Editor. Medical Information San Jose, CA 611321.034 ?lathenoheolth Cloud-based services For medical groups and health systems. From: Peaker, Brandy (vha? cdc. ov> Sent: Tuesday, June 26, 2018 1:47 PM To: Rebecca Ray ; Simon, Thomas (CDCIONDIEHXNCIPQ Stone, Deborah cdc. ova- Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Rebecca and Walt- Our felt like the revision made it sound like the result was only true for the 27 states. They also thought some of the abbreviations looked more like misspellings than abbreviations. We propose the following: 1) Remove the word ?instead? in the paragraph 2) Shorten the first bullet to: ?Provide high-quality, ongoing care focused on pt safety 3: suicide prevention, esp during transitions eg. in providers/settings (http:fizcrosuicidespreorgl; 3) Change the paragraph to: Suicide rates have risen in nearly every state from 1999 to 2016, w] half of states seeing at least a 30% increase, according to a CDC Vital Signs report. Data from 27 states also showed that more than half of people who died by suicide didn?t have a known mental health condition; a range of other contributing factors included relationship, substance use, physical health, job, financial, 3: legal problems. The report urges health care systems to: From: Rebecca Ray Sent: Monday, June 25, 2018 5:01 PM To: Peaker, Brandy cvhaB cdc. 0v} Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US No problem. Thanks! Rebecca Ray Senior Associate Content Editor, Medical information San Jose. CA "-"Iothenoheolth Cloud-based services for medical groups and health systems. From: Peaker, Brandy (CDCIOPHSSICSELSIDPHID) cvha? cdc. ov> Sent: Monday, June 25, 2018 1:59 PM To: Rebecca Ray Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Rebecca did receive it and forgot to follow-up, so thank you for the ping. Please always feel free to ping me if I am not responsive in a timely manner. I welcome pings! I think OK, but let me just double check with my SME. Will have an answer by tomm. From: Rebecca Ray Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, Just wanted to make sure you got this message. Rebecca Ray Senior Associate Content Editor. Medical Information San Jose. CA ?bothenoheokh Cloud-based services for medical groups and health systems. From: Rebecca Ray Sent: Thursday, June 21, 2018 4:42 PM To: 'Peaker, Brandy Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Thanks, Brandy. We liked all of the revisions. Unfortunately, they did make it run a little long?but we were able to trim it back down to <900 characters by using abbreviations. Also, instead of beginning the second sentence with "In an analysis of 2? states,? would it be OK if we shortened it to "ln 2? states?? When I first read it, I thought it meant the entire study covered 27 states. But if we eliminate ?analysis,? think it's clear. Here?s how it would read: Vital Signsl?Suicide rates have risen in nearly every state from 1999 to 2016, w! half of states seeing at least a 30% incr, according to a CDC Vito! Signs report. In 27 states, more than half of people who died by suicide didn?t have a known mental health condition; a range of other contributing factors instead included relationship, substance use, physical health, job, financial, 8: legal problems. The report urges health care systems to: Provide high-quality, ongoing care focused on pt safety 8: suicide prevention, esp during care transitions?eg, between health care providers/settings 0 Ensure access to affordable 8: effective mental 3: physical health care; - Train providers in proven treatments for at risk of suicide. See CDC Vital Signs for links to the graphic fact sheet other communication tools. More info is available in the MMWR article PDF. Rebecca Ray Senior Associate Content Editor, Medical Information San Jose. CA 132 I .0134 *iothenoheokh services For medical groups and health systems. From: Peaker, Brandy Cc: Walt Hadikin Peaker, Brandy Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Rebecca and Walt please see revisiOns from our SMEs. This was a big One for us as you can imagine. Made front page of NYT, WSJ, and USA Today. Let us know if revisions make Doc Alert too long. Also picture is OK for us. Thanks Brandy From: Rebecca Ray Sent: Tuesday, June 12, 2018 7:51 PM To: Peaker, Brandy Cc: Walt Haclikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, Thank you for sending us the latest Vital Signs report. We have attached the draft of our DocAlert message for your expert review. In keeping with our new practice of more image-rich DocAlert messages, we have included an image from our stock-photo account; however, if you object to it for any reason, don?t hesitate to let us know! Thank you in advance for reviewing this. Please let us know if you have any questions. Ruheeca Ray Senior Associate Content Editor. Medical Information San Jose, CA 617.32 .0734 'l'tothenoheolth Cloud-based services for medical groups and health systems. From: Peaker, Brandy Sent: Thursday, June 07, 2018 7:12 AM To: Peaker, Brandy Subject: CDC Vital Signs: Rising Suicide Rates Across the US Embargoed until today, June 7, 2018 at 1:00 pm EDT Dear Healthcare Partner: The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month's edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortality Weekly Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm following a media telehriefing at noon; all attached materials are EMBARGOED until 1:00 pm EDT. CDC Telebriefing New Vital Signs Report Suicide prevention.html) Thursday, June 7. at 12:00 p.m. ET Dial-In Media: 888-795?0355 Non-Media: 800-359-1505 INTERNATIONAL: 1-630-395-0331 PASSED DE ll) it 6i Key points in the Vitolegns report include: I In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older II From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 2? states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition . A range offactors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. Healthcare systems can: 1- Provide highrquality, ongoing care focused on patient safety and suicide prevention. - Make sure affordable and effective mental and physical healthcare is available where people live. - Train providers in adopting proven treatments for patients at risk of suicide. Helpful tools: Preventing Suicide: A Technical Package of Policy, Programs, and Practices National Suicide Prevention Lifeline Talk: {8255} Chat: After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Sions Webpageto find the MMWR article, fact sheet, and other materials. Take advantage of CDC's social media tools, such as the VitolSigns buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EDT). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Thank you for your support. Brandy L. Peaker, MD, MPH LCDR, 0.5. Public Health Service Deputy Director, CDC Vita! Signs Center for Surveillance, Epidemiology, and Laboratory Services Centers for Disease Control and Prevention 1500 Clifton Rd. M5 E-90, Atlanta, GA 30333 E: bpeakerlg?cdcgov; O: BB: F: (404) 498-6055 l?ltZ?ll vaftai'signs From: Simon, Thomas Sent: 2? Jun 2018 09:27:32 -0400 To: Peaker, Brandy Cc: Stone, Deborah Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, lam ok with this approach. Thank you for your help! -Tom From: Rebecca Ray Sent: Tuesday, June 26, 2018 7:04 PM To: Peaker, Brandy Cc: Walt Hadikin Simon, Thomas Stone, Deborah Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, Thank you for checking with the subject matter experts. We are happy to use the phrase ?Data from 27 states? to make the sentence more accurate, as well as a shortened version of the first bullet. However, in the first bullet, we think it would be better to say between providersfsettings," vs. in providers/settings," since people generally say that transitions occur between two different entities. I understand your concern about the abbreviations?especially since l?m not a clinician myself. if we change "incr" to ?increase," we can still stick to the BOD-character limit. However, we have to preserve the rest of the abbreviations, since spelling them out would put us over the limit. Also, the abbreviations have been part of our company?s unique style since its inception, and we use them throughout our Rx content, as well as in every DocAlert message that would otherwise run too long, so most of our readers are familiar with them. We will send you the screenshots of the message once it is published. Rebecca Ray Senior Associate Content Editor, Medical Information San Jose. CA ?-"Iotheno health Cloud-based services for medical groups and health systems. From: Peaker, Brandy Sent: Tuesday, June 26, 2018 1:47 PM To: Rebecca Ray Cc: Walt Hadikin Peaker, Brandy Simon, Thomas Stone, Deborah cdc. ova- Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Rebecca and Walt? Our felt like the revision made it sound like the result was only true for the 2? states. They also thought some of the abbreviations looked more like misspellings than abbreviations. We propose the following: Remove the word ?instead" in the paragraph 2) Shorten the first bullet to: ?Provide high-quality, ongoing care focused on pt safety suicide prevention, esp during transitions eg. in providerst?settings 3) Change the paragraph to: Suicide rates have risen in nearly every state from 1999 to 2016, WI half of states seeing at least a 30% increase, according to a CDC Vital Signs report. Data from 27 states also showed that more than half of people who died by suicide didn't have a known mental health condition; a range of other contributing factors included relationship, substance use, physical health, job, financial, 8t legal problems. The report urges health care systems to: From: Rebecca Ray Sent: Monday, June 25, 2018 5:01 PM To: Peaker, Brandy Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US No problem. Thanks! Rebecca Ray Senior Associate Content Editor, Medical information San Jose. CA til 13?. I .034 \?iothenoheolth lCloud-based services for medical groups and health systems. From: Peaker, Brandy Sent: Monday, June 25, 2018 1:59 PM To: Rebecca Ray Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Rebecca did receive it and forgot to follow-up, so thank you for the ping. Please always feel free to ping me if I am not responsive in a timely manner. I welcome pings! I think OK, but let me just double check with my SME. Will have an answer by tomm. From: Rebecca Ray Sent: Monday, June 25, 2018 4:44 PM To: Peaker, Brandy (CDCIOPHSSICSELSIDPHID) Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, Just wanted to make sure you got this message. Rebecca Ray Senior Associate Content Editor, Medical Infomiation San Jose, CA 61132l.0?34 "iothenaheoith Cloud-based services For nmdical groups and health systems, From: Rebecca Ray Sent: Thursday, June 21, 2018 4:42 PM To: 'Peaker, Brandy Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Thanks, Brandy. We liked all of the revisions. Unfortunately, they did make it run a little long?but we were able to trim it back down to <900 characters by using abbreviations. Also, instead of beginning the second sentence with ?in an analysis of 27 states," would it be OK if we shortened it to "in 2? states?? When I first read it, I thought it meant the entire study covered 27 states. But if we eliminate ?analysis," i think it?s clear. Here's how it would read: Vital Signsi?Suicide rates have risen in nearly every state from 1999 to 2016, w! half of states seeing at least a 30% incr, according to a CDC Vital Signs report. In 27 states, more than half of people who died by suicide didn?t have a known mental health condition; a range of other contributing factors instead included relationship, substance use, physical health, job, financial, legal problems. The report urges health care systems to: Provide high-quality, ongoing care focused on pt safety 8t. suicide prevention, esp during care transitions?eg, between health care providersfsettings - Ensure access to affordable effective mental physical health care; I Train providers in proven treatments for at risk of suicide. See CDC Vital Signs for links to the graphic fact sheet 3; other communication tools. More info is available in the MMWR article PDF. Rebecca Ray Senior Associale Content Editor, Medical Information San Jose, CA 511.32I.o?34 "Iothenoheolth Cloud?based services For medical groups and health systems. From: Peaker, Brandy Cc: Walt Hadikin Peaker, Brandy Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Rebecca and Walt please see revisions from our SMEs. This was a big one for us as you can imagine. Made front page of NYT, and USA Today. Let us know if revisions make Doc Alert too long. Also picture is OK for us. Thanks Brandy From: Rebecca Ray Sent: Tuesday, June 12, 2018 2:51 PM To: Peaker, Brandy Cc: Walt Hadikin {whadikin@athenahealth.com> Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, Thank you for sending us the latest Vital Signs report. We have attached the draft of our DocAlert message for your expert review. In keeping with our new practice of more image-rich DocAlert messages, we have included an image from our stock-photo account; however, if you object to it for any reason, don?t hesitate to let us know! Thank you in advance for reviewing this. Please let us know if you have any questions. {9 Rebecca Ray Senior Associate Content Editor, Medical Information San Jose, CA (ml 13?. ?'Iothenoheolth lCloud-based services for medical groups and health systems. From: Peaker, Brandy Sent: Thursday, June 07, 2013 7:12 AM To: Peaker, Brandy Subject: CDC Vital Signs: Rising Suicide Rates Across the US Embargoed until today, June 7, 2018 at 1:00 pm EDT Dear Healthcare Partner: The CDC Vitoi Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortoiity Weekiy Report (MMWR) article, "Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four-page consumer fact sheet. This latest edition of CDC Vita! Signs will he released today, Thursday, June 7, 2013, at 1:00 pm following a media telebriefing at noon; all attached materials are EMBARGOED until 1:00 pm EDT. CDC Telebriefing New Vital Signs Report Suicide prevention.html) Thursday, June 7.at12:00 p.m. ET Dial-In Media: 888-795-0855 Non-Media: 800-369-1505 1-630-395-0331 Key points in the Vitoi Signs report include: II In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older I From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I- Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition - A range offactors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. Healthcare systems can: - Provide high-quality, ongoing care focused on patient safety and suicide prevention. I Make sure affordable and effective mental and physical healthcare is available where people live. - Train providers in adopting proven treatments for patients at risk of suicide. Helpful tools: Preventing Suicide: A Technical Package of Policy, Programs, and Practices National Suicide Prevention Lifeline Talk: 1-8004273-TALK {8255] Chat: After the embargo is lifted today at 1 pm (EDT), please share the CDC Vito! Signs information broadly with your colleagues and partners. Visit the Vital Sions Webpageto find the MMWR article, fact sheet, and other materials. Take advantage of CDC's social media tools, such as the Vitoi Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EDT). Vito! Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Thank you for your support. Brandy L. Peaker,MD,l?v1PH LCDR, U.S. Public Health Service Deputy Director, CDC Vitoi Signs Center for Surveillance, Epidemiology, and Laboratory Services Centers for Disease Control and Prevention 1600 Clifton Rd. MS Atlanta, GA 30333 E: bgeakerl?cdcgov; O: (404)493~6705; BB: [5?8ll341?7037; F: (404) 498-6055 ?(Eff- vgvitol?signs From: Rebecca Ray Sent: 26 Jun 2013 23:03:41 +0000 To: Peaker, Brandy Cc: Walt Hadikin;Simon, Thomas Deborah Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, Thank you for checking with the subject matter experts. We are happy to use the phrase "Data from 27 states? to make the sentence more accurate, as well as a shortened version of the first bullet. However, in the first bullet, we think it would be better to say between providers/settings," vs. in providers/settings," since people generally say that transitions occur between two different entities. I understand your concern about the abbreviations?especially since l?m not a clinician myself. if we change ?incr? to "increase," we can still stick to the SUD-character limit. However, we have to preserve the rest of the abbreviations, since spelling them out would put us over the limit. Also, the abbreviations have been part of our company's unique style since its inception, and we use them throughout our Rx content, as well as in every DocAlert message that would otherwise run too long, so most of our readers are familiar with them. We will send you the screenshots of the message once it is published. Rebecca Ray Senior Associate Content Editor, Medical Information San Jose, CA 5113210734 "'Iothenoheolth Cloud-based services for medical groups and health systems. From: Peaker, Brandy Sent: Tuesday, June 26, 2018 1:47 PM To: Rebecca Ray Cc: Walt Hadikin Peaker, Brandy Simon, Thomas Stone, Deborah Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Rebecca and Walt- Our SME's felt like the revision made it sound like the result was only true for the 2? states. They also thought some of the abbreviations looked more like misspellings than abbreviations. We propose the following: 1. Remove the word ?instead" in the paragraph 2. Shorten the ?rst bullet to: ?Provide high?quality, ongoing care focused on pt safety suicide prevention, esp during transitions eg. in providers-?settings 3. Change the paragraph to: Suicide rates have risen in nearly every state from 1999 to 2016, w/ half of states seeing at least a 30% increase, according to a CDC Vital Signs report. Data from 27 states also showed that more than half of people who died by suicide didn?t have a known mental health condition; a range of other contributing factors included relationship, substance use, physical health, job, financial, 8: legal problems. The report urges health care systems to: From: Rebecca Ray Sent: Monday, June 25, 2018 5:01 PM To: Peaker, Brandy Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US No problem. Thanks! Rebecca Ray Senior Associate Content Editor, Medical Information San Jose, CA 517.321.0734 Cloud-based services for medical groups and health systems. From: Peaker, Brandy Sent: Monday, June 25, 2018 1:59 PM To: Rebecca Ray Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Rebecca I did receive it and forgot to follow-up, so thank you for the ping. Please always feel free to ping me if I am not responsive in a timely manner. I welcome pings! G3 I think OK, but let me just double check with my SME. Will have an answer by tomm. From: Rebecca Ray Sent: Monday, June 25, 2018 4:444 PM To: Peaker, Brandy Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, Just wanted to make sure you got this message. Rebecca Ray Senior Associate Content Editor, Medical Information San Jose, CA 512.321.0234 ""Iothenoheolth Cloudvbased services for medical groups and health systems. From: Rebecca Ray Sent: Thursday, June 21, 2018 4:42 PM To: 'Peaker, Brandy Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Thanks, Brandy. We liked all of the revisions. Unfortunately, they did make it run a little long~but we were able to trim it back down to ?1900 characters by using abbreviations. Also, instead of beginning the second sentence with ?In an analysis of 27 states,? would it be OK if we shortened it to ?In 27 states?? When I first read it, I thought it meant the entire study covered 27 states. But if we eliminate "analysis,? I think it?s clear. Here's how it would read: Vital Signsl-Suicide rates have risen in nearly every state from 1999 to 2016, w/ half of states seeing at least a 30% incr, according to a CDC Vital Signs report. In 27' states, more than half of people who died by suicide didn?t have a known mental health condition; a range of other contributing factors instead included relationship, substance use, physical health, job, financial, 8; legal problems. The report urges health care systems to: I Provide high-quality, ongoing care focused on pt safety a: suicide prevention, esp during care transition5*~eg, between health care providersfsettings {htmiggrosuicidesprcogg}; I Ensure access to affordable E: effective mental physical health care; . Train providers in proven treatments for at risk of suicide. See CDC Vital Signs for links to the graphic fact sheet other communication tools. More info is available in the MMWR article PDF. Rebecca Ray Senior Associate Content Editor, Medical Information San JOSE, CA 511321.07?? '--'Iotheno health Cloud-based services for medical groups and health systems. From: Peaker, Brandy cvha? cdc. ova Sent: Tuesday, June 19, 2013 11:45 AM To: Rebecca Ray Cc: Walt Hadikin Peaker, Brandy Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Rebecca and Walt please see revisions from our SMEs. This was a big one for us as you can imagine. Made front page of NYT, WSJ, and USA Today. Let us know if revisions make Doc Alert too long. Also picture is OK for us. Thanks, Brandy From: Rebecca Ray Sent: Tuesday, June 12, 2018 7:51 PM To: Peaker, Brandy Cc: Walt Hadikin Subject: RE: CDC Vital Signs: Rising Suicide Rates Across the US Hi Brandy, Thank you for sending us the latest Vital Signs report. We have attached the draft of our DocAlert message for your expert review. In keeping with our new practice of more image-rich DocAlert messages, we have included an image from our stock-photo account,- however, if you object to it for any reason, don?t hesitate to let us know! Thank you in advance for reviewing this. Please let us know if you have any questions. Rebecca Ray Senior Associate Content Editor, Medical Information San Jose, CA 611.321.0734 ?'Iothenaheolth CIoud-basad services for medical groups and health systems. From: Peaker, Brandy Date: June 7, 2018 at 6:02:51 PM EDT To: Grusich, Katharina (Kate) Hi Kate: Another team did this story for the Evening news, so I didn?t hear the telebriefing. Would you mind clarifying what the overall rate of suicide increase is in the us since 1999 as I can?t find that in the report. (1:05) From: Knuth, Alida Sent: 26 Feb 2013 13:10:03 -0500 To: Black, Erin Deborah Subject: RE: CDC x? SAM HSA SMVF TA Center Call Yes, I had a call with Angela Wright and their graphic designer on February 8. They wanted art from the Technical Package poster showing the strategies. I sent them the design files for that illustration and the designer follow up that she had received the files and had everything she needed. I also talked with them about sending hard copies of the TP for the event in March. I explained that a reprint is in process but we may not have 200 copies delivered from the printer in time for the event. I do have the last 50 copies squirreled away in my office, so if we don?t have the reprint delivered I will send them the last 50 copies we have, and they will offer instructions about how to order a hard copy when our supply is restocked. Thanks Alida From: Black, Erin Sent: Monday, February 26, 2018 12:47 PM To: Knuth, Alida Stone, Deborah Subject: RE: CDC 1? SAM HSA SMVF TA Center Call Deb haven?t heard anything. Aldia did they ever contact you about this? From: Stone, Deborah Sent: Monday, February 26, 2018 12:05 PM To: Black, Erin ce m? cdc. 0v:- Subject: FW: CDC 1 SAM HSA SMVF TA Center Call Hi Erin, Have you heard any more about this? There has been little follow?up from the SMVF TA Center since the call which was a while ago now. Deb From: Angela Wright Sent: Friday, February 02, 2018 3:51 PM To: Stone, Deborah Donna Aligata Burrows-McElwain, Cicely (SAMHSA) McKeon, Richard Philip Paty at rainc.com> Cc: Black, Erin Knuth, Alida Girod, Candace cmrv?? cdc. ov> Subject: RE: CDC SAM HSA SMVF TA Center Call Thank you, Deb! I greatly appreciate the links and connecting me to Alida. Alida, 1?d like to set up a time to talk next week about the graphics and printing. I?ll ask our project assistant to send you some available times under separate cover. Have a wonderful weekend everyone! Angela From: Stone, Deborah Sent: Friday, February 02, 2018 3:17 PM To: Angela Wright Donna Aligata BurrowsuMcElwain, Cicely (SAM McKeon, Richard Philip Paty at rainc.com> Cc: Black, Erin Knuth, Alida Girod, Candace Subject: RE: CDC SAM HSA SMVF TA Center Call Thank you so much, Angela and the rest of the team. It was so great to talk to you today and I very much appreciate you sending along the materials. What a wonderful opportunity you are providing to cities! Here?s the link to access the suicide technical package . When you click on the link, if it doesn?t take you directly to the technical package page, enter Violence Prevention: Suicide in the first drop down list. However, the document is currently out of stock (but save the link for future referencel]. I'm cc?ing Alida Knuth who can provide guidance on how best to get the number of copies you need. Alida can also provide guidance around the use ofthe graphics you are interested in reproducing from the technical package and from the infographic. I look forward to continued conversations! Have a great weekend! Deb Deb Stone, Sol), MSW, MPH Behavioral Scientist Suicide, Youth Violence, and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence PreventiOn Research 8. Evaluation Branch 47?0 Buford Highway, MS F-E4 Atlanta, GA 30341 FWD-488.3942 d5tone3@cdc.gov From: Angela Wright Sent: Friday, February 2, 2018 11:39 AM To: Stone, Deborah (CDCKONDIEHXNCIPQ Girod, Candace Donna Aligata Burrows-McElwain, Cicely (SAMHSA) McKeon, Richard Philip Paty at rainc.com> Cc: Black, Erin Subject: CDC SAM HSA SMVF TA Center Call Good morning, Thank you for a great call today. We are so pleased to be able to collaborate and help roll out the CDC Suicide Prevention Technical Package to cities this year. As promised on the call, I am attaching the following items: I- Save-the-Date - Mayor?s Challenge Fact Sheet 0 Team Selection Tool - Contact sheet for the Mayor?s Challenge - Article on the Implementation Academy model Please let me know howl can get in touch with Alita Knuth, so I may work with her on obtaining graphics and copies of the Technical Package as handouts for the Academy on March 14-16. We also look forward to being connected with those who are working on the implementation guidance. Again, we appreciate your time today. Let us know if you have any questions as you read through the materials we?ve provided. Warm regards, Angela J. Wright, J.D. Assistant Director Service Members, Veterans, and Their Families Technical Assistance Center Policy Research Associates, Inc. 345 Delaware Ave. Delmar Phone: 518.439.7415 ext. 5258 Fax: 850.295.5481 Email: awrieht@orainc.com Creating positive sociai change for people who are disadvantaged through technicai assistance, research, and training. From: Stone, Deborah Sent: 1? Apr 2018 02:06:11 +0000 To: Schieber, Richard A. Cc: Simon, Thomas Brandy Shannon L. Subject: RE: Change in June VS release date go Thurs June 7' Thank you for the update Rich. Sharing with our team now. Deb From: Schieber, Richard A. Sent: Monday, April 16, 2018 6:35 PM To: Schuchat, Anne MD Daniel, Katherine Lyon Dauphin, Leslie Cc: Sorrells, Marjorie J. Downie, Diane {Dee Dee] Stone, Deborah Simon, Thomas Sokler, Peaker, Brandy Omisore, Shannon L. Harben, Kathy Bonds, Michelle E. Roberts, Ursula (CTR) Kent, Charlotte Kate lademarco, Michael Schieber, Richard A. Smith, Rhonda K. (cocfoo/OADC) Smith, Patti Guest, Megan (cation/Dane) Subject: Change in June V5 release date go Thurs June 7 Folks, We?re now set up have the Tues June 5 Suicide Prevention VS release and telebriefing moved to Thurs June 7 at Noon instead. There will not be an early release of this issue as we usually do. This should better accomodate Dr. Schuchat?s trayel schedule. Thank you. Rich Rich Schieber, MD MPH CAPT, USPHS Director, CDC Vital Signs Program RBS4@cdc.goy 404 697 9666 From: Houry, Debra E. Sent: 30 May 2018 18:40:11 -0400 To: Schuchat, Anne MD Cc: Sokler, Leslie Subject: Re: change to Vital Signs telebriefing lineup- need your input Got it. Sounds good! From: Schuchat, Anne MD Date: May 30, 2018 at 6:27:43 PM EDT To: Houry, Debra E. Cc: Dorigo, Leslie Sokler, Subject: Re: change to Vital Signs telebriefing lineup- need your input Suggest solid but offer Sg options to tweet or do other messaging on his own schedule and give his of?ce slides nd TPs to use pm Sent from my iPhone On May 30, 2018, at 5:18 PM, Houry, Debra E. wrote: Hi Anne My comm director called me today after talking to Vital Signs office (both cc?d) and wanted to get your thoughts on some options for the Vital Signs telebriefing. 56 can no longer do the date/time of the telebriefing. He?s offered to do a pre? recorded message for telebriefing, however this hasn?t been done before to my knowledge and doesn?t really seem like the right flow or time to do that. Potential options include: We could ask for the 56 to release a brief, written media statement supportive of the V5 56 office also suggested we have the ASH do the telebriefing {as a short call? topper)- caveat being I don?t know if he?s available. He?s also given feedback at various points and has a focus area more aligned with serious mental illness vs our ?more than mental health message?. But, on the flip side he?s been very interested and supportive of CDC work and this might be a way to get our suicide prevention work and more on his radar. Or, you could do telebriefing solo Thoughts? Happy to chat more offline through these options too Deb From: fo=cdcfou=exchange administrative group Sent: 13 Feb 2018 18:07:32 +0000 Subject: RE: Clarification of meeting dates and details From: Stone, Deborah Sent: Monday, February 12, 2018 12:49 PM To: Sokler, Cc: Schieber, Richard A. Peaker, Brandy Omisore, Shannon L. Subject: Clarification of meeting dates and details Hi Lynn, It was nice to meet you last week at the kick-off meeting. I was reviewing the calendar and the list of meetings {from the CDC Vital Signs Products document} side by side and I had some questions. Would you be able to check the info i have and fill in any of the blanks? ljust want to make sure everything gets on the calendar accurately and with plenty of notice. Also, if you could let me know what the colors on the calendar mean again that would be helpful. I know the green are items with the same date and it looks like pink indicates program deliverables [but not all]. Thank you! Deb Meeting Date Time Location Corresponding Note stEp from calendar Lmal-Kziek?e? 9?1930 Ghamblee completed y?B; 294:8 2. Roundtable April 3 1:30-4:30 Chamblee 13 SMES, Comm, Policy go word for word Need AV equipment 3. Medical Outreach Week of 23 30 min call, Call 4f11- send invite 4f15 Main comms and partnership people 4. Town Hall Prep Around 24 Tanya May 3th Joiner main contact, can contact her to set 5. Social Media kickoff April 24 35/36 (4 and OADC, prep call weeks ahead) Shannon will schedule; email her; will be a call 6. Pro-brie?ng meetings May 7th 21, 40 We?ll get with week 12?! that on the Directori?ASiADS calendar in March] 45 min to go over main messages. Dr gets in the weeds. Discuss tough questions from the . media. 7. Media Telebrie?ng June 5 11:40-12 21, 43 Dr. will and pre~release pre meeting 12?? send meeting With Dr. inVltES Telebriefing Noon with media Release 12- 12:30 8. Town Hall June 12 Maybe at 2 51 Tanya pm joiner will go over details. lsend: Medical outreach?send invite to brandy (call-30 min) Roundtable confirmation (rich, brandy, lynn, Shannon) Podcast is optional NPHIC call Thursday before release, contact Shannon about this. Shannon 3 meetings in total Everything in the fact sheet has to be in the Science clips?give list of 10 references (bibliography); 8 have to be from 2 from review articles for reader context [meta-analysis, systematic review, IOM report], summary of topic area (highlight these] Abstract Median, quartiles instead of alphabetically. MMWRIFactsheet word version (non cleared)?these are used at the roundtabie Revise factsheets after MMWR and Factsheet sent to DD for first review {cleared} OD will review and give comments Respond to comments on factsheet and Revisions to MMWR go to Scholar One to MMWR Editors (normal process?VS team hands off) Another revised version of the fact sheet and that goes back to US (we go back and forth on that with graphics) Ideas for graphics from us, maps will be different; whole integers, collapse categories {could be increase, decrease, stay the same] Graphic version of the F5 to 0D along with all other pre-brief materials (mmwr, telebriefing script, press release, dear colleague letter) We have another chance for revisions after this Graphic F5 and press release goes to ASPAA HHS for clearance [only thing} ?5tep 20 they have a week to review Revise again [hopefully no substantive comments which would FS lockdown a week before release Discussion section?there are roles for multiple partners in addressing this problem which include (insert high level items] All data MMWR Deb Stone, MSW, MPH Behavioral Scientist Suicide, Youth Violence. and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research Evaluation Branch 4WD Buford Highway, MS Atlanta, GA 30341 770.488.3942 dstone3@cdo.gov From: Stone, Deborah Sent: 12 Feb 2018 21:27:48 +0000 To: Peaker, Brandy Subject: RE: Clarification of meeting dates and details Hi Brandy, I was in a training all afternoon but thanks so much for the reply. I?m sending you an invite now for tomorrow. Deb From: Peaker, Brandy (CDCXOPHSSICSE Sent: Monday, February 12, 2018 4:01 PM To: Stone, Deborah Subject: RE: Clarification of meeting dates and details Deb - doesn?t look like we will be able to connect today. I?m open all day tomm, but then out of the office the rest of the week. Are you available anytime tomm? I develop the calendars so am the best person on the team to answer questions about it. From: Peaker, Brandy Sent: Monday, February 12, 2018 1:00 PM To: Stone, Deborah Sokler, <2520@cdc.gov> Cc: Schieber, Richard A. Omisore, Shannon L. ch l5 cdc. ov> Subject: Re: Clarification of meeting dates and details Hi Deb - I can help with explaining calendar dates. Are you available this afternoon to chat. Maybe 3:00? Thank; Brandy From: Stone, Deborah <2an cdc. ov> Date: February 12, 2018 at 12:48:52 PM EST To:Sokler, <2520 cdc. ova Cc: Schieber, Richard A. Peaker, Brandy Omisore, Shannon L. Subject: Clarification of meeting dates and details Hi Lynn, It was nice to meet you last week at the kick-off meeting. I was reviewing the calendar and the list of meetings {from the CDC Vital Signs Products document} side by side and I had some questions. Would you be able to check the info have and fill in any of the blanks? ljust want to make sure everything gets on the calendar accurately and with plenty of notice. Also, if you could let me know what the colors on the calendar mean again that would be helpful. I know the green are items with the same date and it looks like pink indicates program deliverables [but not all). Thank you! Deb Meeting Date Time Location Corresponding Note step from hmeel?Kiek-ef-F Februar T37 2018 Z.Roondtable April 3 3. Social Media kickoff prep April 24 call 4. Recording of podcast {by phone or in person) S.NPHIC Call May 31 6. Pre?brie?ng meetings with Director/?AS 7.Media Telebrie?ng and pre- June 5 release meeting 8. Town Hall June 12 Bob Stone. Sci). MPH Behavioral Scientist Suicide, Youth Violence. and Elder Maltreatment Team Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Research 8: Evaluation Branch 4770 Buford Highway, MS F-64 Atlanta, GA 30341 deten?sy?egev 9. 1:30- 4:30 1 1:40 Ghamhlee 21, 12"h fl 21, 121th calendar completed Don?t see this on calendar From: Stone, Deborah Sent: 8 Jun 2018 1:120:40 +0000 To: Dahlberg, Linda L. Subject: RE: Congratulations everyone!! Thanks, Linda! From: Dahlberg, Linda L. Sent: Friday, June 8, 2018 10:13 AM To: Stone, Deborah (CDCIONDIEHXNCIPQ Holland, Kristin Simon, Thomas Fowler, Katherine A. Kegler, Scott R. Crosby, Alexander lvey-Stephenson, Asha Z. Richmond-Crum, Malia Bruce, Black, Erin Ballman, Marie R. Yuan, Keming Cc: Mercy, James Young, Joni Basile, Kathleen Ferdon, Corinne Herbst, Jeffrey Massetti, Greta M. Payne, Gayle H. Ballesteros, Michael {Mick} Kresnow-Sedacca, Marcie-jo Subject: Congratulations everyonell Awesome team! Awesome work! Congratulations on the Vital Signs. I couldn?t be more proud of you and all that you have done to elevate this issue and provide compelling and actionable information for the nation to prevent suicide. I watched the nevvs last night and have been listening to the news this morning covering Anthony Bourdain?s death. The news stations are going into greater detail about the findings from the ivital Signs and telling viewers that we need to do more to stay connected to those aroUnd us and to be aware of how relationship and financial problems and other things going on in people's lives contribute to suicide. The findings and the prevention messages are getting out there. Well done everyone! Linda From: Simon, Thomas (CDCIONDIEHJNCIPC) Sent: Thursday, June 7, 2013 3:43 PM To: Mercy, James Young, Joni -: 2:8 cdc. 0w; Dahlberg, Linda L. (lldD cdc. 0v:- Cc: Ferdon, Corinne (CDCIONDIEHINCIPQ Basile, Kathleen Stone, Deborah Black, Erin Herbst, Jeffrey Cc: Bartholow, Brad Herbst, Jeffrey Subject: Updates? Hi Everyone, Since we didn?t have a meeting last week or this week [yikesl] and our next meeting isn?t until next Tuesday, I wanted to take the time to provide some updates to keep everyone in the loop (apologies for the delay on this). I invite anyone to add to this update in case I?ve forgotten anything, which I?m so sure I have. One REQUEST: By next week it would be great if the three task groups Fact Sheet, CommfPolicy} can update their to-do lists through May 15th. don?t have any specific guidance since it?s late but will be good to keep ourselves organized and no what?s coming next (mostly I?m suggesting this for myself Where things stand currently: I The MMWR was routed through clearance and successfully. It will be submitted to the MMWR office today. I The Fact sheet team led heroically by Tom and aided by Kristin, Asha, and myself has come a long way! Thank you to everyone who reviewed the latest version ofthe FS. Torn will submit the FS back to the US team COB. 0 One sticking point right now is finding two good photos to include! This is no small task. The first photo is on page 1 and is next to the 'states and communities can: [insert 7 strategies]. Here some are thinking a group of people would be good to suggest organizing, collaboration, and connectedness. However, it really needs to convey the problem of suicide somehow. The second picture is placed right next to the heading on page 2 about the percentage change in rate increases. This is not a happy message of course so what do we place there? Trying to avoid depressed looking people. I personally am also trying to avoid pictures of women and teenagers so we represent the population with the highest burden, men. Molly and are helping with this conundrum. Attaching latest mock-up of F5. Also, Molly now has the native files of the Bethelto campaign image in her hands {yayl}. Please see attached for what I?m talking about. The folks at Mental Health America are thrilled that their campaign will be featured. a The Comm team has been extremely busy drafting the critical contacts email, the telebriefing script, the press release, and the dear colleague letter. These documents were routed from to Marie, myself, Malia, Tom, and will be reviewed in the next clay by Leslie. These items are due to the VS office this Friday, April I?m working on some FAQs today to include with the telebriefing script. He Partnerships, Dr. uchat mentioned the US at the Action Alliance Executive Committee meeting a few weeks ago, and Robin Ikeda mentioned the VS at the American Association of Suicidology meeting last week. Kristin also mentioned the US to the Data and Surveillance Task Force of the Action Alliance, and she and i met with Colleen Carr and Farrah Kaufmann also of the Action Alliance. Kimberly Torguson of the Action Alliance's Media workgroup has been alerted as have Federal Partners on our call. was recommended that we reach out to the National Council for Suicide Prevention if we haven?t already done so. An update re the Surgeon General?s participation is forthcoming (Feel free to update here]. I The medical outreach call with Brandy Peaker occurred this past Monday. This was a productive meeting. ?Feel free to update here. I The ore-briefing with Dr. Schuchat has been scheduled and rescheduled multiple times. It?s currently on May 8th from 1?1:45. In addition, to accommodate Dr. Schuchat?s travel schedule the VS has been pushed back until JUNE - NCHS data brief on suicide will be delayed until after our VS comes out. That was very generous of them. Thanks to Tom for working that out! II One piece of bad news, the AJPH commentary was rejected 69 I will assess whether it makes sense to try JAMA or AJPM (Le. whether content is appropriate and whether timing is at all possible?? guessing no on both fronts). The next idea is to have a commentary come out after the V5 in another journal. In Other items?I'm sure I?m forgetting or don?t know about many things so please add here! That?s all for now. Sorry for the long email. Please let me know if you have anyf questions or concerns. Thanks a million to everyone for the great work. We've really made great strides thus far! Six week to go. Go Team! Deb Deb Stone, MSW, MPH Centers for Diseaso Control and Prevention National Center for Injurv Prevention and Control Division of Violence Prevention Suicide. Youth violence 8a. Elder Maltreatment Team d5tone3??cdogov CDC's Injury Center Preventing Injuries and Violence Through Science and Action From: Basile, Kathleen Sent: 14 Jun 2018 12:38:45 -0400 To: Holland, Kristin Deborah Subject: RE: cost of suicide source Actually, I just found in the Vital signs that you cited WISQARS. Thanks and sorry to bother you! From: Holland, Kristin Sent: Thursday, June 14, 2018 12:38 PM To: Basile, Kathleen Stone, Deborah Subject: RE: cost of suicide source Hi Kathleen, I think that?s a conservative estimate. Another study we reference in the TP suggests the costs were about $93.5 billion in 2013 after adjusting for under reporting of suicide, and drawing on health expenditures per capita, GDP per capita, and varability among states in per capita health expenditures and income. Reference: Sheoard DS, Gurewich D, Lwin AK, Reed GA, Jr., Silverman MM. Suicide and suicidal attempts in the United States: costs and policyI implications. Suicide the Threat Behov. 2016;461312352-362. Kristin From: Basile, Kathleen Sent: Thursday, June 14, 2018 12:32 PM To: Stone, Deborah Holland, Kristin Subject: cost of suicide source Hi Deb and Kristin, i am working on the self-harm objective proposal for Healthy People 2030, and I?m trying to find info about the economic cost of suicide. i see on our website that we say Suicide and suicide attempts cost society about $70 billion a year in combined medical and work loss costs. What is the source for that statement? There is no citation. I found the Corso, Mercy, Simon et al article but that appears to be the cost of interpersonal AND selfsdirected violence. Thanks for any help, From: Stone, Deborah Sent: 19 Jan 2018 20:01:28 +0000 To: Black, Erin Subject: RE: Discussion on NREPP and building the suicide prevention field Exactly. It would be so easy for him to do. From: Black, Erin Sent: Friday, January 19, 2018 2:56 PM To: Stone, Deborah (CDCXONDIEHKNCIPQ Subject: RE: Discussion on NREPP and building the suicide prevention field Ya I sensed Richard was lukewarm too was going to straight up ask him to include the technical package in their communication about the NREPP discontinuation as where people could now go for evidenced based suicide prevention approaches but thought not given the From: Stone, Deborah (CDCIDNDIEHKNCIPQ Sent: Friday, January 19, 2018 2:51 PM To: Black, Erin Subject: RE: Discussion on NREPP and building the suicide prevention field Thanks for the notes Erin. I think we have more work to do with SAMHSA around promotion of the technical package. Jane has always been very positive about it. Richard is more lukewarm. And yes, I think it would be good to make sure it?s brought up at the Action Alliance meeting. And I will send a link to the listserv. I'll keep you posted on other opportunities or anything I hear. Sorry the call wasn?t more directly relevant. I thought there would be a greater focus on the technical package but I guess we're not all on the same page yet as to how the to could help fill the gap. Deb From: Black, Erin Sent: Friday, January 19, 2018 2:44 PM To: Stone, Deborah <2an cdc. ov> Subject: RE: Discussion on NREPP and building the suicide prevention field Thanks Deb for letting me join the call and thanks for sending the matrix out. Soonds like you will send out the suicide technical package to the AAS list serve. I will make sure it?s on Jim's radar to think about how we can help shape the conversation on where to find evidence based programs and policies now lie. the Technical Package) at the Action Alliance meeting. Let me know if you hear of other opportunities to ensure CDC and the technical package are part of the conversation. Original Appointmentww? From: Kurikeshu, Rebecca Sent: Tuesday, January 16, 2018 11:48 AM To: Kurikeshu, Rebecca McKeon, Richard Raider, Eve Stone, Deborah Black, Erin Pearson, Jane Subject: Discussion on NREPP and building the suicide prevention field When: Friday, January 19, 2018 2:00 PM Eastern Time (US 8: Canada). Where: 866-808-4568 code 715 2974 Hello all, just a reminder that this conference call is today at 2pm. 866-808-4568 code Talk to you soon. Thanks, Becky From: Colleen Creighton Sent: 11 Jun 2018 12:37:10 +0000 To: Stone, Deborah Subject: Re: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates Thanks so much for the clarification! From: Stone, Deborah Sent: Monday, June 11, 2018 8:36 AM To: Colleen Creighton Subject: FW: EMBARGOED Until 1pm June 7: Vital Si gns, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HiCoHeen, was provided update information; ethanol would not be included under other substances. My apologies. Deb From: Black, Erin Sent: Sunday, June 10, 2018 11:26 PM To: Stone, Deborah Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Thanks for following up Deb! From: Stone, Deborah Sent: Friday, June 8, 2018 3:29 PM To: ccreighton@suicidologvorg Cc: Lenard, Courtney (CDCIONDIEHXNCIPC) Black, Erin Subject: FW: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HiCoHeen, I?m responding to your question that Erin shared. The common substance under 'Other? are something like Acetaminophen, eth. Also, it includes alcohol and ethanol. We don?t have specific substance class for those substance, so theyr are all under ?Dther'. 1 hope this helps! Thanks Deb Deb Stone, MSW, MPH Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Suicide, Youth Violence 8: Elder Maltreatment Team 770. 488 3942 dstone3@cdc. gov slnjury Center Preventing Injuries and Violence Through Science and Action From: Black, Erin (CDCXONDIEHINCIPC) Sent: Friday, June 8, 2018 10:15 AM To: Stone, Deborah (CDCIONDIEHKNCIPCJ <2af9 cdc. ov> Subject: FW: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates See question below re the VS. From: Colleen Creighton Sent: Thursday, June 7, 2018 5:45 PM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin Thanks so much for the call today and for all your work going into this report. One question that came up from our end is under ?Other? 1 what is included in this category in addition to Other over-the?counteri 1,021i34.0 Thanks so much, CoHeen Colleen Creighton Executive Director American Association of Suicidologv 5221 Wisconsin Avenue, NW, 2?d Floor Washington, DC 20015 T: (202)237-2280, F: [202) 237-2282 Direct: 202-830-3399 Register for FREE trainings here: Ak AAS is a membership organization for those in voived in suicide prevention and intervention, or touched by suicide. AAS is a ieader in the advancement of scientific and programmatic e??orts in suicide prevention through research, education and training, the deveiopment of standards and resources, and survivor support services. From: Black, Erin [mailtozepm7@cdc.gov} Sent: Thursday, June 7, 2018 10:04 AM To: Torguson, Kimberly Belyeu, Ayery ibenson@reingold.com; Bray, Miranda Bruce, Carr, Colleen SCoggin@afsp.org; Colleen Creighton Crosby, Alexander Curtin, Sally C. Daniel, Valerie M. mgdyak@eiconline.org; iohnd@mhaofnyc.org; fgonzalez@mhaofnyc.org; Gass, Jesse Hausman, Bridgette Hedegaard, Holly Subject: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates In prep for our call today to discuss our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, attached is an embargoed copy of the Fact Sheet. The Vital Signs includes state-level trends in suicide rates from 1999- 2016, and, with data from National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. We appreciate this partnership and hope you can all help us disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Erin The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month's edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains an advance copy of the four-page Vito.l Signs fact sheet. This latest edition of CDC Vitoi Signs will be released today, Thursday, June 7, 2018, at 1:00 pm (EST) following a media telebriefing at noon; the attachment is EM BARGOED until 1pm EST. Key points in the Vit?i Signs report include: it In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999?2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each 0 Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC VitoiSigns information broadly with your colleagues and partners. Visit the Vito! Sions Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of m1 media tools such as the Vit??i Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vito! Signs Town Hall Teleconference on June 12 at 2:00 pm Vitoi Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Original From: Torguson, Kimberly Sent: Monday, May 14, 2018 6:59 PM To: Torguson, Kimberly; Belyeu, Avery; ibenson@reingold.com; Black, Erin Bray, Miranda Bruce, Carr, Colleen; SCoggin@afsp.org; ccreighton@suicidology.org; Crosby, Alexander Curtin, Sally C. Daniel, Valerie M. mgdyak@eiconline.org; JohnD@mhaofnyc.oLg; fgonzalez@mhaofnvc.oLg; Gass, Jesse; Hausman, Bridgette; Hedegaard, Holly Holland, Kristin ajkuposuicidologyorg; Kurnit, Molly Regina plauricella@reingold.com; cmaxwell@suicidology.org; McElroy, James McShane, Kristen eneely@reingold.com; AOBrien@afsp.org; O'Keefe, Lindsey ipearson@nih.gov; Pearson, Jane Reed, Jerry; dreidenberg@save.org; Richmond-Crum, Malia mrosen@mhaofnyc.org; michaeliescanlon@nih.gov; Sobottka, Linda; Stone, Deborah Stout, Elly; AVactor@mhaofnyc.org; Warner, Margaret Wright, James (SAM Subject: Media Messaging Work Group Call When: Thursday, June 7, 2018 11:00 AM Eastern Time (US 8: CanadaL Where: Phone Number: 866-370-2808 (access code Phone Number: 866-370-2808 (access code Email Context (From 5/14): Hello Media Messaging Work Group (MMWG), Following the email below, we wanted to let you know that the CDC data expected to be released on June 5 will now be released on June 7. Additionally, we received word that we will not be receiving an embargoed copy so we'll be rescheduling our MMWG group call (originally scheduled for Thursday, May 31) to Thursday, June 7 at 11:00 am. The goal of this call is to convene our partners to: 1} discuss the data, and 2} develop consensus on our messaging that will be used to craft a statement. If you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you can join us on Thursday, June 7 at 11:00 a.m. Lastly, we want to thank CDC for giving us the heads up about the data. Best Hello Media Messaging Work Group, We wanted to call to your attention to a just-released article published in the American Journoi of Preventive Medicine that looks at county-specific estimates of suicide rates. The paper titled "County-level Trends in Suicide Rates in the U.S., 2005-2015" was written by our Partner, CDC (authors include: Lauren M. Rossen, Holly Hedegaard, Diba Khan and Margaret Warner from NCHS). Key findings include: - Posterior predicted mean cou nty-level suicide rates increased by >10% from 2005 to 2015 for 99% of counties in the U.S., with 37% of counties showing increases of - Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S., with the exception of southern California and parts of Washington. ICompared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community?based suicide prevention efforts in the 0.5. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement {written in collaboration with the MMWG partners) released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please find below some tailorable social media posts to help further promote the data: I Data released by @CDCInjury featured in @AmJPrevMed shows county-level trends in suicide rates in the US http?bitiyjleo?hk I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts ITrends about suicide, like geographic patterns, helps us develop more targeted community-based #suicideprevention strategies so we can reduce annual suicide rate 20% by 2025 I Rural counties in the U.S. had the highest estimated suicide rates from 2005-2015 according to just-released @AmJPrevMed http://bitJy/ZIHoBhk ITracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts htth/bitJy/ZIHo?hk ITogether we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: I @Action Alliance I @AASuicidology I @afspnational I I I @DeptofDefense I @DeptVetAffairs I @EDCTweets I I I @samhsagov I @SAVEvoicesofedu I I @TrevorProiect I Some resources that you may also find helpful as you promote the data include: I Action Alliance?s Transformingjiommunities: Key Elements for the implementation of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. a Preventing Suicide: A Technicai Package of Poiicy, Programs, and Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this larger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Piease join usfar a pianning caii on Thursday, May 31 at 2:00 p.m. ET to plan ahead for caiiective statement about CDC data. We will send you a calendar invite (containing call-in information) to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC for giving us the heads up about the data. Thank you. From: Stone, Deborah Sent: 11 Jun 2018 12:37:45 +0000 To: Yuan, Keming Subject: RE: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates Thank you. I appreciate your attention to this! Deb From: Yuan, Keming Sent: Monday, June 11, 2018 12:56 AM To: Stone, Deborah Subject: RE: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Deb, I run the code again during this weekend. The two most common substance under ?Other? are ACETAIVIINOPHEN and There is no Alcohol under 'Other? group. Sorry for the confusion. Last Friday, I was in the class and run the code too quick to give it a careful thought. Thanks, Keming From: Yuan, Keming (CDCIDNDIEHKNCIPC) Sent: Friday, June 3, 2018 4:23 PM To:Stone, Deborah cdc. oy> Subject: RE: EMBARGDED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Deb, Alcohol has its own class, which we didn?t mean to include it in ?Dther'. In my coding, I only used substance class and didn't check substance name. In the data, some alcohol were put under ?Dther? in error, which I didn?t excluded. But, it didn't account for much. Keming From: Stone, Deborah Sent: Friday, June 8, 2018 3:22 PM To: Yuan, Keming Jack, Shane P. Davis Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Thank you Keming! Deb From: Yuan, Keming DIEHINCIPC) Sent: Friday, June 8, 2018 3:21 PM To: Stone, Deborah Jack, Shane P. Davis Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Deb, The common substance under ?Other? are something like Acetaminophen, eth. Also, it includes Alcohol and ethanol. We don?t have specific substance class for those substance, so they are all under ?Other?. Keming From: Stone, Deborah Sent: Friday, June 8, 2018 1:10 PM To: Yuan, Keming Jack, Shane P. Davis Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Thanks, Keming! Deb From: Yuan, Keming Sent: Friday, June 8, 2018 1:09 PM To: Stone, Deborah Jack, Shane P. Davis Subject: RE: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Deb, I'm in training class now and I don?t have access to SAS and my code. I will get it back to vou later this afternoon. Keming From: Stone, Deborah Sent: Friday, June 8, 2018 10:32 AM To: Yuan, Kerning Jack, Shane P. Davis Subject: FW: EM BARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Can either of you help answer this questions? Think it?s things like Benadrvl etc but not sure if there?s a specific list or descriptor: Deb From: Black, Erin Sent: Fridav, June 8, 2018 10:15 AM To: Stone, Deborah <2an cdc. ov> Subject: FW: EM BARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates See question below re the VS. From: Colleen Creighton Subject: RE: EMBARGOED Until 1pm June Iv'ital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin Thanks so much for the call today and for all vour work going into this rEport. One question that came up from our end is under ?Other" what is included In this category in addition to Other leg, over-the?counler) 1,021 (34.0 Thanks so much, CoHeen Colleen Creighton Executive Director American Association of Suicidology 5221 Wisconsin Avenue, NW, 2"d Floor Washington, DC 20015 T: (202} 2312280, F: (202) 2312282 Direct: 202-830?3399 Register for FREE trainings here: Ak AAS is a membership organization for those invoived in suicide prevention and intervention, or touched by suicide. AAS is a ieader in the advancement of scientific and programmatic efforts in suicide prevention through research, education and training, the deveiopment of standards and resources, and survivor support services. From: Black, Erin Sent: Thursday, June 7, 2018 10:04 AM To: Torguson, Kimberly Belyeu, Avery eu edc.or a; Bray, Miranda Bruce, Carr, Colleen SCoggin@afsp.org; Colleen Creighton ; iohnd@mhaofnvc.org; fgonzalez?mhaofnvc.org: Gass, Jesse Hausman, Bridgette Hedegaard, Holly Holland, Kristin Amy Kulp Kurnit, Molly Regina wendy.e.lakso.civ@mail.mil; Chris Maxwell McElroy, James McShane, Kristen eneelv@reingold.com; A03rien@afsp.org; O'Keefe, Lindsey jpearson@nih.gov; Pearson, Jane Reed, Jerry dreidenberg@save.org; Richmond-Crum, Malia mrosen@mhaofnyc.org; michaeilescanlon@nih.gov; Sobottka, Linda Stone, Deborah Stout, Elly AVactor@mhaofnyc.org; Warner, Margaret Wright, James (James.Wright@samhsa.hhs.gov> Subject: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates In prep for our call today to discuss our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, attached is an embargoed copy of the Fact Sheet. The Vital Signs includes state-level trends in suicide rates from 1999-2016, and, with data from National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. We appreciate this partnership and hope you can all help us disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Erin The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27' states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains an advance copy ofthe four-page Virai Signs fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at [:00 pm (EST) following a media telebrie?ng at noon; the attachment is EMBARGOED until 1pm EST. Key points in the Vital Signs report include: I In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older I From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each 0 Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Virai Signs information broadly with your colleagues and partners. Visit the Vital Siaris Webpage to find the MMWR article, fact sheet, and other materials. Take advantage ofCDC?s social media tools, such as the Viiai Signs buttons and email updates. Visit CDC 's Public Health Media Library at and search on the term Vital Signs. We also invite you tojoin us for the Viird Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Original From: Tcrguson, Kimberly Sent: Monday, May 14, 2018 6:59 PM To: Torguson, Kimberly; Belyeu, Avery; ibenson@reingold.com; Black, Erin Bray, Miranda Bruce, Carr, Colleen; SCoggin@afsp.org; Crosby, Alexander Curtin, Sally C. Daniel, Valerie M. mgdyak@eiconline.org; iohnD@mhaofnyc.org; fgonzalez@mhaofnyc.org; Gass, Jesse; Hausman, Bridgette; Hedegaard, Holly Holland, Kristin Kurnit, Molly Regina McElroy, James McShane, Kristen eneely@reingold.com; AOBrienQafsporg; O'Keefe, Lindsey ipearsonQnihgov,? Pearson, Jane Reed, Jerry; dreidenberg@save.org; Richmond- Crum, Malia mrosen@mhaofnyc.org; michaelle.scanion@nih.gov; Sobottka, Linda; Stone, Deborah Stout, Elly; AVactor@mhaofnyc.org; Warner, Margaret Wright, James Subject: Media Messaging Work Group Call When: Thursday, June 7, 2018 11:00 AM Eastern Time 3: Canada). Where: Phone Number: 856-370?2308 (access code Phone Number: 866-370-2308 (access code Email Context (From Hello Media Messaging Work Group (MMWG), Following the email below, we wanted to let you know that the CDC data expected to be released on June 5 will now be released on June 7. Additionally, we received word that we will not be receiving an embargoed copy so we?ll be rescheduling our MMWG group call (originally scheduled for Thursday, May 31) to Thursday, June 7 at 11:00 am. The goal of this call is to convene our partners to: 1) discuss the data, and 2) develop consensus on our messaging that will be used to craft a statement. if you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you can join us on Thursday, June at 11:00 a.m. Lastly, we want to thank CDC for giving us the heads up about the data. Best, Hello Media Messaging Work Group, We wanted to call to your attention to a just?released article published in the American Journoi of Preventive Medicine that looks at countyuspecific estimates of suicide rates. The paper titled ?County? level Trends in Suicide Rates in the U.S., 20052015? was written by our Partner, CDC {authors include: Lauren M. Rossen, Holly Hedegaard, Diba Khan and Margaret Warner from NCHS). Key findings include: . Posterior predicted mean county~leve suicide rates increased by )1096 from 2005 to 2015 for 99% of counties in the 0.5., with 87% of counties showing increases of - Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S., with the exception of southern California and parts of Washington. - Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the U.S. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement (written in collaboration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county?level trends data. Please find below some tailorable social media posts to help further promote the data: I Data released by featured in @AmJPrevMed shows county?level trends in suicide rates in the US I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community?based suicide prevention efforts I Trends about suicide, like geographic patterns, helps us develop more targeted community-based #suicideprevention strategies so we can reduce annual suicide rate 20% by 2025 I Rural counties in the U5. had the highest estimated suicide rates from 2005-2015 according to just-released @AmlPrevMed I Tracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts I Together we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: I @Action Alliance I @AASuicidology I @afsgnational I I I @DeptofDefense I @DegtVetAffairs I @EDCTweets I I I @samhsagov I @SAVEvoiCEsofedu I I @TrevorProiect . Some resources that you may also find helpful as you promote the data include: I Action Alliance?s Transforming Comm uni ties: Key Elemen ts for the implementation of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. I CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this larger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Please join us for a planning call on Thursday, May 31 at 2:00 gm. ET to glen ahead [or collective statement about CDC data. We will send you a calendar invite (containing call-in information] to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC for giving us the heads up about the data. Thank you. From: Black, Erin Sent: 8 Jun 2018 10:32:45 -0400 To: Stone, Deborah Subject: RE: EMBARGDED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates thanks From: Stone, Deborah Sent: Friday, June 8,2018 10:32 AM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates I passed the question to Shane. Deb From: Black, Erin Sent: Friday, June 8, 2018 10:15 AM To: Stone, Deborah <2an cdc. 0y) Subject: FW: EM BARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates See question below re the VS. From: Colleen Creighton Sent: Thursday, June 7, 2018 5:45 PM To: Black, Erin (e m? cdc. ov> Subject: RE: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin ?Thanks so much for the call today and for all your work going into this report. One question that came up from our end is under "Other" what is included in this category in addition to Other over-the-counter) 1,021 (34.0 Thanks so much, CoHeen Colleen Creighton Executive Director American Association of Suicidology 5221 Wisconsin Avenue, NW, 2nd Floor Washington, DC 20015 T: (202) 237-2280, F: (202) 237-2282 Direct: 202-830-3399 Register for FREE trainings here: Ak AAS is a membership organization for those invoived in suicide prevention and intervention, or touched by suicide. AAS is a ieader in the advancement of scientific and programmatic efforts in suicide prevention through research, education and training, the deveiopment of standards and resources, and survivor support services. From: Black, Erin Sent: Thursday, June 7, 2018 10:04 AM To: Torguson, Kimberly Belyeu, Avery ibenson@reingold.corn; Bray, Miranda Bruce, Carr, Colleen SCoggin@afsp.org; Colleen Creighton Crosby, Alexander Curtin, Sally C. Daniel, Valerie M. mgdvak@eiconline.org: iohnd@mhaofnyc.org; fgonzalez@mhaofnyc.org; Gass, Jesse Hausman, Bridgette Hedegaard, Holly Holland, Kristin Amy Kulp Kurnit, Molly Regina wendy.e.lakso.civ@mail.mil; plauricella@reingold.com; Chris Maxwell (cmaxwell@suicidologyorg}; McElroy, James McShane, Kristen (SAMHSAIOQ AOBrien@afsp.org; O'Keefe, Lindsey (NIHJNIMH) ipearson@nih.gov; Pearson, Jane Reed, Jerry dreidenberg@save.org; Richmond-Crum, Malia mrosen@mhaofnyc.org; Sobottka, Linda Stone, Deborah Stout, Elly AVactor@mhaofnyc.org; Warner, Margaret Wright, James Subject: EMBARGOED Until 1pm June it: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates In prep for our call today to discuss our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, attached is an embargoed copy of the Fact Sheet. The Vital Signs includes state-level trends in suicide rates from 1999?2016, and, with data from (1305 National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. We appreciate this partnership and hope you can all help us disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Erin The CDC Vitai Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and DC, examines contributing factors to suicide in 2? states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains an advance copy of the four-page Vital Signs fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm (EST) following a media telebrie?ng at noon; the attachment is EMBARGOED until 1pm EST. Key points in the Vital Signs report include: I In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older I From 1999?2016. suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Tv?iolent Death Reporting System in 2015 indicate that more than halfof people who died by suicide did not have a known mental health condition IA range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, ?nancial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Virai Signs buttons and email updates. Visit CDC's Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Virai Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Original From: Torguson, Kimberly Sent: Monday, May 14, 2018 6:59 PM To: Torguson, Kimberly; Belyeu, Avery; ibenson@reingold.com; Black, Erin Bray, Miranda Bruce, Carr, Colleen; SCoeein@afsp.org; Crosby, Alexander Curtin, Sally C. Daniel, Valerie M. mgdyak@eiconline.ore; JohnD@mhaofnyc.org; fgonzaiez@mhaofnyc.org; Gass, Jesse; Hausman, Bridgette; Hedegaard, Holly Holland, Kristin aikulo@suicidology.org; Kurnit, Molly Regina wendy.e.lakso.civ@mailmil; plauricella@reingold.com: sheriJunn@thetrevorproiectorg; cmaxwelI@suicidoloay.org; McElroy, James McShane, Kristen AOBrien@afsp.org; O'Keefe, Lindsey AmitPaIey@thetrevorprojectorg; igearsonQnihgov: Pearson, Jane Reed, Jerry; dreidenberg@save.org; Richmond- Crum, Malia mrosen@mhaofnyc.org; michaellescanlon@nih.gov; Sobottka, Linda; Stone, Deborah Stout, Elly; AVactor@mhaofnyc.ora; Warner, Margaret Wright, James Subject: Media Messaging Work Group Call When: Thursday, June 7, 2018 11:00 AM Eastern Time 8: Canada). Where: Phone Number: 865?370?2308 (access code Phone Number: 866-370-2303 (access code Email Context [From 51'14): Hello Media Messaging Work Group (MMWG), Following the email below, we wanted to let you know that the CDC data expected to be released on June 5 will now be rele? on June 7. Additionally, we received word that we will not be receiving an embargoed copy so we?ll be rescheduling our MMWG group call (originally scheduled for Thursday, May 31) to Thursday. June 7 at 11:00 a.m. The goal of this call is to convene our partners to: 1) discuss the data, and 2) develop consensus on our messaging that will be used to craft a statement. if you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you can join us on Thursday, June 7 at 11:00 am. Lastly, we want to thank CDC for giving us the heads up about the data. Best, Hello Media Messaging Work Group, We wanted to call to your attention to a just?released article published in the American Journal of Preventive Medicine that looks at county?specific estimates of suicide rates. The paper titled "County? level Trends in Soicide Rates in the U.S., 2005-2015" was written by our Partner, CDC {authors include: Lauren M. Rossen, Holly Hedegaard, Diba Khan and Margaret Warner from NCHS). Key findings include: - Posterior predicted mean county-level suicide rates increased by >10% from 2005 to 2015 for 99% of counties in the U.S., with 32% of counties showing increases of I Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S., with the exception of southern California and parts of Washington. I Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the U5. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement (written in collaboration with the MMWG partners] released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please find below some tailorable social media posts to help further promote the data: I Data released by @CDCInjury featured in @AmJPrevMed shows county-level trends in suicide rates in the US I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts . Trends about suicide, like geographic patterns, helps us develop more targeted community-based #suicideprevention strategies so we can reduce annual suicide rate 20% by 2025 - Rural counties in the U.S. had the highest estimated suicide rates from 2005?2015 according to just?released @AmJPrevMed Ir Tracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts http://bitly/ZlHoBhk I Together we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: I @Action Alliance I @AASuicidology I @afspnational I @CDCIniury I I @DeptofDefense I @DeptVetAffairs I @EDCTweets I I I @samhsagov I @SAVEvoicesofedu I I @TrevorProiect Some resources that you may also find helpful as you promote the data include: I Action Alliance's Transforming Communities: Key Eiements for the impiementation of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. I CDC's Preventing Suicide: A Technicai Package of Poiicy, Programs, and Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this larger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Piease join us for a pianning caii on Thursaa Ma 31 at 2:00 ET to fan ahead or coiiective statement about CDC data. We will send you a calendar invite (containing call-in information) to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC for giving us the heads up about the data. Thank you. From: Colleen Creighton Sent: 8 Jun 2018 19:32:13 +0000 To: Stone, Deborah Cc: Lenard, Courtney Erin Subject: Re: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates Absolutely does. Thanks so muchll From: Stone, Deborah Sent: Friday, June 8, 2018 3:28 PM To: Colleen Creighton Cc: Lenard, Courtney Black, Erin Subject: FW: EMBARGOED Until June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HiCoHeen, I?m responding to your question that Erin shared. The common substance under ?Other? are something like Acetaminophen, eth. Also, it includes alcohol and ethanol. We don"t have specific substance class for those substance, so they are all under ?Other?. 1 hope this helps! Thanks Deb Deb Stone, MSW, MPH Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Suicide, Youth Violence at Elder Maltreatment Team ??0.488.3942 dstoneBtEcdcgov Injury Center Preventing Injuries and Violence Through Science and Action From: Black, Erin Sent: Friday, June 3, 2018 10:15 AM To: Stone, Deborah Subject: FW: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates See question below re the VS. From: Colleen Creighton Sent: Thursday, June 7, 2018 5:45 PM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin Thanks so much for the call today and for all your work going into this report. One question that came up from our end is under "Other? what is included in this category in addition to Other over-the-counter) 1,021 {34.0 Thanks so much, CoHeen Colleen Creighton Executive Director American Association of Suicidology 5221 Wisconsin Avenue, NW, 2nld Floor Washington, DC 20015 T: (202} 237-2280, F: (202) 237?2282 Direct: 202-830-3399 Register for FREE trainings here: A a? AAS is a membership organization for those in voived in suicide prevention and intervention, or touched by suicide. AAS is a ieaa'er in the advancement of scientific andI programmatic efforts in suicide preven tian through research, education and training, the deveiopment ofstondards and resources, and survivor support services. From: Black, Erin Sent: Thursday, June 7, 2013 10:04 AM To: Torguson, Kimberly Belyeu, Avery Subject: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates In prep for our call today to discuss our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, attached is an embargoed copy of the Fact Sheet. The Vital Signs includes state-level trends in suicide rates from 1999? 2016, and, with data from National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. We appreciate this partnership and hope you can all help us disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Erin The CDC Vitai Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains an advance copy of the four-page Vita! Signs fact sheet. This latest edition of CDC Vitai Signs will be released today, Thursday, June 7, 2018, at 1:00 pm following a media telebriefing at noon; the attachment is EMBARGDED until 1pm EST. Key points in the Vitai Signs report include: - In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of CDC's media tools, such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on lune 12 at 2:00 pm (EST). VitolSigns is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Original From: Torguson, Kimberly Sent: Monday, May 14, 2018 6:59 PM To: Torguson, Kimberly; Belyeu, Avery; jbenson@reingold.com; Black, Erin Bray, Miranda Bruce, Carr, Colleen; Crosby, Alexander Curtin, Sally C. Daniel, Valerie M. mgdyak@eiconline.org; JohnD@mhaofnyc.org: fgonzalez@mhaofnyc.org: Gass, Jesse: Hausman, Bridgette; Hedegaard, Holly Holland, Kristin aikulo@suicidology.org; Kurnit, Molly Regina wendy.e.lakso.civ@mail.mil; plauricella@reingold.com; cmaxwell@suicidology.org; McElroy, James McShane, Kristen eneely@reingold.com: AOBrien@afsp.org; O'Keefe, Lindsey jpearson@nih.gov; Pearson, .lane Reed, Jerry; dreidenberg@save.org; Richmond-Crum, Malia mrosen@mhaofnyc.org; michaelle.scanlon@nih.gov; Sobottka, Linda; Stone, Deborah Stout, Elly; AVactor@mhaofnyc.org; Warner, Margaret Wright, James Subject: Media Messaging Work Group Call When: Thursday, June 7, 2013 11:00 AM Eastern Time (US CanadaL Where: Phone Number: 866-370-2808 (access code Phone Number: 866-370-2808 (access code Email Context (From 5/14): Hello Media Messaging Work Group (MMWG), Following the email below, we wanted to let you know that the CDC data expected to be released on June 5 will now be released on June 7. Additionally, we received word that we will not be receiving an embargoed copy so we'll be rescheduling our MMWG group call (originally scheduled for Thursday, May 31) to Thursday, June 7 at 11:00 am. The goal of this call is to convene our partners to: 1} discuss the data, and 2) develop consensus on our messaging that will be used to craft a statement. If you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you can join us on Thursday, June 7 at 11:00 am. Lastly, we want to thank CDC for giving us the heads up about the data. Best Hello Media Messaging Work Group, We wanted to call to your attention to a just-released article published in the American Journal of Preventive Medicine that looks at county-specific estimates of suicide rates. The paper titled "County-level Trends in Suicide Rates in the U.S., 2005-2015? was written by our Partner, CDC (authors include: Lauren M. Rossen, Holly Hedegaard, Diba Khan and Margaret Warner from NCHS). Key findings include: I Posterior predicted mean cou nty-level suicide rates increased by >10% from 2005 to 2015 for 99% of counties in the U.S., with 87% of counties showing increases of I Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S., with the exception of southern California and parts of Washington. I Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the 1.1.5. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement {written in collaboration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. You?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please find below some tailorable social media posts to help further promote the data: I Data released by @CDCInjury featured in @AmJPrevMed shows county-level trends in suicide rates in the U5 I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts ITrends about suicide, like geographic patterns, helps us develop more targeted community-based #suicideprevention strategies so we can reduce annual suicide rate 20% by 2025 a Rural counties in the U.S. had the highest estimated suicide rates from 2005-2015 according tojust-released @AmJPrevMed http://bitJv/BIHoShk -Tracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts ITogether we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: I @Action Alliance - @AASuicidology a @afspnational - @CDCiniury - I @DeptofDefense I @DeptVetAffairs I @EDCTweets - 0 @samhsagov 0 @SAVEvoicesofedu 0 @TrevorProiect Some resources that you may also find helpful as you promote the data include: - Action Alliance's Transforming Communities: Key Elements for the impiementation of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. I Preventiry?uicide: A Technicai Package of Poiicyi Programs! and Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this group to develop consensus messaging around this impending data release. In preparation for this iarger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Piease join us for a pianning caii on Thursday, May 31 at 2:00 p. m. ET to pian ahead for coiiective statement about CDC data. We will send you a calendar inyite (containing call-in information} to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly. we wanted to thank CDC for giving us the heads up about the data. Thank you. From: Stone, Deborah Sent: 7 Jun 2018 13:41:22 +0000 To: Smith, Lakeesha (Shakiy a} Subject: RE: Embargoed until 1pm June 7: Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Thank you! Fingers and toes crossedlii! From: Srnith, Lakeesha {Shakiylal Sent: Thursday, June 7, 2018 9:37 AM To: Stone, Deborah Subject: FW: Embargoed until 1pm June Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Congratulationsll Good luck today! I know you?ll rock it! 5 From: Core VIPP Sent: Thursday, June 7, 2018 9:12 AM Subject: Embargoed until 1pm June 7: Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Dear Colleague: The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and DC, examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e?mail contains advance copies of several Vital Signs materials, including the Morbidity: and Mortality Weekly Report (MWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four?page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, one 7, 2018, at 1:00 pm (EST) following a media telehrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: . In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each oData from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than halt?of people who died by suicide did not have a known mental health condition - A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Viioi' Signs information broadly with your colleagues and partners. Visit the VitolSions Webpage to ?nd the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite yen tojoin us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Thank you for your support. James A- Mercy, Debra Horny: MD, MPH Director Director Division of Violette Prevention National Center fa- Injun, Ptarm?on and Control National Center for Injury Prevention and Control From: Stone, Deborah (CDCJONDIEHINCIPC) Sent: 7 Jun 2018 13:31:27 +0000 To: Richmond-Crum, Malia Subject: RE: Embargoed until 1pm June 7: Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Thank you. Deb From: Richmond-Crum, Malia Sent: Thursday, June 7, 2018 9:30 AM To: Stone, Deborah (CDCIONDIEHKNCIPCJ Subject: Embargoed until 1pm June 7: Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Here you go. Feel free to add your own note before sending to personalize. The CDC Vital Signs series, launched in 2010, addresses a single, important public .health topic each month. This month?s edition. presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states. and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vita! Signs materials, including the Morbidity and Morioiin! Weekiv Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four?page consumer fact sheet. This latest edition of CDC Vital Signs will he released today, Thursday, one 2018., at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older I From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each 0 Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, ?nancial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Sions Webpage to ?nd the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vita? Signs buttons and email updates. Visit CDC ?s Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. From: Richmond-Crum, Malia Sent: 7 Jun 2018 09:14:58 -0400 To: Jack, Shane P. Davis Cc: Blair, Janet Deborah Erin Marie R. Subject: RE: EMBARGDED UNTIL 1PM June Vital Signs: Contributing Circumstances to Suicide and increasing Trends in State Suicide Bates Thank you Shane. Please let me know if there are any questions from the folks that I can help with. From: Jack, Shane P. Davis (CDCIONDIEHINCIPC) Sent: Thursday, June 7, 2018 9:13 AM To: Richmond-Crum, Malia Cc: Blair, Janet Stone, Deborah Black, Erin Ballman, Marie R. Bruce, Subject: RE: EMBARGOED UNTIL 1PM June Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Good morning Malia, The email below was sent to at 9:01am. Thank you! Shane From: Richmond-Crum, Malia Sent: Wednesday, June 5, 2018 4:36 PM To: Jack, Shane P. Davis do4 cdc. ova Cc: Blair, Janet Stone, Deborah <2an cdc. ov>; Black, Erin Ballman, Marie R. Bruce, czigx?g?icdcgov} Subject: EMBARGOED UNTIL 1PM June Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Shane Here is the email {below} and attachments to share with tomorrow morning at 9am [please do not send out before 9am}. As requested by the principle investigators, I?ve also attached internal talking points that they my use if they choose. Malia Dear Principle Investigators: The CDC VitoiSigns series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 2? states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortoiity Weekiy Report article, "Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four~page consumer fact sheet. This latest edition of CDC Vito! Signs will be released today, Thursday, June 7, 2013, at 1:00 pm following a media telebriefing at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vitoi Signs report include: I in 2016, nearly 45,000 suicides occurred in the US among people 10 years and older From 1999?2015, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each . Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition I A range of factors contributes to suicide bevond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadlyI with your colleagues and partners. Visit the Vital Signs Webpageto find the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vitoi Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vito! Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Social Media Handles and Twitter Chat: Please save the date for our upcoming Twitter chat: The Twitter chat, scheduled forJune 11th from 2-3PM ET, will be co-hosted by CDC (@CDCIniurv} and The National Action Alliance for Suicide Prevention (@Action Alliance). Day: Monday, June 11th Time: ET Place: Twittercom from your computer or mobile device and search the hashtag #SuicideChat During the chat, vou?ll be able to: I Gain kev insights into the most recent Vital Signs issue It Ask questions of experts from and @Action_Al iance I Share your own prevention resources and stories Spread the Word I Tweet: Join the @CDCinjurv 8t. @ActionAlliance #SuicideChat on Monday June 11 2-3PM ET. Topics covered include the latest @CDCgov #VitalSigns issue and rates of #suicide in the US. Additionally, watch for social posts from these handles: CDC Facebook 0 CDC Twitter c: CDC el-iealth Twitter 0 CDC injury Twitter 0 CDC VetoViolence Facebook 5- CDC Linkedln C: CDC Q?gm?t-?i? CDC instagram [check the stories after 1pm ET) CDC Director Twitter From: Jack, Shane P. Davis Sent: 6 Jun 2018 18:14:25 -0400 To: Richmond-Crum, Malia Cc: Blair, Janet Deborah Erin Marie R. (CDCIOPHPRIOD) Subject: RE: EMBARGDED 1PM June Vital Signs: Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates Awesome! i will not release until 9:013m. Shane From: Richmond-Crum, Malia Sent: Wednesday, June 6, 2018 4:36 PM To: Jack, Shane P. Davis Cc: Blair, Janet Stone, Deborah Black, Erin (cociouolEHiNCIPcl Ballman, Marie R. Bruce, Subject: EMBARGUED UNTIL 1PM June Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Shane Here is the email (below) and attachments to share with tomorrow morning at 9am (please do not send out before 9am]. As requested by the principle investigators, I?ve also attached internal talking points that they my use if they choose. Malia Dear Principle Investigators: The CDC Viroisi'gns series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortoiity Weekiy Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four-page consumer fact sheet. This latest edition of CDC Vito! Signs will be released today, Thursday, June 1, 2013. at 1:00 pm following a media tale-briefing at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: - in 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Sions Webpageto find the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vital Signs buttons and email updates. Visit CDC's Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Social Media Handles and Twitter Chat: Please save the date for our upcoming Twitter chat: The Twitter chat, scheduled for June 11th from 2-3PM ET, will be co-hosted by CDC (@CDCIniury} and The National Action Alliance for Suicide Prevention (@Action Alliance). Day: Monday, June 11th Time: ET Place: Twittercom from your computer or mobile device and search the hashtag #SuicideChat During the chat, you?ll be able to: I Gain key insights into the most recent Vital Signs issue - Ask questions of experts from @CDCinjury and @ActionwAlliance I Share your own prevention resources and stories Spread the Word I Tweet: Join the @CDCinjury @ActionAlliance #SuicideChat on Monday June 11 2-3PM ET. Topics covered include the latest @CDCgov #VitalSigns issue and rates of #suicide in the US. Additionally, watch for social posts from these handles: {3 CDC Facebook CDC Twitter a eHealth Twitter CDC Injury Twitter CDC VetoViolence FacebODK CDC Linkedln CDC Google+ CDC Pinterest CDC lnstagram [check the stories after 1pm 0 CDC Director Twitter From: Black, Erin Sent: 4 May 2018 11:58:55 0400 To: Simon, Thomas Cc: Stone, Deborah Subject: RE: Fact Sheet revisions-telebrief revisions No problem, thanks. From: Simon, Thomas Sent: Friday, May 4, 2018 10:20 AM To: Peaker, Brandy Stone, Deborah Black, Erin Cc: Schieber, Richard A. (CDCIOPHSSICSELSIDPHIDJ Sokler, Omisore, Shannon L. (cocrooroaoq Subject: RE: Fact Sheet revisions?telebrief revisions Hi everyone, Given the urgent need to prepare the next version for Dr. Schuchat, I am going to take out the sentence. I agree with Brandy?s point that saying more research is needed takes away from the impact of our other points in that paragraph. We can consider if there are other ways to address this issue in the FS or other materials. I think the telebrief is a good opportunity. -Tom From: Peaker, Brandy Sent: Friday, May 4, 2018 10:16 AM To: Stone, Deborah (CDCKONDIEHXNCIPQ Simon, Thomas Black, Erin Ce m7 cdc. ov> Cc: Schieber, Richard A. Sokler, Omisore, Shannon L. Peaker, Brandy Date: May 4, 2018 at 9:15:01 AM EDT To: Simon, Thomas Black, Erin Peaker, Brandy {vhafir??cdegovlb Subject: RE: Fact Sheet reyisions-telebrief revisions I think the phrase is useful; without it people will think the contributing factors we list subsequently are responsible for the increases just mentioned. They may be but we don't know. I think it keeps us more honest. Deb From: Simon, Thomas Sent: Friday, May 4, 2018 3:01 AM To: Black, Erin Stone, Deborah Peaker, Brandy Subject: RE: Fact Sheet revisionsvtelebrief revisions Hi Brandy, Erin, Deb, We are getting different opinions about the following sentence: Although the reasons for the increases need more study, many factors are known to contribute to suicide. Several people have said that we need something like this because there is so much emphasis on the increasing rates we need to acknowledge that we don?t know why the increase is happening. We don't have the space to fully describe what people think is happening with the increase. This sentence transitions to the description of circumstances. Others have said it is not necessary. Do you feel strongly either way? ?Tom From: Omisore, Shannon L. Sent: Thursday, May 3, 2018 6:38 PM To: Simon, Thomas Sokler, Bruce, Stone, Deborah Black, Erin Richmond? Crum, Malia Kurnit, Molly Regina Cc: Schieber, Richard A. Peaker, Brandy Subject: RE: Fact Sheet revisions-telebrief revisions Tom, That sentence will be added to the FS. Attached are the Word and PDF files. Brandy has reviewed the fact sheet and left some suggested changes. Please read the comments and indicate whether the changes can be made. If you disagree with a suggestion, please delete the comment box or sticky. For the PDF, most of her comments are regarding the graphics on page 3. For example, can ?lethal" be changed to "deadly? in the graphic at the bottom of page 3? Please respond by Friday, May 4 at 10 a.m. The fact sheet is going to be sent to DD on Friday, so this would allow enough time for the graphic artist to work on the fact sheet. Thanks, Shannon From: Simon, Thomas Sent: Thursday, May 3, 2013 5:25 PM To: Sokler, Bruce, Stone, Deborah Black, Erin Omisore, Shannon L. DeNoon, Daniel Richmond-Crum, Malia Kurnit, Molly Regina ; Schieber, Richard A. Peaker, Brandy Subject: RE: Fact Sheet revisions-telebrief revisions Hi and Shannon, I had not noticed that the bullets above the pie charts were dropped. Can we still add at least the following bullet to explain what the pie charts mean?l - People without known mental health problems were more likely to be male and to die by firearm. Otherwise, the pie charts are hard to interpret. Thank you, Tom From: Simon, Thomas Sent: Thursday, May 3, 2018 2:21 PM To: Sokler, Bruce, Stone, Deborah Black, Erin Omisore, Shannon L. DeNoon, Daniel Richmond-Crum, Malia Kurnit, Molly Regina Cc: Omisore, Shannon L. DeNoon, Daniel (CTR) Grusich, Katherina {Kate} Schieber, Richard A. Peaker, Brandy Subject: RE: Fact Sheet revisionsvtelebrief revisions Hi and US team, Thank you very much for all your help on the fact sheet and for talking through some important issues this morning. I am attaching a tracked version of the Word document and a version of the with stickies added. Hopefully all of these comments are clear but let me know if you have any questions. I think the two big issues are: First, trying to make the top image on page 3 work better. We liked the suggestions you offered on the call to connect the bullets to the boxes by using the same colored font for the first work. Our communications team suggested some other helpful edits. Second, we?d like to make the two boxes (media and Lifeline] fit on page 4. In the Word document I provided draft examples of the boxes that we hope will work. We look forward to seeing the next version. Thank you, ?Tom From: Sokler, Sent: Wednesday, May 2, 2013 12:18 PM To: Bruce, (CDCIOPHPRIOD) Stone, Deborah Simon, Thomas Black, Erin Dmisore, Shannon L. DeNoon, Daniel Richmond-Crum, Malia (CDCIONDIEHINCIPCJ Cc: Omisore, Shannon L. Sokler, (CDCIODIOADCJ Subject: Fact Sheet revisions-telebrief revisions Hi Attached is the revised Fact Sheet for your review. We?ve done some more work on the telebrief script as well. So, could you please do the following: 0 Provide Fact Sheet graphic changes in stickies on the I Provide Fact Sheet text changes in the Word document in track changes - Provide telebrief changes in track changes to the CLEAN document. We need you to provide Dr. Adam?s comments to it as well. 0 Under separate cover, we provided press release changes that we need you to accept, or edit, and give us back a CLEAN and TRACKED copy. I?ve reattached here to make it easier for you. We?d like to have all changes NLT COB tomorrow so that we have Thurs to revise and for your review. In an earlier email I mentioned shorter timeframes. I am thinking that If you have any of these documents ready before COB, please send them along (doesn?t have to be in one email). For example, if the Fact Sheet is ready first with edits, please get that back to us so we can give the artist more time for changes. I plan to send everything for the pre?brief out to everyone on Monday. Thanks much, From: Bailey, Keith Sent: Wednesday, May 2, 2018 10:12 AM To: Sokler, Cc: Omisore, Shannon L. (CDCIODIOADQ Subject: RE: June VS FS: Changes Hi Lynn, Please see updated and word files for June edition of I.iital signs. Thanks, Keith Keith A. Bailey Visual Information Specialist [Design Team} Graphic Services Branch, Division of Communication Services Office of the Associate Director for Communication Centers for Disease Control and Prevention 1600 Clifton Rd, NE Atlanta, GA 30333 Phone: 404313-5403 Tour of Duty: 7 3:30 PM. From: Omisore, Shannon L. Sent: Tuesday, May 1, 2018 3:26 PM To: Bailey, Keith Cc: Sokler, Omisore, Shannon L. Subject: RE: June VS FS: Changes Hi Keith, Thanks! I will review this in the morning. Please pull the Word file for the May Vital Signs fact sheet. Shannon From: Bailey, Keith Sent: Tuesday, May 1, 2018 3:14 PM To: Omisore, Shannon L. Cc: Sokler, <2520@cdc.goy> Subject: RE: June VS FS: Changes HiShannon, Please find attached, the latest iteration of the June Edition of Vital Signs. Also, please note that all of the suggested edits provided to me, via both and word files, have been applied. Several things are worth mentioning. The photographs pasted into the PDF, by "Program?, were treated as a visual guide to use similar ones. For the map on page two, there is the singular use of blue which was broken down into different gradations/tints in response to the comment made about "depth of color". Here is hoping all is in order to keep things moving along to subsequent phases in the production process. Thank you, Keith Keith A. Bailey Visual Information Specialist [Design Team} Graphic Services Branch, Division of Communication Services Office of the Associate Director for Communication Centers for Disease Control and Prevention 1600 Clifton Rd, NE Atlanta. GA 30333 Phone: 404?718?5403 Tour of Duty: A.M.- 3:30 PM. From: Omisore, Shannon L. Sent: Friday, April 2018 2:26 PM To: Bailey, Keith cokki] cdc. ov> Cc: Sokler, Subject: May VS F5: Changes Hi Keith, Attached are changes for the fact sheet indicated in the PDF and Word files. Also attached are the pie charts to replace the current ones and the PowerPoint of the graphic on page 3. Please feel free to contact me with any questions or concerns. To view the graphic at the bottom of page 2 in the Word file, select the simple markup or no markup option. Please update this fact sheet and send to us by the close of business (COB) on Tuesday, May 1. Thanks, Shannon Shannon Omisore, MA Health Communication Specialist Office of the Associate Director for Communication 2500 Century Parkway, MS Atlanta, GA 30345 Office: ?1044-4980153 E-mail: CDC (263/7 mam. From: Black, Erin Sent: 4 May 2018 11:13:36 -0400 To: Stone, Deborah Thomas Subject: RE: Fact Sheet revisions-telebrief revisions Are we over our word limit is that why they are pushing back so much? From: Peaker, Brandy Sent: Friday, May 4, 2018 10:27 AM To: Black, Erin Cc: Schieber, Richard A. Sokler, Omisore, Shannon L. (cation/once} Stone, Deborah (CDCKONDIEHINCIPQ Simon, Thomas Subject: RE: Fact Sheet revisions-telebrief revisions Can address increases need more research in telebriefing script to get ahead of question. Also it is in MWR. Even if you say more research needed in PS, media will ask what are your guesses as to why. I think having it in F8 uses up real estate iwith info that doesn?t contribute to your main message. But more importantly, it complexes the sentence which takes away from the punch of a de?nitive statement that ?Many factors contribute to suicide."? which is your SOHCO. From: Black, Erin {corona-{doggy} Date: May 4, 2018 at 10:18:23 AM EDT To: Peaker, Brandy (CDCHOPHSSICSELSIDPHID) Cc: Schieber, Richard A. Sokler, (CDCKODIOADC) Omisore, Shannon L. (C <11y15 {Redeem}, Stone, Deborah (CDCIONDIEHXNCIPC) Simon, Thomas Cc: Schieber, Richard A. Sokler, Dmisore, Shannon L. Peaker, Brandy Subject: RE: Fact Sheet revisions-telebrief revisions Adding Rich, Lynn, and Shannon. I don?t think the ?Although the reasons for the increases need more study" clause is needed for the following reasons: 1) Aside from a couple of topics (ie tobacco), most reasons for increases in disease trends need more study or are multi?factorial. So it?s sort of a given. It?s the whole ?more research is needed? sentence at the end of a discussion section that make cringe. More research is always needed. 2) It makes the reader pause before getting to the meat of the sentence and your SOHCO which is that many factors contribute to suicide. So it water downs one of your main points. 3) We try hard not to start sentences with a propositional phrase be it?s not clear language and makes the sentence harder to understand, which again will soften the impact of your main SOHCO. 4) Recommend including that the reasons for increases is not fully understood as part of the telebrie?ng script and Media is going to ask your hypothesis for the increases even if you put in the FS, more research is needed. Thanks, Brandy From: Stone, Deborah Date: May 4, 2018 at 9:15:01 AM EDT To: Simon, Thomas (CDCJONDIEHINCIPC) Black, Erin (CDCKONDIEHWCIPC) Peaker, Brandy Subject: RE: Fact Sheet revisions?telebrief revisions I think the phrase is useful; without it people will think the contributing factors we list subsequently are responsible for the increases just mentioned. They may be but we don?t know. I think it keeps us more honest. Deb From: Simon, Thomas Sent: Friday, May 4, 2018 8:01 AM To: Black, Erin Stone, Deborah (CDCIONDIEHINCIPC) Peaker, Brandy Subject: RE: Fact Sheet revisions-telebrief revisions Hi Brandy, Erin, Deb, We are getting different opinions about the following sentence: Although the reasons for the increases need more study, many factors are known to contribute to suicide. Several people have said that we need something like this because there is so much emphasis on the increasing rates we need to acknowledge that we don?t know why the increase is happening. We don?t have the space to fully describe what people think is happening with the increase. This sentence transitions to the description of circumstances. Others have said it is not necessary. Do you feel strongly either way? ?Torn From: Omisore, Shannon L. Sent: Thursday, May 3, 2018 6:38 PM To: Simon, Thomas Sokler, Bruce, cigx?chcgow; Stone, Deborah Black, Erin Richmond? Crum, Malia Kurnit, Molly Regina (CDCXONDIEHINCIPC) Cc: Schieber, Richard A. Peaker, Brandy cyha? cdc. 0y:- Subject: RE: Fact Sheet revisions~telebrief revisions Tom, That sentence will be added to the FS. Attached are the Word and PDF files. Brandy has reviewed the fact sheet and left some suggested changes. Please read the comments and indicate whether the changes can be made. If you disagree with a suggestion, please delete the comment box or sticky. For the PDF, most of her comments are regarding the graphics on page 3. For example, can "lethal" be changed to "deadly" in the graphic at the bottom of page 3? Please respond by Friday, May 4 at 10 am. The fact sheet is going to be sent to DD on Friday, so this would allow enough time for the graphic artist to work on the fact sheet. Thankg Shannon From: Simon, Thomas Sent: Thursday, May 3, 2018 5:25 PM To: Sokler, Bruce, x6 cdc. ova; Stone, Deborah Black, Erin (CDCXONDIEHINCIPC) Omisore, Shannon L. DeNoon, Daniel Richmond-Crum, Malia <'ry8 cdc. oy?a; Kurnit, Molly Regina cdc. oy> Cc: Omisore, Shannon L. DeNoon, Daniel (CDCIODIOADC) (CTR) (xlzil cdc. our); Grusich, Katharina (Kate) Schieber, Richard A. (CDCIOPHSSICSELSIDPHID) Peaker, Brandy Subject: RE: Fact Sheet revisions-telebrief revisions Hi and Shannon, I had not noticed that the bullets aboye the pie charts were dropped. Can we still add at least the following bullet to explain what the pie charts mean? . People without known mental health problems were more likely to be male and to die by firearm. Otherwise, the pie charts are hard to interpret. Thank you, Tom From: Simon, Thomas (CDCIDNDIEHKNCIPC) Sent: Thursday, May 3, 2018 2:21 PM To: Sokler, Bruce, x6 cdc. ow; Stone, Deborah Black, Erin (CDCIONDIEHJNCIPC) Dmisore, Shannon L. (CDCIODIDADC) DeNoon, Daniel (CDCHODJOADC) (CTR) Richmond-(2mm, Malia Cc: Omisore, Shannon L. DeNoon, Daniel Grusich, Katharina {Kate} Schieber, Richard A. Peaker, Brandy Subject: RE: Fact Sheet revisions?telebrief revisions Hi and VS team, Thank you very much for all your help on the fact sheet and for talking through some important issues this morning. I am attaching a tracked version of the Word document and a version of the with stickies added. Hopefully all of these comments are clear but let me know if you have any questions. I think the two big issues are: First, trying to make the top image on page 3 work better. We liked the suggestions you offered on the call to connect the bullets to the boxes by using the same colored font for the first work. Our communications team suggested some other helpful edits. Second, we?d like to make the two boxes (media and Lifeline] fit on page 4. In the Word document I provided draft examples of the boxes that we hope will work. We look forward to seeing the next version. Thank you, -Tom From: Sokler, Sent: Wednesday, May 2, 2018 12:18 PM To: Bruce, (CDCIOPHPRIOD) Stone, Deborah Simon, Thomas (CDCIONDIEHINCIPQ Black, Erin Omisore, Shannon L. sh l5 cdc. ove; DeNoon, Daniel Richmond?Crum, Malia Cc: Omisore, Shannon L. Sokler, DeNoon, Daniel Grusich, Katherina (Kate) (CDCIODIOADC) hb3 cdc. ova; Schieber, Richard A. Cc: Omisore, Shannon L. (CDCIODJOADQ Subject: RE: June ?v'S FS: Changes Hi Lynn, Please see updated and word files for June edition of Vital signs. Thanks, Keith Keith A. Bailey visual Information Specialist [Design Team} Graphic Services Branch, Division of Communication Services Office of the Associate Director for Communication Centers for Disease Control and Prevention 1600 Clifton Rd, NE Atlanta, GA 30333 Phone: 404-718-5403 Tour of Duty: 7 AM: 3:30 PM. From: Omisore, Shannon L. Sent: Tuesday, May 1, 2018 3:26 PM To: Bailey, Keith Cc: Sokler, (CDCIODIOADC) Omisore, Shannon L. Subject: RE: June VS FS: Changes Hi Keith, Thanks! I will review this in the morning. Please pull the Word file for the May Vital Signs fact sheet. Shannon From: Bailey, Keith Sent: Tuesday, May 1, 2018 3:14 PM To: Omisore, Shannon L. Subject: RE: June VS FS: Changes HiShannon, Please find attached, the latest iteration of the June Edition of Vital Signs. Also, please note that all of the suggested edits provided to me, via both and word files, have been applied. Several things are worth mentioning. The photographs pasted into the PDF, by ?Program?, were treated as a visual guide to use similar ones. For the map on page two, there is the singular use of blue which was broken down into different gradations/tints in response to the comment made about "depth of color". Here is hoping all is in order to keep things moving along to subsequent phases in the production process. Thank you, Keith Keith A. Bailey Visual Information Specialist [Design Team} Graphic Services Branch, Division of Communication Services Office of the Associate Director for Communication Centers for Disease Control and Prevention 1600 Clifton Rd, NE Atlanta, GA 30333 Phone: 404??18?5403 Tour of Duty: A.M.- 3:30 PM. From: Omisore, Shannon L. Sent: Friday, April 27, 2018 2:26 PM To: Bailey, Keith (CDCIDDKOADC) Cc: Sokler, Subject: May VS F5: Changes Hi Keith, Attached are changes for the fact sheet indicated in the PDF and Word files. Also attached are the pie charts to replace the current ones and the PowerPoint of the graphic on page 3. Please feel free to contact me with any questions or concerns. To View the graphic at the bottom of page 2 in the Word file, select the simple markup or no markup option. Please update this fact sheet and send to us by the close of business (COB) on Tuesday, May 1. Thanks, Shannon Shannon Omisore, MA Health Communication Specialist Office of the Associate Director for Communication 2500 Century Parkway, MS 5-21 Atlanta, GA 30345 Office: 404-498-0153 E-mail: hyl5@cdc.goy DC 7 I1.- From: Peaker, Brandy Sent: 4 May 2018 10:28:30 0400 To: Black, Erin Cc: Schieber, Richard A. Shannon L. Deborah Thomas (CDCKONDIEHINCIPCJ Subject: RE: Fact Sheet revisions-telebrief revisions Sorry- emails crossed. Good dialogue team. Brandy From: Peaker, Brandy Date: May 4, 2018 at 10:26:37 AM EDT To: Black, Erin Cc: Schieber, Richard A. . Solder, (CDCJODXOADC) Omisorc, Shannon L. (CDCHODIOADC) Stone, Deborah Simon, Thomas Subject: RE: Fact Sheet revisions-telebrief revisions Can address increases need more research in telebriefing script to get ahead of question. Also it is in MMWR. Even if you say more research needed in F3, media will ask what are your guesses as to why. I think having it in F8 uses up real estate iwith info that doesn?t contribute to your main. message. But more importantly, it complexes the sentence which takes away from the punch of a de?nitive statement that ?Many factors contribute to suicide."- which is your SOHCO. From: Black, Erin Date: May 4, 2018 at 10:18:23 AM EDT To: Peaker, Brandy (CDCIOPHSSICSELSIDPHID) Cc: Schieber, Richard A. Sokler, (CDCIODXOADC) Omisore, Shannon L. (CDCEODJOADC) Stone, Deborah (CDCIONDIEHINCIPC) Simon, Thomas Subject: RE: Fact Sheet revisions-telebrief revisions i do think a natural question will be WHY are rates increasing so it?s helpful to elude to the fact that we don?t have all the answers but that more studies are needed {and thus mere resources are needed to conduct those studies). if we don't provide this answer ourselves, everyone using our materials will make up their own answer so best to give them the message we think is most appropriatefaccurate. From: Peaker, Brandy Sent: Friday, May 4, 2013 10:16 AM To: Stone, Deborah Simon, Thomas Black, Erin Cc: Schieber, Richard A. Sokler, Omisore, Shannon L. Peaker, Brandy Subject: RE: Fact Sheet revisions-telebrief revisions Adding Rich, Lynn, and Shannon. i don?t think the "Although the reasons for the increases need more study? clause is needed for the following reasons: 1) Aside from a couple of topics (ie tobacco}, most reasons for increases in disease trends need more study or are multi-factorial. So it?s sort of a given. It?s the whole "more research is needed? sentence at the end of a discussion section that make cringe. More research is always needed. 2) it makes the reader pause before getting to the meat of the sentence and your SOHCO which is that many factors contribute to suicide. So it water downs one of your main points. 3) We try hard not to start sentences with a prepositional phrase bc it?s not clear language and makes the sentence harder to understand, which again will soften the impact of your main SOHCO. 4) Recommend including that the reasons for increases is not fully understood as part of the telebriefing script and Media is going to ask your hypothesis for the increases even if you put in the FS, more research is needed. Thanks Brandy From: Stone, Deborah <2af9@cdc.gov> Date: May 4, 2018 at 9:15:01 AM EDT To: Simon, Thomas Black, Erin Peaker, Brandy Subject: RE: Fact Sheet revisions?telebrief revisions I think the phrase is useful; without it people will think the contributing factors we list subsequently are responsible for the increases just mentioned. They may be but we don?t know. I think it keeps us more honest. Deb From: Simon, Thomas (CDCIONDIEHINCIPQ Sent: Friday, May 4, 2018 8:01 AM To: Black, Erin Stone, Deborah Peaker, Brandy Subject: RE: Fact Sheet revisions?telebrief revisions Hi Brandy, Erin, Deb, We are getting different opinions about the following sentence: Although the reasons for the increases need more study, many factors are known to contribute to suicide. Several people have said that we need something like this because there is so much emphasis on the increasing rates we need to acknowledge that we don?t know why the increase is happening. We don't have the space to fully describe what people think is happening with the increase. This sentence transitions to the description of circumstances. Others have said it is not necessary. Do you feel strongly either way? JTom From: Omisore, Shannon L. Sent: Thursday, May 3, 2018 6:38 PM To: Simon, Thomas Sokler, Bruce, Stone, Deborah Black, Erin Richmond-Crum, Malia Kurnit, Molly Regina cdc. ov> Cc: Schieber, Richard A. Subject: RE: Fact Sheet revisions-telebrief revisions Tom, That sentence will be added to the FS. Attached are the Word and PDF files. Brandy has reviewed the fact sheet and left some suggested changes. Please read the comments and indicate whether the changes can be made. If you disagree with a suggestion, please delete the comment box or sticky. For the PDF. most of her comments are regarding the graphics on page 3. For example, can ?lethal" be changed to "deadly? in the graphic at the bottom of page 3? Please respond by Friday, May 4 at 10 am. The fact sheet is going to be sent to 00 on Friday, so this would allow enough time for the graphic artist to work on the fact sheet. Thankg Shannon From: Simon, Thomas (CDCIONDIEHINCIPQ Sent: Thursday, May 3, 2018 5:25 PM To: Sokler, Bruce, Stone, Deborah Black, Erin Omisore, Shannon L. (CDCXODJDADC) DeNoon, Daniel (CDCIODIOADC) (CTR) Richmond?(2mm, Malia Kurnit, Molly Regina Cc: Omisore, Shannon L. DeNoon, Daniel (CDCIODIOADQ (CTR) Grusich, Katharina (Kate) (CDCJODIDADC) Schieber, Richard A. Peaker, Brandy cdc. ov> Subject: RE: Fact Sheet revisions-telebrief revisions Hi and Shannon, i had not noticed that the bullets above the pie charts were dropped. Can we still add at least the following bullet to explain what the pie charts mean? - People without known mental health problems were more likely to be male and to die by firearm. Otherwise, the pie charts are hard to interpret. Thank you, Tom From: Simon, Thomas Sent: Thursday, May 3, 2018 2:21 PM To: Sokler, Bruce, (CDCIOPHPRIDM Stone, Deborah Black, Erin Omisore, Shannon L. DeNoon, Daniel (CTR) Richmond-Crum, Malia Kurnit, Molly Regina Cc: Dmisore, Shannon L. DeNoon, Daniel (CTR) Grusich, Katherina (Kate) Schieber, Richard A. Peaker, Brandy cdc. 0v:- Subject: RE: Fact Sheet revisions-telebrief revisions Hi and VS team, Thank you very much for all your help on the fact sheet and for talking through some important issues this morning. I am attaching a tracked version of the Word document and a version of the with stickies added. Hopefully all of these comments are clear but let me know if you have any questions. I think the two big issues are: First, trying to make the top image on page 3 work better. We liked the suggestions you offered on the call to connect the bullets to the boxes by using the same colored font for the first work. Our communications team suggested some other helpful edits. Second, we?d like to make the two boxes {media and Lifeline) fit on page 4. In the Word document I provided draft examples of the boxes that we hope will work. We look forward to seeing the next version. Thank you, ?Tom From: Sokler, (CDCIODIOADQ Sent: Wednesday, May 2, 2018 12:18 PM To: Bruce, Stone, Deborah Simon, Thomas Black, Erin Omisore, Shannon L. DeNoon, Daniel (CDCIODIOADC) Cc: Omisore, Shannon L. (CDCIODIOADC) Sokler, DeNoon, Daniel Grusich, Katherina {Kate) (CDCIODIOADQ Schieber, Richard A. ; Peaker, Brandy Subject: Fact Sheet revisions-telebrief revisions Hi Attached is the revised Fact Sheet for your review. We?ve done some more work on the telebrief script as well. So, could you please do the following: 0 Provide Fact Sheet graphic changes in stickies on the I Provide Fact Sheet text changes in the Word document in track changes 0 Provide telebrief changes in track changes to the CLEAN document. We need you to provide Dr. Adam's comments to it as well. 0 Under separate cover, we provided press release changes that we need you to accept, or edit, and give us back a CLEAN and TRACKED copy. I?ve reattached here to make it easier for you. We?d like to have all changes NLT COB tomorrow so that we have Thurs to revise and for your review. In an earlier email I mentioned shorter timeframes. lam thinking that If you have any of these documents ready before COB, please send them along (doesn?t have to be in one email]. For example, if the Fact Sheet is ready first with edits, please get that back to us so we can give the artist more time for changes. I plan to send everything for the pre-brief out to everyone on Monday. Thanks much, From: Bailey, Keith Sent: Wednesday, May 2, 2018 10:12 AM To: Sokler, <2520 cdc. ov> Cc: Omisore, Shannon L. Subject: RE: June V5 FS: Changes Hi Lynn, Please see updated and word files forJune edition of Vital signs. Thanks Keith Keith A. Bailey Visual Information Specialist (Design Team] Graphic Services Branch, Division of Communication Services Of?ce of the Associate Director for Communication Centers for Disease Control and Prevention 1500 Clifton Rd, NE (3-27} Atlanta, GA 30333 Phone: 404?218?5403 Tour of Duty: 7 AM.- 3230 PM. From: Omisore, Shannon L. Sent: Tuesday, May 1, 2018 3:26 PM To: Bailey, Keith Cc: Sokler, Omisore, Shannon L. Subject: RE: June VS FS: Changes Hi Keith, Thanks! I will review this in the morning. Please pull the Word file for the May Vital Signs fact sheet. Shannon From: Bailey, Keith Sent: Tuesday, May 1, 2018 3:14 PM To: Omisore, Shannon L. Subject: RE: June VS FS: Changes HiShannon, Please find attached, the latest iteration of the June Edition of Vital Signs. Also, please note that all ofthe suggested edits provided to me, via both and word files, have been applied. Several things are worth mentioning. The photographs pasted into the PDF, by "Program?, were treated as a visual guide to use similar ones. For the map on page two, there is the singular use of blue which was broken down into different gradations/tints in response to the comment made about ?depth of color?. Here is hoping all is in order to keep things moving along to subsequent phases in the production process. Thank you, Keith Keith A. Bailey Visual Information Specialist {Design Team} Graphic Services Branch, Division of Communication Services Of?ce of the Associate Director for Communication Centers for Disease Control and Prevention 1600 Clifton Rd, NE Atlanta, GA 30333 Phone: 404-113-5403 Tour of Duty: 7 A.M.- 3:30 PM. From: Omisore, Shannon L. Sent: Friday, April 27, 2018 2:26 PM To: Bailey, Keith Cc: Sokler, Subject: RE: June VS F5: Changes The changes are for the June VS. From: Omisore, Shannon L. Sent: Friday, April 27, 2018 2:25 PM To: Bailey, Keith (okkO cdc. ow Cc: Sokler, (2510 cdc. 0y:- Subject: May VS F5: Changes Hi Keith, Attached are changes for the fact sheet indicated in the PDF and Word ?les. Also attached are the pie charts to replace the current ones and the PowerPoint of the graphic on page 3. Please feel free to contact me with any questions or concerns. To View the graphic at the bottom of page 2 in the Word file, select the simple markup or no markup option. Please update this fact sheet and send to us by the close of business (COB) on Tuesday, May 1. Thanks, Shannon Shannon Omisore, MA Health Communication Specialist Office of the Associate Director for Communication 2500 Century Parkway, MS Atlanta, GA 3?345 Office: 404-498-0153 E?mail: 24/ Sotyl?g LIV-M Prrfactmg People" From: Sokler, Sent: 6 Jun 2018 16:16:18 -0400 To: Stone, Deborah Subject: RE: FINAL MATERIALS FOR DISTRIBUTION: June 7 - Vital Signs Suicide Prevention Disregard, just saw that you sent it. From: Sokler, Sent: Wednesday, June 6, 2018 4:16 PM To: Stone, Deborah Subject: RE: FINAL MATERIALS FOR DISTRIBUTION: June 7 - Vital Signs Suicide Prevention Sure, we don?t usually have one which is why I didn't. Can you send me the final, so I?m sure?I From: Stone, Deborah Sent: Wednesday, June 6, 2018 4:14 PM To: Sokler, (CDCXODIOADC) Subject: RE: FINAL MATERIALS FOR DISTRIBUTION: June 7 - Vital Signs Suicide Prevention HiLynn, Can you also add the supplementary table? Thank you, Deb From: Sokler, (CDCKODIOADC) Sent: Wednesday, June 6, 2018 2:33 PM To: Houry, Debra E. Lenard, Courtney Dorigo, Leslie Stone, Deborah ; Kent, Charlotte Knight, Dianna Knotts, Ashley (CDCXODKOCS) Kroop, Seth Mac Kenzie, William R. Martin, Laura Yerdon McGowan, Robert {Kyle} Olivares, Dagny Pa rikh, 5a pana Parker, Stacey M. (CTR) Payne, Chelsea C. Putman, Ami D. (ivaiQ-cdcgov?; Rasmussen, Sonja <5er cdc. Redd, Stephen Redfield, Robert R. Schattner, Aimee Schindelar, Jessica Schuchat, Anne MD (acs'l cdc. ov>, Simon, Gia M. Smith, Patti Sokler, Sorrells, Marjorie J. (may Sta nojevich, Joe] G. (may Ware, Nina (ev 5 cdc. Weatherwax, Douglas Wilkinson, Kelly (We; Wilson, Michelle <2wv2 Cdc. ov> Cc: Sokler, <2520@cdc.goya; Schieber, Richard A. Peaker, Brandy Dmisore, Shannon L. Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Are you in office today? Or I call you? From: Stone, Deborah Sent: Thursday, June 21, 2018 1:58 PM To: Kurnit, Molly Regina Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Ok I will hit pause on this story until I hear back from you? From: Stone, Deborah Sent: Thursday, June 21, 2018 10:49 AM To: Kurnit, Molly Regina Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Thank YOU From: Stone, Deborah Sent: Monday, June 18, 2018 10:23 AM To: Kurnit, Molly Regina Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Ok, thanks!! From: Kurnit, Molly Regina Sent: Monday, June 18, 2018 10:23 AM To: Stone, Deborah Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Nope, but this is the same item that I resent to you last week [with updates) so may want to use more recent doc From: Stone, Deborah Sent: Monday, June 18, 2018 10:21 AM To: Kurnit, Molly Regina Subject: For SME review AFTER VITAL SIGNS IS OVER Hey Deb, Please feel free to file this away until after the Town Hall! lam excited to present a creative brief for a video to help demonstrate how everyday heroes {regular people!) can implement strategies and approaches from our technical packages to prevent violence. This story is from Ohio and is focused on preventing youth suicide. Please let me know if you have questions. If you could turn this back around before you go on leave in June, that would be wonderful! I have left in some comments from our new PMF, Morgan, to show you our thinking. Thanks, Molly From: Kurnit, Molly Regina Sent: 18 Jun 2018 18:23:08 0400 To: Stone, Deborah Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Have n?t asked Linda hasn?t even been to ADS yet. Thank youll From: Stone, Deborah Sent: Monday, June 18, 2018 3:55 PM To: Kurnit, Molly Regina Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Here?s my review of the two documents. Have we heard back from Linda Dahlberg yet? I need to try and find out why we didn?t include SOS in the tp. Seems odds to highlight in this video if it?s not included in the to. Deb From: Kurnit, Molly Regina Sent: Monday, June 18, 2018 10:24 AM To: Stone, Deborah <2an cdc. ov> Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Thank YOU From: Stone, Deborah Sent: Monday, June 18, 2018 10:23 AM To: Kurnit, Molly Regina Subject: RE: For SIVIE review AFTER VITAL SIGNS IS OVER Nope, but this is the same item that I resent to you last week [with updates) so may want to use more recent doc From: Stone, Deborah Sent: Monday, June 18, 2018 10:21 AM To: Kurnit, Molly Regina Cc: Bartholow, Brad Ballman, Marie R. Subject: For SME review AFTER VITAL SIGNS IS OVER Hey Deb, Please feel free to file this away until after the Town Hall! I am excited to present a creative brief for a video to help demonstrate how everyday heroes {regular people!) can implement strategies and approaches from our technical packages to prevent violence. This story is from Ohio and is focused on preventing youth suicide. Please let me know if you have questions. If you could turn this back around before you go on leave in June, that would be wonderful! Ihaye left in some comments from our new PMF, Morgan, to show you our thinking. Thanks, Molly From: Stone, Deborah (CDCJONDIEHXNCIPC) Sent: 18 Jun 2018 19:55:19 +0000 To: Kurnit, Molly Regina Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Attachments: John Ackerman Signs of Suicide_Creative ds.docx, SuicideVideoMotionG raphicScript_ak_6_5_18 feedback for SME review ds.docx Here?s my review of the two documents. Have we heard back from Linda Dahlberg yet? I need to try and find out why we didn?t include SOS in the to. Seems odds to highlight in this video if it's not included in the tp. Deb From: Kurnit, Molly Regina Sent: Monday, June 18, 2018 10:24 AM To: Stone, Deborah Subject: RE: For SME review AFTER VITAL SIGNS IS OVER Thank YOU From: Stone, Deborah Sent: Monday, June 18, 2018 10:23 AM To: Kurnit, Molly Regina Cc: Bartholow, Brad Ballman, Marie R. (CDCIONDIEHJNCIPC) Subject: For SME review AFTER VITAL SIGNS IS OVER Hey Deb, Please feel free to file this away until after the Town Hall! I am excited to present a creative brief for a video to help demonstrate how everyday heroes {regular people!) can implement strategies and approaches from our technical packages to prevent violence. This story is from Ohio and is focused on preventing youth suicide. Please let me know if you have questions. If you could turn this back around before you go on leave in June, that would be wonderful! I have left in some comments from our new PMF, Morgan, to show you our thinking. Thanks, Molly DVP Technical Package Video: John AckermanlSigns of Suicide CDC SME reviewer: Deb Stone Video Creative Brief 2016 in the United States, it?suicide is the Story Overview Youth suicide is a growing public health concern. In second ltinted?leading cause of death for young people aged 10-24 years old and results in ives lost each year. Suicide is rarely caused by any _a_r_1_d therefore 15 . ggnm_r_eh_en_si_ve_prevention is essential. In Ohio, Nationwide Children?s Hospital. one of the largest behavioral health centers in the country. is working to better understand and create solutions to reduce suicide among children and teens. In 2015. the hospital created the Center for Suicide Prevention and Research (CSPR) both to serve as a suicide prevention resource for youth. parents. schools. clinicians. and community partners. and to help address gaps in Prevention services. has also developed a proactive prevention program. [signs of Suicide (soc). for middle and high school students. see aims to dispel misunderstandings about suicide. teach students (and the community} about depression and the warning signs of suicide. and connect those at risk to support services. The program also helps schools deveiop gold-standard safety plans for at?risk youth John Ackerman. a clinical child leads the SOS program at CSPR. He underscores the need for proactive prevention programs. John works with children and teens with mood and anxiety disorders, and has conducted extensive research on gaps in local trend data and suicide prevention hany more people . programs. He believes that the Extent of suicide is underestimated by data: experience suicidal thoughts. make suicide plans and nonfatal suicide attempts than the data suggest [rlg?j?g John and his team of clinicians partnered with Screening for Mental Health. a nonpro?t organization, to setup 808 in 38 schools across 12 counties in central Dhid: Approximately. 23.350 students participating in the program were screened for suicide and depression. The screenings revealed that more than BUG students were at increased risk for suicide. John?s team conducted lethality assessments (which measure risk of fatal violence} on the 800 students. Of the 300 students. 118 required urgent crisis referrals {outpatient crisis care within 48 hours or hospitalization}; the remaining students received butpatienthi; school-based mental health ['eferral . John has also partnered with other suicide prevention groups to establish [guidelines to help journalists and social media practitioners write about suicide in ways that honor the experiences of survivors without sensationaiizing then']. He has shared the guidelines with many media outlets. Comment Did we ever check with Linda D. about this program and if technical package. I've forgotten now why exactly we didn't include. I think there was some questioning of the Lresults. Comment How does this link to his 803 and preventative work? Seems only to highlight the potential greater scope of the problem, which is good but doesn't help understand whyI preventative approaches are .necessary. Comment Missing the inciting incident?in the summary it describes increasing sulcide rates and John's new job title and research into data gaps. I don't think we need everything from the summary. but we do need to know why he began this work. {The :Why new?" story question.) Comment This is the story we?re telling. as I understand it from kthis brief. Speci?c to 505. Comment They received outpatient referrals? I think i understand. but this could be clearer? they were referred for outpatient or school-based mental health services? . P??n Commont A sentence explaining why this is important {results section from summary]? Hopefully that will be clear in the .video. Comment [amt]: Do we have an ability to cross check their guidelines with the reporting on suicide guidelines? Comment [2319]: Wondering if these are the same guidelines as the current guidelines?maybe CSPR worked with AL AL 1 AFSP and the other orgs to put the including the Columbus Dispatch and Seltcom, and reports that journalists have embraced the guidelines. In addition. the American Association of Suicidology is working to convert the guidelines into an easy-to-use toolkit torjournalists. The toolkit will reside on the association's website. Linkage to the Technical Package Suicide Prevention Technical Package - Create Protective Environments - Lessen harm and prevent future risk (safe reporting and messaging about suicide) - Promote connectedness Lcurrent guidelines together? .4 Comment [This]: Ifthis can be made speci?cto one school. as an example, the story will be more clear. Singular more werful and eci?c than lural. Comment Okay. but the story can't be driven by data. The story needs to be driven by John and the he saw and titled- Identify and support people at risk Story Goals The goal of this project is to demonstrate that everyday heroes can carry out technical package strategies and approaches to prevent suicide. The video will have these primary purposes: 1. Highlight ways that data can be used to identify gaps in existing programs in order to select strategies and approaches to ?ll the gaps. 2. Emphasize how a program that started in a health care system recognized the need for greater primary prevention. 3. Feature successful school-based suicide prevention interventions. Interview Guide Interview guides can help direct the interviewee toward the topics and issues you want to learn more about. The questions below are samples: 0 ?'low does SOS help schoolsljevelop gold-standard safety plag_s__f_or_high-nsk yogth? What?s involved, and how do you ensure consistent implementation? - What methods were used to identifyichoose schools or school districts to pilot the program? 0 What challenges, it any. did you face in setting up 808 at schools? What does the data show about the relationship between SDS and youth suicide? Video Approach STYLE We propose an animation with voice-over style to help explain John's research and data. How have students responded to 308'? ll i MAIN FDCUSNOICE The main focus is the voice of a narrator. STORY FLOW John Ackerman is featured as an animated character. The narrator will guide the viewer through personal experiences with setting up suicide prevention strategies in schools and describing research ?ndings. The video will be [driven by key ?ndings with based stories. helping to bring statistics to life. Through this narration, we hope to bring to light the importance of suicide prevention and awareness and hear primary prevention successes. Suicide Motion Graphic Video RT We open on flashing text that appears on the top left side of the screen over a Bait image. Text that refers to the problem appears on top left of the [*Note: screen while CDC solutions appear on the bottom right over the same image) TOE: Suicide is a serious public health problem and the lCIlh leading cause of death in the United States. Image remains on the screen. communities, and society, at large. {possibly TOS: It hurts families, overlay drawing NEW IMAGE APPEARS TOE top left: The causes of suicide are numerous?esd?{eemel?e?yi. But Suicide is Preventable. (on the bottom right of the imagel CDC is dedicated to using a T08 T05 over same image: public health approach to NEW IMAGE APPEARS TOS: CDC monitors, tracks, and growing problem of suicide. Same image remains ?y conducting and supporting research to understand the underlying causes of suicide, CDC works with partners to hearers?identify, ?evelop, revention strategies. and test new a NEW TOS bottom right: Strategies like developing progra Il?L?fiCiIJ-?i 1 and protective factors at all levels - I timesharesgr of the star-2;; Strategies like fostering community connectedness, and [creatinng opportunities to access to health care and social support systems. T05 NEW APPEARS: IMAGE RPPEARS ms that target risk Comment 131119]: I was told we aren?t supposed to say complex since this implies it?s too hard to finr or prevent. Comment 0r examines? I ?r Comment [Hi9]: Yeah, I might sai,f t. examines instead. While investigate isn't 'll wrong I wonder if it may send the ii i I .1 0133?- I CnmmentiKMR?: Not sure ifthis is l: Lno wavto knowthisComment ls CDC developing and testing? And agree with Molly?s comment above about removing far- treaching. rComment lean']: This could be two ll i Ir if! The wailr the sentence is ._right. Maybe y'all can fix this. overstated. How about creating Lgpportunitiesmessage that we are out in the ?eld every needed/honest, considering that we have . things. We conduct research is one aspect and then I'd sen,t we work with partners to worded now with the edits it doesn?t ?ow I Comment This seems a little A .l A TOS on bottom right: 3 goal is to prevent suicide and save lives - . - - - - -in order to at: art the nation in reachin its cal to reduce the annual suicide If rate 20% 132 2025. I NEW IMAGE T03 in MIDDLE OF SCREEN: Fix; r- 2-- r1.- a r1309: {Later-.441 ere-?Fri: z?i-u-E-erp-rr?HB-qu?vf??H-hc- ?awe- Lat?t.? ?thezbl-ir?LW .qw?u?rm?p thaw-v. other? nn.lK- J. .I ?3341- 31:11:12 .1511, "are prevent sulClde. website . com r(Jinnmenl: [mm I think this part should refer to the National Strategy for Suicide Prevention: goal of reducing the annual suicide rate 20 percent Lby 2025 A Comment H: I like this idea. r?I Comment Sounds nice. but if this video is meant to carve out CDC's niche in.suicide prevention, it could be Lmuddled. Marie agrees. (N05) From: Simon, Thomas Sent: 19 Apr 2018 10:50:25 -0400 To: Stone, Deborah Subject: RE: For Your Review: quick turnaround? Communication Pieces Attachments: RB dsbocx, cc_v1_4.17.18.03.15pm_ce_Ma dsbocx Hi Deb, I think your input is fine. I actually encourage you to be critical at this point and really be certain that you can defend each point, particularly those in the script and PR. only had 30 minutes to skim this and didn?t get through everything but I added some initial comments for you to consider. One thing that I think we should do is list the other contributing factors when appropriate so people have a sense of what we mean. I?m thinking about some variations on the following: "Knowing the many factors in addition to mental health concerns that contribute to suicide risk such as relationship problems, crises, substance use, poor health, job/financial problems, arguments or conflicts, and legal problems can help us identify and support people at risk of suicide.? Best, -Tom From: Stone, Deborah Sent: Thursday, April 19, 2018 12:20 AM To: Simon, Thomas Subject: RE: For Your Review: quick turnaround? Communication Pieces Hi Tom, I received the 4 comm items noted below today. I found myself having a lot of comments and was wondering if you might help me by looking at what I?ve commented on and letting me know your thoughts? Am I being too critical or getting too far a field?? Or am I on the right track? I just don?t want to start changing things as I?m prone to do without another set of eyes seeing my train of thought. [as a reminder, I?m supposed to review in a day and send to Malia and then she reviews and sends to you?l think tag team review it might be more efficient, i.e. if you and I review together it can save time when the documents get to you]. I'm not able to be on my work computer so easily here art AAS, so maybe if you can text me after you?ve replied/?reviewed my comments then I'll know when to login. Sorry to be so high maintenance!! I know you are super busy. Thanks, P.S. The MMWR was cleared and cross?cleared now. ljust need to upload the version we sent to the VS office into e-clearance. I hope we?ll get DD comments soon! From: Bellman, Marie R. Sent: Wednesday, April 13, 2018 6:57 AM To: Stone, Deborah <2af9@cdc.gov> Cc: Bruce, x6 cdc. ov> Subject: For Your Review: quick turnaround? Communication Pieces Deb, Attached are the Vital Sign Communication documents for your review in one day to keep us on track for our deadline. Note, that these adhere and stick very closely to the fact sheet and pulls from the MMWR itself. Documents included are: . Press Release I Dear Colleague Letter - Tele-briefing Script with 0 Critical contacts with email Please note that there is a list at the top. Please add your review date next to your name. The list will be taken off before sending to Vital Signs office but thought it would be a good internal tracking double check. Also, let or I know if you have any questions or concerns. Thank; Marie From: Stone, Deborah Sent: Friday, April 13, 2013 5:03 PM To: Simon, Thomas Richmond-Crum, Malia Mercy, James Dorigo, Leslie Cc: Ballman, Marie R. Cc: Daniel, Valerie M. (CDCJONDIEHINCIPQ Ballman, Marie R. Subject: RE: Vital Signs Prep Meeting Hi Everyone, It looks like most people will be out next Tuesday at EIS sol cancelled our meeting. I will follow up with the MMWR group related to any feedback we get back from CDC OD. I'm guessing the same will be true for Tom and the factsheet group. If it?s needed, I may reschedule us for 4,124 so if you could hold that date at noon that would be great. if you don?t mind sending an email update to everyone about comm/policy progress that would be great too (by next Tuesday?}. I know you all have been doing a lot so I want to make sure that everyone is up to speed. Thanks so much! If anyone has any questions, please contact me. Deb Comment [2am]: lwouldn't include this. Rates increased more than 30% over the period 1999-2015, other leading causes of death decreased over the past few years I believe {and we didn?t look at those rates in our study}. I?d ratherjust sailr between 1999-2016 Suicide rates increased by more than 30% in half of all states. {Comment [1am]: I'm not sure we need to say this here?? {Comment lwould keep it. Comment I: This transition is awkward. It makes it sound like the circumstance analysis is at the state lave. Review Tracker DC Leslie Dorigo: DVP ADS Torn Simon: DVP Policy Malia Richmondtrum: DVP SME Deb Stone: DVP HCET Marie Ballman: #1772018 Jk. JUL. Press Release i Embargoed until 1:00 pm ET Tuesday. June 5.. 2MB Contact: Eli??lsi?ili??l?tlli?j u- 404~639+3286 Rising suicide rates across states ii Rates increased more than 30% in half of states. hvhife most other leading causes .l ill declined] i ii Suicide is a leading cause of death in the us. and is on stasisErrata:Headset;dirtiest; 1_lil report by the Centers for Disease Control and Prevention (CDC). in 2016, nearly 45,000 pcoplc Ego 10 or older]died by suicide. This report examines suicide deaths at the state level from [999 to 2016. Wombl??FHElH-?i?ii?. problems are just one factor contributing to suicide. ?Mental health problems are often cited as the cause I of suicide, but suicide is rarely caused by only one factor," said ?In fact, many people who die by suicide are not known to have mental health problems at the time of death?. l'i'lanf,r factors contribute to suicide For this report, CDC examined state?level trends in suicide rates between 1999?2016. In addition, they used data from the National Violent Death Reporting System [add hyperlink]. which covers 27' suites. to look at the circumstances of suicide deaths among people with and without known mental health problems. The researchers found that more than half of people who died by suicide did not have a known mental health problem. This group suffered more from relationship problems and other life stressors such as criminal-legal matters, evictioni?loss of home. and recent or impending crises. however these circumstances were common to people with and without mental health problems. Firearms were the most common method ot'suicidc used in both groups. Wide range of prevention activities needed ?We need comprehensive statewide suicide prevention activities to address the full range of factors fl Comment In?ll: contributing to suicide.? added, ?fThere are opportunities for prevention every,r day. . Kilose coordination of government. business, education, faith, and the media sectors are important for a preventing addition, everyone can: Comment I'm not a fan of this language. I'm not sure what this means in rectice and we could be asked that. Comment Suggest either dropping r" from the PR or moving this down to raise the profile of the othersComment Infill: Might be nice to I Contact the National Surcide Prevention Lifeline for help for themselves or others: l-800-273- if reference the bet-helm" TALK (3255}. I lie?J I Learn the warning signs of suicide to help identify and refer people at risk. k._J Vital Sinns is a CDC report that typically appears on the first Tuesday of the month as part of the CDC journal Morbidiw and Mortalitv Weeklv Report. The report provides the latest data and information on key health indicators, These are cancer prevention, obesity, tobacco use? injury prevention, prescription drug overdose, HIWAIDS, alcohol use, healthcarc-associated infections. cardiovascular health, teen pregnancy, and food safety. LLS. DEPARTMENT {Jl? AND HUMAN SERVICES [Comment Opportunities for preventing suicide exist everyday. Review Tracker - DC Leslie Dorigo: - DVP ADS Tom Simon; DVP Policv Malia Richmond-trunk - DVP SME Deb Stone: DVP HCET Marie Baliman: ?17/2018 Vital Signs Rising Suicide Rates Across U.5. Desired Headlines Nearlv 45,000 suicides occurred in 2015, but suicide is preventable. Suicide rates increased more than 30% in halfof US. states since 1999. Manv factors other than mental health problems contribute to suicide. i June 2013 i i Moderator: Thank vou And thank vou ail forjoining us tow for the release of a new CDC Vital Signs. We are joined bv CDC Director Dr. Robert Redfield, as well as Dr. An_n SChLEhat, Deputv Director. Dr. Redfield is gnavailable to stav for t_he media portion of the briefing, so Dr. Schuchat will take your questions. I?d like to turn the call over now to Dr. Red?eld. Dr. Redfield I Good afternoon and thank you forjoining us today. I CDC provides for the common defense of the countrv against health threats. Each month in our Vital Signs report, we focus on a public health threat from the front lines and give vou information to help stop it. II Today?s report contains new information about rising suicide rates across the U.5. Let?s start with the good news[rhere are opportunities for preventing suicides everv factors eatheH-hanin addition to mental health isseesconcerns that contribute to suicide risk such as relationship problems, crises, substance use, -poor health Job/?nancial problemsunemployment, arguments or conflicts, and legal 1 problems can help us identify and support people at risk of suicideleoreshan halt of?peepie?vvheaied? lavsmeide?elidnert haee- knownmentai?healthpeebiem? and communities can take actions now based on the best available evidence States can use Preventing Suicide: A Technical Package of Policy, Programs and Practices to guide actions based on what is known about keeping people safe: - Preventing suicide involves everyone in the communitv.[Evervone can learn the signs of suicide, how best to respond, and where to get help i the report. a Thank you, Dr. Schuchat. For this Vital Signs report, we analyzed data from the National Vital StatIstIcs System for 50 states and Washington, D.C. We looked at data from the National Violent Death Reporting System gr N?xf?FiS, covering 27 states in 2015 ?g examined circumstances surrounding suicidegeeaths among people with and without known mental health problems. II From 1999 2016 suicide rates increased significantly in 44 states, wIth 25 states experiencing increases of more than 30%. respectively. Using In 2015 from we found that among In 2? I. Comment [now]: It's not just about identifying people with these concerns Lthings. Comment In?ll: This is a little Comment I agree and suggest Comment Iza?l]: Not sure what this is but also taking action to prevent these problematic since we aren?t saying in 2? states. I don't know that we can generalize. Pretty sure we can?t. kclropping this from Dr. Red?eld?s scrIpt. referring to, the sentence above? If so, it Ldoesn?t follow. Comment [2:119]: State public health departments can be leaders in bringing 1L Comment Iza?lli Don't think we should just focus on that strategy. We need to highlight a comprehensive approach Lsp. together the necessary partners such 1 Comment Who is this? Should this be you, Deb? [states more than half Comment This isa little confusing health problem. going from the 34 and 43 to the half of people in 2? states. r?elationship problemslloss (45.1% vs life stressors (54.2% vs and recentlimpending crises (32.9% vs 26.0%) were significantly more likely among thesepeople who died by suicide without a known mental health problem than thosedeathswith mental health problems, but these problems were common across groups. Although these ?ndings are concerning, prevention is possible; vale-Heed comprehensive statewide; suicide grevention activities ten?can address the full range of factors contributing to suicide. On a Federal level, the government is tracking the problem to understand trends and groups at greatest risk. They are developing, implementing and evaluating suicide prevention strategies and working with local, state, tribal and other partners to prevent suicide. States and communities, can: 0 identify and support people at risk for suicide. Teach coping and problem?solving skills to help youth and adults manage challenges with relationships, jobs, health, or other concerns. :3 Create safe and supportive environments where people live, learn, work, and play. 0 Make sure people are connected to others in their community and don?t feel alone. 0 Make sure those at risk are connected to health systems that include mental and physical healthcare. 0 Strengthen options for temporary assistance for those struggling to make ends meet. 0 Lessen harms and prevent future risk of suicide. ,{Comment Stopped here. I The bottom line is: it will take and if [Comment Izai?i: I?d put this in the next comprehensive approach to prevent suicide. paragraph. See my comment below. Comment zaf9]; Instead ofthisl'd satI E1 . I Thank YOU. ll It bad? to our moderator ..44 states, with 24 states experiencing il?reases of more than 30%. Comment [2:119]: Iwouldn't highlight this. I'd highlight the ages of suicide ?decedents. 1 Comment lzaI?J]: While Nevada's suicide rate did not inCrease, it remained across the studv period. 4, Moderator: Thank you. [Operator?s name}, I believe we are ready for questions, please. tum i Media 015A FINAL QUESTIUN- (Moderator): Thank you Drs. Redfield and Schuchat for joining us today. as well as reporters For follow~up questions, call the press of?ce at 4014-6393286 or send an email to media@cclc.gov. Thank you forjoining us; this concludes our call. How was this research conducted? Trends in age?adjusted suicide rates among people aged 210 years, by state and sex, across six consecutive three?veer periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and Washington, DC. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among decedents with and without known mental health problems (MHPI. what are some of tire key?ndings? Across the studv period, suicide rates increased in all states, except Nevada {which had a consistentlv high rate throughout). with absolute increases ranging from +0.8 {Delaware} to +8.1 [Wvomingi per 100,000. Percentage increases in rates ranged from +53% {Delaware} to 67.6% [North increases of more than 30observed in 25 states] Trends in state significant increases fer?E44 statesfor males {34 statesfemales [43 states}, as well as for the 0.5. overall] ?NhiIe all decedents were predominateiv male white those without knownw MHF, relative to those with MHP, were more likeiv male [83.5% vs. odds ratio 95% CI 2.2?2.and racialfethnic minorities range: more from relationship problems and other life stressors such as criminal?legal matters, eviction/loss of home, i and recent or impending crises. Why did Nevada not see a signi?cant increase in suicide rates? 5 Nevada had a consistently high rate of suicide throughout the study period. Nevada?s suicide rates were not I i? I decreasing, but staving relativelv the Earn? 4 What are some of the iimitations to the study? [Comment [15119]: Can we go right to the . strategies below? There are three limitations to the study, first in the state-level analysis, rankings for four states (MD, MA, RI, might have been impacted by large proportions ofinjury deaths of undetermined intent [potentially biasing reported suicide rates downward], or decreased percentages ofsuch deaths over time {potentially biasing estimated rate trends upward]. Second, is not yet nationally representative,- the 2? states included represent 49.6% ofthe population Third, abstractors of data are limited to information contained in investigative reports. Therefore, the extent of informant knowledge can affect data completeness and accuracy. Studies including more in-depth interviews with next-of?kin often see greater attributions to mental disorders however many methodological variations across studies exist It is likely that some people without known in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. Nonetheless, the high prevalence of diverse contributing circumstances among those with and Without known MHP suggests the importance of addressing the broad range of factors that contribute to suicide. Did the study provide recommendations for prevention? Comprehensive statewide suicide prevention activities are needed to address the full range of factors contributing to suicide. [this study identified a need for additional safety supports, including broader implementation of affordable and effective treatment modalities such as doctor-patient collaborathE care models and proven cognitive-behavioral therapies. Additionally, greater access to behavioral health providers in underserved areas is noeded, as is expansion of healthcare systems needed that integrates physical and Prevention strategies include: Identity and support people at risk of suicide. Teach coping and problem?solving skills to help youth and adults manage challenges with relationships, jobs, health, or other concerns. Create safe and supportive environments where people live, learn, work, and play. Make sure people are connected to others in their community and don't feel alone. Make sure those at risk are connected to health systems that include mental and physical healthcare. - Strengthen options for temporary assistance for those struggling to make ends meet. I Lessen harms and prevent future risk of suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are available. States and communities can use data from and resources such as CDC's Preventing Suicide: 0 Technical Package of Policies, Programs, and Practices, available at: to better understand their suicide problem, prioritize evidence-based comprehensive suicide prevention, and save lives. Some states, such as Colorado, are planning to implement such a comprehensive approach to suicide prevention. Additional Resources Recommendations for Media Reporting on Suicide, reportingonsuicdeorg If you or someone you know is thinking about suicide or needs support, help is always available. Call the National Suicide Prevention Lifeline at [8255) or visit Preventing Suicide: A Technical Package of Policy, Programs, and Practices: 1 loam]: This month?s edition presants trends in suicide rates across states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive Review Tracker tsuicide prevention. Comment 15th]: Would like to see a polnt about the range of other Leontributing circumstances. NCIPC DC Leslie Dorigo: DUP ADS Tom Simon: DVP Policy Malia Richmond-Cram: SME Deb Stone. D?liP HCET Marie Dear Colleague: Vim! Si as series. launched in Zilltl, addresses a single, important public health topic edition presents our latest ?ndings on suicide trends in the United The one each month. ll his month?s prevention to help reduce suicides. i This e?mail contains advance copies of several Vito! Signs materials. including the Morbidity and i Morroiirv Wealth: Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates," and a four-page consumer Fact sheet. This latest edition of CDC Virui Signs will be released today, Tuesday, June 7, 2013, at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vita! Signs report include: In 2016. nearly 45:13.00 suicides occurred in the US among people it] years and older I From 1999?2016. suicide rates increased in 44 states, with 25 states experiencing . increases of more than 30% each. More than halfof people who died by suicide did not have a known mental health II brobie After the embargo is lifted today at 1 pm please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Web page to ?nd the MMWR article, fact sheet. and other materials. Take advantage social media tools, such as the Virai Signs buttons and email updates. Visit CDC's Public llealth Media Library at ww*.cdc.govisvndication and search on the term Vital Signs. We also invite you tojoin us for the Vita! Signs Town Hall Teleconference on Junell, 2016, at 2:00 pm (EST). Vitoi Signs is about more than data. it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Thank you for your support. James A. Mercy, Debra lloury, MD. MPH Director Division ofViolence Prevention National Center for Injury Prevention and Control Director National Center for injury Prevention and Control JL Review Critical Contacts email First Name, in suicide rates from 1999 2016. The key ?ndings ofthe report are: wanted te let you knew CDC will be Comment Tracker NCIPC 0C Leslie Dorigo: DVP ADS Torn Simon: DVP Policy Malia Richmond-Crum: SME Deb Stone: DVP HCET Marie Bellman: MINNIE twith. Lcoo There were nearly 45,000 suicides deaths in 2016 Suicide rates increased by more than 30% in half of US states since 1999' More than half of people who died by suicide did not have a known mentaishealth problem I Suicide remains a leading cause of death in the US and is on the rise in 44 late I I I Te reverse this alarming trend, we meet [ventieuetteesereiaals appreciate Secretary Azar's leadership and the collaboration across HHS and the Federal goyemrnent to monitor and evaluate this public health problem to understand trends and the humps at greatest something stronger here - an ?important? VS or "the ?rst US on suicide prevention" Ler something like that. Comment IAI: These four points are in order from the fact sheet but do we need to keep them in the same order? I?d prefer: bullet point 1 then 4 then 2 then 3. I also don?t like *suicide remains a leading cause of death? since I?m sure many people didn?t know it was to start Comment IAI: What about a point about there being other contributing Comment Don?t like continue here since I don't think we have been Co groups at greatest risk we compared people with and without MHP and we looked at common circumstances other _than H. Comment [Ah Could say the factors that contribute to risk and opportunities for prevention. lCan we include 1 1 rdinating well enough to start. mment We didn't exactly look at I?m surprised not to see mention of the look forward to continuing our work. with local, state, tribal, and other partners to prevent suicide. Together we can address the opportunities for prevention every day. Please feel free to share the information broadly after the embargo lifts at 1 pm, after which the Hoe-"vital si information will be posted at: Look forward to speaking with you this afternoon. [coo SAMHSA, Pam Hyde, Pa ntl-lydeifriiSAMl-iSAJihseov - NIDA. Nora Volkow, - CMS, Andy SlaVitt, Andy.Slayitt@oms.hhs.goy - 0NDCP, Michael Botticelli, Michael Botticel lira-:ondcoeoogov - DEA. Chuck Rosenburg, chuckrosenberg?usdoigoy - HHS, Richard Frank, Richard.Frank@hhs.goy NIH, Francis Collins, franciscollins@nih.goiir -Iosl I {'[contacts Ltechnical package. Comment Policy to add the key From: Lenard, Courtney Sent: 6 Aug 2018 11:03:03 -0400 To: Logan, Joseph Deborah Thomas Alexander Kristin Asha Z. Cc: Eschelbach, Julie Gabraelle Erin Marie R. Valerie M. Subject: RE: FW: media inquiry: suicide epidemic Good morning all! J. I haven?t responded to Zachary with any of this information yet. To all, please let me know your thoughts on the responses and what you would like me to provide him with. It also sounds like his story is pretty much written and this info may or may not be includedfattributed, but since he?s interested in the issue overall and for future stories, he?d like to have for his own knowledge. Thanks! Courtney From: Logan, Joseph Sent: Sunday, August 5, 2013 2:53 PM To: Lenard, Courtney Stone, Deborah Simon, Thomas (CDCIDNDIEHXNCIPC) Crosby, Alexander Holland, Kristin lvey-Stephenson, Asha Z. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie M. Subject: RE: FW: media inquiry: suicide epidemic Please do not make these statements attributed to me. While they make good points about how to prevent suicide using the public health approach, the messages are not strongly tailored to how to address ?suicide epidemics Sudden increases],' which was the focus of Zachary?s article. If the preference is to stick with the messaging from the Vital Signs and Technical Package, then please attribute those messages to the authors of those deliverables and feel free to use them and not me for this response. From where I am sitting, have to respond to Zachary?s questions as written and, to me, he is asking questions to improve understanding of how to address ?suicide epidemics? and there are some important nuances in approaches to address suicide epidemics versus using a broader public health approach to preventing suicide across all populations. If not stated delicately, some of our messaging on using the public health approach can contradict what is known about how to address suicide epidemics. If folks think Zachary is just asking about suicide as a public health problem in general, then I agree to proceed with the messages used for the V5 and TP. If folks prefer to hold Zachary to a strict interpretation of his questions, then I recommend editing the responses to address epidemics specifically. From: Lenard, Courtney Sent: Tuesday, July 31, 2013 2:51 PM To: Stone, Deborah Logan, Joseph U.) Simon, Thomas Crosby, Alexander Holland, Kristin (CDCIONDIEHINCIPC) Ivey- Stephenson, Asha Z. (CDCIONDIEHINCIPC) Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie M. Subject: RE: FW: media inquiry: suicide epidemic Hi all, I want to make sure that these responses can be sent via email with attribution to J. Looks like that will work for Zachary's story. Thanks much! Courtney From: Stone, Deborah Sent: Monday, July 30, 2018 6:44 PM To: Lenard, Courtney (CDCKONDIEHINCIPC) Logan, Joseph U.) Simon, Thomas Crosby, Alexander Holland, Kristin Ivey- Stephenson, Asha Z. si m9 cdc. ov> Cc: Eschelbach, Julie Lane, Gabraelle (xk94@cdc.gove; Black, Erin Ballman, Marie R. (CDCIONDIEHINCIPC) Daniel, Valerie M. (CDCIONDIEHINCIPC) uh8 cdc. ov> Subject: RE: FW: media inquiry: suicide epidemic Hi Courtney. I don?t know if it?s too late but I?m attaching the most updated response inclusive of technical package and vital signs and J?s talking points. Deb From: Lenard, Courtney Sent: Thursday, July 26, 2018 5:26 PM To: Logan, Joseph U.) Simon, Thomas Crosby, Alexander Stone, Deborah Holland, Kristin Ivey? Stephenson, Asha Z. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie M. uhS cdc. ov> Subject: RE: FW: media inquiry: suicide epidemic Hi all, Apologies for not circling back on this request sooner, is everyone good with J?s talking points? Thanks! Courtney From: Logan, Joseph Sent: Monday, July 16, 2013 3:44 PM To: Lenard, Courtney Simon, Thomas Crosby, Alexander Stone, Deborah Holland, Kristin vey~Stephenson, Asha Z. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie M. Subject: RE: FW: media inquiry: suicide epidemic Hi Courtney et aI., Sorry for the delay. 1 drafted some talking points for Zachary Siegel. Please edit as you see fit. J. J. Logan. Suicide and Youth Violence, Emerging Topics Team Research 8. Evaluation Branch Division of Violence Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention MS: F-63 Email: ?a3@cdc.gov Telework day: Monday, Wednesday, Friday Office phone: 770?4334 529 Telework phone: 404-834-48T9 From: Lenard, Courtney Sent: Thursday, July 12, 2018 11:30 AM To: Logan, Joseph U.) Simon, Thomas Crosby, Alexander Stone, Deborah Holland, Kristin lvey- Stephenson, Ashe Z. (CDCIONDIEHINCIPC) Cc: Eschelbech, Julie Lane, Gebreelle Subject: RE: FW: media inquiry: suicide epidemic It?s more the case that we, CDC, use the term ?epidemic? appropriately, at the appropriate time, and to the right audience. Suicide is not an epidemic but there can be an epidemic of suicide cases, depending on the population and time period. Normally, we don?t use it in media relations because the term could be wildly misused unless we are clarifying its meaning and how it can provide insight and messaging on how to stop the onset of new incidents. Let?s see what his questions entail. I can take an initial crack at drafting the talking points and send them to everyone on this email plus REB management. J. J. Logan. Suicide and Youth Violence, Emerging Topics Team Research 8. Evaluation Branch Division of Violence Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention MS: F-63 Email: ffa3@cdc.gov Telework day: Monday, Wednesday, Friday Office phone: HID-4384 529 Telework phone: 404-834-4879 From: Lenard, Courtney Sent: Wednesday, July 11, 2018 4:44 PM To: Simon, Thomas (CDCIONDIEHXNCIPC) Crosby, Alexander Logan, Joseph U.) (CDCIONDIEHINCIPCII Stone, Deborah Holland, Kristin (CDCIONDIEHJNCIPC) ; Bellman, Marie R. Daniel, Valerie M. uh8 cdc. ove- Subject: FW: FW: media inquiry: suicide epidemic Hi All! I just want to make sure all of us are in the loop with this request. I'll be asking the reporter again for more specific questions before setting up something with J. I did want to bring up the term epidemic, has CDC ever said suicide is an epidemic? Thanks much! Courtney From: Zachary Siegel Sent: Wednesday, July 11, 2018 12:16 PM To: Lenard, Courtney cm 5 cdc. ov> Cc: Logan, Joseph Subject: Re: FW: media inquiry: suicide epidemic My NYT editor asked for a draft by July 30 {with a ?sooner the better? caveat). Perhaps scheduling a call early next week would work? Thanks, Zach On Mon, Jul 9, 2018 at 2:55 PM, Zachary Siege] {easiegelgd?iusoedu} wrote: Thanks, Courtney. Will do. On Mon, Jul 9, 2018 at 2:55 PM, Lenard, Courtney wrote: Good afternoon, Zachary, please feel free to reach out to me when you have additional information and I can work with J. on setting up something. Will you please send your questions in advance? Thanks much! Courtney From: Logan, Joseph U.) Sent: Monday, July 9, 2018 3:44 PM To: Zachary Siegel czasie el usc.edu> Cc: Lenard, Courtney Subject: RE: FW: media inquiry: suicide epidemic Sure, sounds good. We also need to coordinate a meeting with our communications liaison. Icc?d her on this email. J. From: Zachary Siegel Sent: Monday, July 9, 2018 1:51 PM To: Logan, Joseph U.) wrote: Hi Zach, i received this email from Deb Stone. I do a considerable amount of research on suicide epidemics. If you are interESted in that area, i can speak to the topic unless you are specifically interested in Deb?s work. If you have any detailed questions, feel free to send them. J.Logan From: Stone, Deborah Sent: Monday, July 9, 2018 12:30 PM To: Logan, Joseph U.) Subject: FW: media inquiry: suicide epidemic Hi J, This seems in your wheelhouse. Would you be able to take this? Deb From: Zachary Siegel Sent: Saturday, July 7, 2018 4:43 PM To: Stone, Deborah Subject: media inquiry: suicide epidemic Hi Deobrah, My name's Zachary Siegel and 1 cover public health and criminal justice for news outlets like Wired, Slate, Vice, New York Magazine, MIT's Undark Magazine, and The Daily Beast, among others. I'm also a Guggenheim Fellow at CUNY's John Jay College of Criminal Justice. For a story I?m researching the history of epidemics. There are suicide, overdose, and gun violence epidemics right now in America. These are serious public health crises, but the causes and solutions are much more complicated than vaccination and inoculation, isolation and quarantine, which we commonly associate with epidemics like say, Zika or Ebola. I've read a lot of your work on suicide and would like to chat about what an epidemic of suicide really means, and what kind of solutions stem from that de?nition. Thank you, Zach Zachary Siegel student, USC ?17 847-502-7933 zuchargsiegelxunt Zachary Siegel student, USC '17 847602-7933 zaeharjgsiegelxum Zachary Siegel student, USC '17 847-502-7933 zachagysiege] .com Zachary Sie gel student, USC ?17" 847-502-7933 zuchamsiegel .cum From: Stone, Deborah (CDCIONDIEHXNCIPC) Sent: 30 Jul 2018 20:17:18 +0000 To: Crosby, Alexander Thomas Courtney Joseph U.) Kristin Asha Z. Cc: Eschelbach, Julie Gabraelle Erin Marie R. Valerie M. Subject: RE: FW: media inquiry: suicide epidemic Since the first question asks about solutions, I think can use the first two paragraphs as Alex suggested and then these two paragraphs below from the technical package talking points. I agree with Alex for (12. I?ll send the full response later today. Have to run now! Thanks! Deb Suicide is preventable. Prevention requires understanding and addressing the factors that in?uence suicide. CDC uses a 4 level model (called the social ecological model) to better understand suicide and what works to help prevent it. This model considers interaction between individual, relationship, community, and societal factors. Just as suicide is not caused by a single factor, research suggests that reductions in suicide will not be prevented by any single strategy or approach. Suicide prevention is best achieved through comprehensive strategies and approaches that target risk and protective factors across individual. relationship, community, and societal? levels and across all sectors, private and public. CDC has developed a technical package to help states and conununities take advantage of the best available evidence to prevent suicide. A technical package is a collection of strategies that represent the best available evidence to prevent or reduce public health problems like violence. They can help improve the health and well-being of communities. This technical package is intended as a resource to guide decision-making in communities and states. CDC expert scientists reviewed the literature and summarized the best-available evidence in the technical package. The technical package highlights seven strategies to prevent suicide: 1) Strengthen economic supports, 2) Strengthen access and delivery of suicide care, 3) Create protective environments, 4) Promote connectedness, 5) Teach coping and problem-solving skills, 6) Identify and support people at risk and 7) Lessen harms and prevent ?sture risk. From: Crosby, Alexander Sent: Monday, July 30, 2013 3:35 PM To: Simon, Thomas Lenard, Courtney Logan, Joseph (J) Stone, Deborah Holland, Kristin Ivey?Stephenson, Ashe Z. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Bellman, Marie R. Daniel, Valerie M. Subject: RE: FW: media inquiry: suicide epidemic Greetings: I think J's response to item #1 is correct however the latter part gets a little too technical. suggest using just the ?lat 2 paragraphs of his response for On suggest we use the response from the MMWR vital signs question 3. answer document. are suicide rates increasing? While the Vital Statistics data are great for describing trends they don't tell us about the causal factors that are driving the increases. We do know that suicide is not caused by one factor, but instead, it is typically caused by a combination of individual, relationship. community, and societal factors. Several such factors could be contributing to the increases: Economic conditions The role of the great recession in the late 2000?s and subsequent financial challenges and concerns about economic instability could have contributed to increases in suicide risk. Past research on the association between business cycles and US. suicide rates indicates that the overall suicide rate rises and falls in connection with the economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by parents may trickle down resulting in vulnerable youth. Opioid epidemic Increased availability and misuse of prescription opioids may be related to increases in suicide rates. Substance misuse itself is an established risk factor for suicide and, therefore, opioid misuse associated with the opioid overdose epidemic could be driving the suicide rate higher. When we look at who is dying from suicide and who is dying from unintentional overdoses involving opioids, we see that there is overlap in the demographics of the populations most highly affected by suicide and unintended opioid overdose deaths. Data also indicate that opioid prescribing rates are higher in counties where there are higher rates of suicide. Social media More research is needed on the impact of social media use on suicide rates. However, changes in social media content or use patterns could potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. Rural While there have been increases and decreases in rates over time, research shows that rates across cities and towns in the United States have been rising, with rural areas experiencing the most increases. The increased rates may be associated with suicide risk factors that are more common in less urban areas, such as limited access to mental healthcare as well as greater social isolation. Bridge to: Although the reasons for the increases in suicide rates are not fully understood, we do know a lot about the circumstances that contribute to suicide risk. It is clear that many factors contribute to suicide beyond mental health factors alone. -These factors inciude such things as relationship problems reiationship loss through death, divorce, or break-up; arguments, interpersonal violence), substance use problems, physical health problems, jobffinancial problems, and legal problems. Item #3 the response looks ?ne. The reporter may ask for some clarification. AMXC From: Simon, Thomas Sent: Monday, July 30, 2018 10:01 AM To: Lenard, Courtney (CDCIONDJEHINCIPCJ Logan, Joseph U.) Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie M. uh8 cdc. ova Subject: RE: FW: media inquiry: suicide epidemic Hi all, Apologies for not circling back on this request sooner, is everyone good with J?s talking points? Thanks! Courtney From: Logan, Joseph Sent: Monday, July 16, 2018 3:44 PM To: Lenard, Courtney Simon, Thomas Crosby, Alexander Stone, Deborah Holland, Kristin lvey- Stephenson, Asha Z. si m9 cdc. ova- Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin (CDCIDNDIEHKNCIPQ Ballman, Marie R. Daniel, Valerie M. (CDCIDNDIEHINCIPC) Subject: RE: FW: media inquiry: suicide epidemic Thanks so much, J. That?s very helpful. Here?s more from Zach: Was hoping for more of a conversation. Generally, I'm interested in discussing: Ebola and Zika are epidemics where the vectors are known and commonirapid-response solutions like isolationjquarantine, vaccinationfinoculation, are largely successful. Today, however, there are epidemics like the opioid epidemic, an epidemic of gun violence, a suicide epidemic, an obesity epidemic, and even more abstract epidemics like loneliness. All of these are, ofcourse, massive public health issues. Some Qs are: How do solutions to a suicide epidemic differ from the kinds of medical and technological solutions associated with contagion? What are the causesiconditionsi?solutions to more complex epidemics like suicide? Is the term epidemic used here a mere metaphor? Some have argued the metaphor doesn't quite match the framework of the crisis. From: Logan, Joseph Sent: Thursday, July 12, 2013 10:51 AM To: Lenard, Courtney (CDCIDNDIEHINCIPC) Simon, Thomas Crosby, Alexander Stone, Deborah Holland, Kristin Ivey- Stephenson, Asha Z. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Bellman, Marie R. Daniel, Valerie M. (CDCIONDIEHINCIPC) uhS cdc. ov> Subject: RE: FW: media inquiry: suicide epidemic It?s more the case that we, CDC, use the term 'epidemic? appropriately, at the appropriate time, and to the right audience. Suicide is not an epidemic but there can be an epidemic of suicide cases, depending on the population and time period. Normally, we don?t use it in media relations because the term could be wildly misused unless we are clarifying its meaning and how it can provide insight and messaging on how to stop the onset of new incidents. Let?s see what his questions entail. I can take an initial crack at drafting the talking points and send them to everyone on this email plus REB management. J. Logan, Suicide and Youth Violence, Emerging Topics Team Research tit Evaluation Branch Division of Violence Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention MS: F-63 Email: ?a3@cdc.gov Telework day: Monday, Wednesday, Friday Office phone: Will-4834 529 Tale-work phone: From: Lenard, Courtney Sent: Wednesday, July 11, 2018 4:44 PM To: Simon, Thomas Crosby, Alexander Logan, Joseph U.) Stone, Deborah Holland, Kristin simh 1@cdc.govb; Ivey- Stephenson, Asha Z. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. ; Daniel, Valerie M. (CDCIONDIEHKNCIPCJ c: uh8 cdc. ov> Subject: FW: FW: media inquiry: suicide epidemic Hi All! just want to make sure all of us are in the loop with this request. I?ll be asking the reporter again for more specific questions before setting up something with J. I did want to bring up the term epidemic, has CDC ever said suicide is an epidemic? Thanks much! Courtney From: Zachary Siegel Sent: Wednesday, July 11, 2018 12:16 PM To: Lenard, Courtney Cc: Logan, Joseph ll.) Subject: Re: FW: media inquiry: suicide epidemic My NYT editor asked for a draft by July 30 (with a ?sooner the better" caveat), Perhaps scheduling a call early next week would work? Thanks, Zach On Mon, Jul 9, 2018 at 2:55 PM, Zachary Siege] sizasiegelgdiuscedula wrote: Thanks, Courtney. Will do. On Mon, Jul 9, 2018 at 2:55 PM, Lenard, CUurtney wrote: Good afternoon, Zachary, please feel free to reach out to me when you have additional information and I can work with J. on setting up something. Will you please send your questions in advance? Thanks much! COurtney From: Logan, Joseph Sent: Monday, July 9, 2013 3:44 PM To: Zachary Siegel (zasie el usc.edu> Cc: Lenard, Courtney Sent: Monday, July 9, 2018 1:51 PM To: Logan, Joseph ll.) wrote: Hi Zach, I received this email from Deb Stone. I do a considerable amount of research on suicide epidemics. If you are interested in that area, I can speak to the topic unless you are specifically interested in Deb's work. If you have any detailed questions, feel free to send them. J.Logan From: Stone, Deborah (CDCIONDIEHINCIPC) Sent: Monday, July 9, 2018 12:30 PM To: Logan, Joseph (J.) Subject: FW: media inquiry: suicide epidemic Hi J, This seems in your wheeihouse. Would vou be able to take this? Deb From: Zacharv Siegel Sent: Saturday, July 2, 2018 4:413 PM To: Stone, Deborah Subject: media inquiry: suicide epidemic Hi Deobrah, My name's Zachary Siegel and I cover public health and criminal justice for news outlets like Wired, Slate, Vice, New York Magazine, MIT's Undark Magazine, and The Daily Beast, among others. I'm also a Guggenheim Fellow at CUNY's John ay College of Criminal Justice. For a story I?m researching the history of epidemics. There are suicide, overdose, and gun violence epidemics right now in America. These are serious public health crises, but the causes and solutions are much more complicated than vaccination and inoculation, isolation and quarantine, which we commonly associate with epidemics like say, Zika or Ebola. I've read a lot of your work on suicide and would like to chat about what an epidemic of suicide really means, and what kind of solutions stem from that de?nition. Thank you, Zach Zachary Siegel MSJ student, USC ?17 842-502-7933 zachar sic cl .com Zachary Siegel student, USC '17 847-502-7933 zacharvsicgc] .com Zachary Siege! student, USC '17 847-502-7933 zacharvsiegelcom Zachary Siege] MSJ student, USC '17 847-502-7933 zachagsiegei?om From: Simon, Thomas Sent: 30 Jul 2018 10:06:12 -0400 To: Lenard, Courtney Joseph Alexander Deborah Kristin Asha Z. Cc: Eschelbach, Julie Gabraelle Erin Marie R. Valerie M. Subject: RE: FW: media inquiry: suicide epidemic I meant Vital Signs and Technical Package (182A. From: Simon, Thomas Sent: Monday, July 30, 2013 10:01 AM To: Lenard, Courtney Logan, Joseph Crosby, Alexander Stone, Deborah Holland, Kristin (CDCIONDIEHXNCIPC) Hey-Stephenson, Asha Z. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin (CDCIONDIEHXNCIPC) Ballman, Marie Fl. Daniel, Valerie M. Subject: RE: FW: media inquiry: suicide epidemic Hi Deb and Alex, Have you reviewed this already? I?d like your take on the response and I also think it would be good to add some of the and broader prevention messages from the TP Thank you, Tom From: Lenard, Courtney Sent: Thursday, July 26, 2018 5:26 PM To: Logan, Joseph (1.) Simon, Thomas Crosby, Alexander (CDCIDNDIEHINCIPC) Stone, Deborah Holland, Kristin lyey? Stephenson, Asha Z. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie M. (CDCIDNDIEHXNCIPC) <1 uhS cdc. am? Subject: RE: FW: media inquiry: suicide epidemic Hi all, Apologies for not circling back on this request sooner, is everyone good with J?s talking points? Thanks! Courtney From: Logan, Joseph U.) Sent: Monday, July 16, 2018 3:44 PM To: Lenard, Courtney (CDCIONDIEHINCIPC) Simon, Thomas Crosby, Alexander Stone, Deborah Holland, Kristin lyey- Stephenson, Asha Z. Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie M. (CDCIONDIEHINCIPCJ Subject: RE: FW: media inquiry: suicide epidemic Hi Courtney et al., Sorry for the delay. I drafted some talking points for Zachary Siegel. Please edit as you see fit. J. J. Logan, Suicide and Youth Vioience, Emerging Topics Team Research Evaluation Branch Division of Violence Preyention National Center for Injury Prevention and Control Centers for Disease Control and Prevention MS: F-63 Email: ffa3@cdc.gov Telework day: Monday, Wednesday, Friday Office phone: T70-4BB-1 529 Telework phone: 404-334-4379 From: Lenard, Courtney Sent: Thursday, July 12, 2018 11:30 AM To: Logan, Joseph (J.) Simon, Thomas Crosby, Alexander Stone, Deborah Holland, Kristin (CDCIDNDIEHINCIFC) Cc: Eschelbach, Julie Lane, Gabraelle Black, Erin Ballman, Marie R. Daniel, Valerie M. t: uhS cdc. oy> Subject: RE: FW: media inquiry: suicide epidemic It?s more the case that we, CDC, use the term ?epidemic? appropriately, at the appropriate time, and to the right audience. Suicide is not an epidemic but there can be an epidemic of suicide cases, depending on the population and time period. Normally, we don?t use it in media relations because the term could be wildly misused unless we are clarifying its meaning and how it can provide insight and messaging on how to stop the onset of new incidents. Let?s see what his questions entail. I can take an initial crack at drafting the talking points and send them to everyone on this email plus REB management. J. J. Logan. Suicide and Youth Violence, Emerging Topics Team Research 8. Evaluation Branch Division of Violence Prevention National Center for Injury Prevention and Control Centers for Disease Control and Prevention MS: F-53 Email: ffa3@cdc.gov Telework day: Monday. Wednesday, Friday Office phone: 770-488-1529 Tale-work phone: 404-334-4379 From: Lenard, Courtney Sent: Wednesday, July 11, 2018 4:44 PM To: Simon, Thomas Crosby, Alexander Logan, Joseph U.) Stone, Deborah Holland, Kristin Sent: Wednesday. July 11, 2018 12:16 PM To: Lenard, Courtney 5 cdc. ova- Cc: Logan, Joseph U.) Subject: Re: FW: media inquiry: suicide epidemic My NYT editor asked for a draft by July 30 {with a "sooner the better" caveat). Perhaps scheduling a call early next week would work? Thanks, Zach On Mon, Jul 9, 2018 at 2:55 PM, Zachary Siegel wrote: Thanks, Courtney. Will do. On Mon, Jul 9, 2018 at 2:55 PM, Lenard, Courtney Cc: Lenard, Courtney 5 cdc. ov> Subject: RE: FW: media inquiry: suicide epidemic Sure, sounds good. We also need to coordinate a meeting with our communications liaison. Icc?d her on this email. J. From: Zachary Siegel Sent: Monday, July 9, 2018 1:51 PM To: Logan, Joseph (J.) Subject: FW: media inquiry: suicide epidemic Hi J, This seems in your wheelhouse. Would you be able to take this? Deb From: Zachary Siegel czasie el usc.edu> Sent: Saturday, July 7, 2018 4:43 PM To: Stone, Deborah Subject: media inquiry: suicide epidemic Hi Deobrah, My name's Zachary Siegel and I cover public health and criminal justice for news outlets like Wired, Slate, Vice, New York Magazine, MIT's 'Undark Magazine, and The Daily Beast, among others. I'm also a Guggenheim Fellow at CUNY's John Jay College ofCriminal Justice. For a story I?m researching the history of epidemics. There are suicide, overdose, and gun violence epidemics right now in America. These are serious public health crises, but the causes and solutions are much more complicated than vaccination and inoculation, isolation and quarantine, which we associate with epidemics like say, like or Ebola. I've read a lot of your work on suicide and would like to chat about what an epidemic of suicide really means, and what kind of solutions stem from that de?nition. Thank you, Zach Zachary Siegel MSJ student, USC '17 841502-7933 Zachary Siegcl MSJ student, USC '17 847602-7933 zacharysicgel .ccm Zachary Sicgcl student, USC '17 847-502-7933 Zachary Siege] MSJ student, USC ?17 847-502-7933 From: Simon, Thomas Sent: 14 May 2018 22:42:03 -0400 To: Holland, Kristin Deborah Subject: RE: Hold the press-?Sorry--big change required Attachments: CIA Document Suicide Vital Signs 5.14.18.docx Hi Kristin, You did a fantasticjob on this! have included a few specific edits throughout in the version attached. I?m thinking that we should add something about circumstances to address Anne?s point that everyone experiences these. We added the following to the MMWR: A range of circumstances (relationship problems, life stressors, and recent/impending crises) has been identified as potential risk factors for suicide. Circumstances captured by are those identified by next of kin as having actively contributed to a person?s suicide. Decedents could have experienced multiple circumstances. Deb, did you hear back from folks about whether this summary is ok? We need to be careful about not implying that everything we looked at were seen as contributing to the suicide. Mental health and substance use problems did not have to be seen as contributing to be captured in Deb, I?m wondering if we should change the title of Table 2 in the MMWR to "Conditions and Circumstances preceding For the (1?5 and a?s we could use more of what Katie provided about this issue. Here is what she wrote Although we don?t have something onhand, here?s something to work from as a starting point if it helps: "In precipitating circumstances are stressors or events that were noted by investigators as having contributed to the person's death. In the case of suicide circumstances, many of these are life stressors that are experienced by many people every day, such as job problems, financial problems, and different types of relationship problems. Nevertheless, they give us valuable information about which of these stressors are most central to suicide deaths as we can see which of these, many of which are based on suicide risk factors previously identified in the literature, most commonly are identified as having actively contributed to a person?s death by suicide. Many people who die by suicide have several of these circumstances identified in their records and additionally, factors such as resiliency, coping skills, and other protective factors help account for the different ways that people in general think and feel about and react to these types of stressors." Thank you very much! ?Tom From: Holland, Kristin Sent: Monday, May 14, 2018 1:22 PM To: Bruce, Stone, Deborah Kurnit, Molly Regina Black, Erin Ballman, Marie R. Richmond-Crum, Malia Simon, Thomas Subject: RE: Hold the press?-Sorry-?big change required Updated FAQs with "mental health conditions? terminology throughout. Kristin From: Bruce, Sent: Monday, May 14, 2018 1:11 PM To: Stone, Deborah Kurnit, Molly Regina (CDCIONDIEHINCIPQ Black, Erin Ballman, Marie R. Richmond-Crum, Malia <'rv8 cdc. ova,- Simon, Thomas Cc: Holland, Kristin (CDCJONDIEHINCIPCJ Subject: RE: Hold the press--Sorry--big change required you From: Stone, Deborah Sent: Monday, May 14, 2018 12:59 PM To: Bruce, Kurnit, Molly Regina Black, Erin Ballman, Marie R. Richmond-Crum, Malia Simon, Thomas Subject: RE: Hold the press--Sorry--big change required How about you send me an email with your revised materials for today and I will forward it (and cc you) to the vital signs team and ask the question about the other materials? Deb From: Bruce, (CDCIOPHPRIOD) Sent: Monday, May 14, 2018 12:58 PM To: Stone, Deborah Kurnit, Molly Regina Cc: Holland, Kristin Subject: RE: Hold the press--Sorry--big change required Thanks by! From: Stone, Deborah Sent: Monday, May 14, 2018 11:23 AM To: Black, Erin Ballman, Marie R. Bruce, Kurnit, Molly Regina Richmond-Crum, Malia Cc: Holland, Kristin Subject: Hold the press--Sorry--big change required Importance: High Hi Ladies, The MMWR editor is requiring that we change the term ?mental health problem? to ?mental health condition.? I know it?s late in the game and very inconvenient but we will likely need to change the terminology in all products. I say likely because I?m waiting for confirmation from the team that this change aligns with the definition in I expect to hear back shortly so I will let you know the final word but wanted to give you a heads-up. I know there?s a deadline today COB for comm materials. Rich suggested if you need extra time that would be ok given the circumstances. Sorry again, for all of us. Deb Deb Stone, 5120, MSW, MPH Centers v?or Disease Control and Prevention National Center for Ingury Prevention and Control D:vision of Violence Prevention Suicide, Youth Violence Eldei Malueazment Team CDC's Injury Center Preventing Injuries and Violence Through Science and Action Contents Suicide Prevention Vital Signs For internal use only. General Background on the Problem of What was the impetus for this study? Why are suicide rates Increasmg? What?s going on globally with respect to suicide rates? 1 2 Is CDC providing funding to states to prevent suicide? .. 2 7 8 Firearms and Suicide . The Present Study MMWR Content and Methods The National Violent Death Reporting System Warning signs of suicide and what to do if you know someone at i. .. . Suicide among Veterans Opioids and Suicide . SurcidePrevention Talking about suicide 8: suicide contagion What role do the economy and social media plainr in increasing suicide rates? 24 New opportunities for tracking suicide and understanding comprehensive suicide prevention efforts Select Recent CDC Research Partner Actiwties Additional Resources General Background on the Problem of Soicide I 0 Suicide is a public health problem. Nearly 45,000 lives were lost to suicide in 2016, which is approximatelyr one suicide ever!?' 12 minutes. Rates have increased by nearly 30% from 139329992016 Suicide rates varv bv racefethniciw, age, and other population characteristics. with the highest rates across the lifespan occurring among non~Hispanic American lndiaanlaska Native [AlfANl and non-Hispanic White population groups, middle-aged adults, veterans and active duty.r personnel, certain occupational groups. and sexual minority vouth. More than half of suicide deaths occur among adults in the prime of their lives, ages 35-64. Suicide rates in rural areas are consistently higher than rates in more urban areas. Suicide and nonfatal self-harm injuries cost more than $69 billion annualivingirect?ediggiandwg?g loss costs. Decades of research have shown that suicide is preventableComment This is from 2015 and Deb might be updating based on information from Curtis. Comment I don?t think we need .3 Suicide ranks as the 10th leading cause 9: death 19; 5 l' 9'5" this. {Comment IHKH: Need to confirm whether this is true. What was the impetus for this study? lsuggesmakingthis number 1 in this section so this is the ?rst response she sees to this question. 1. A CDC employee went missing in February and was later found deceased. Some speculate his death may have been a suicide. Is that why you're publishing this study now? I i and analyses for this study began prior to the date when Commander Cunningham disappeared. The rising suicide rates in the US. have been well documented, and the CDC has a strong portfolio of research describing these trends as well as geographic trends and trends in suicide by age group, sex, and race. The present study was a logical next step in understanding suicide trends at the state level, monitor the trends for their state. 2. Did Commander Tim Cunningham die by suicide? CDC does not have that information. The law enforcement and coroner/medical examiners investigating so that many states that have specific suicide prevention efforts in place could better understand and i i i i i Dr. Cunningham's case are the ones who make that determination, not CDC. CDC has cooperated with i investigating of?cials to provide information that may be of use for their investigation. 3. What was the impetus for this Eitudyi? The CDC has a strong portfolio of research describing the increasing trends in suicide, as well as geographic tre The present study was a iogicni next step in understanding suicide trends at the state ievei. so that many states that have specific suicide prevention efforts in place could better understand and monitor the trends for their state. is CDC providing funding to states to prevent suicide? 4. Has CDC provided states resources to prevent suicide? Who in the state does this work? CBC does not provide direct funding to states to conduct suicide prevention work, as CDC has no appropriation for suicide prevention. However, states have some mental health resources through 5AMHSA and Garrett Lee Smith grant funding. CDC has created a technicai package for suicide prevention that states and communities can use to inform and guide their prevention e?arts. 5. What is CDC doing to prevent suicide? The CDC takes a public health approach to preventing suicide, which involves a number of steps. CDC is: 0 Tracking and monitoring data to observe trends and inform policies and programs [for example, - identifying risk and protective factors; and developing evidence?based prevention programs. I Evaluating programs, policies, practices to determine if they prevent risk. 0 Sharing information about the best available evidence (for example, the suicide prevention technical package). Why are suicide rates increasing? 6. Why are suicide rates increasing? While the Vital Statistics data are great for describing trends they don?t tell us about the causal factors that are driving the increases. We do know that suicide is not caused by one factor, but instead, it is typically caused by a combination of individual, relationship, community, and societal factors. Several factors could be contributing to the increases: Economic conditions The role of the great recession in the late 2000?s and subsequent financial challenges and concerns about economic instability could have contributed to increases in suicide risk. Past research on the association between business cycles and U.S. suicide rates indicates that the overall suicide rate rises and falls in connection with the economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by parents may trickle down resulting in vulnerable youth. Opioid epidemic increased availability and misuse of prescription opioids may be related to increases in suicide rates. Substance abuse itself is an established risk factor for suicide and, therefore, the epidemic of opioid misuse could be driving the suicide rate higher. When we look at who is dying from suicide and who is dying from overdoses involving opioids, we see that there is overlap in the demographics of the populations most highly affected by suicide and opioid overdose deaths. Data also indicate that opioid prescribing rates are higher in counties where there are higher rates of suicide. Social media Comment Prescription is important because other forms of opioids More research is needed on the impact of social media use on suicide rates. However, changes in social {heroin} is impacting urban areas. media content or use patterns could potentially be Contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. Rural While there have been increases and decreases in rates over time, research shows that rates across cities and towns in the United States have been rising, with rural areas experiencing the most increases. The increased rates may be associated with suicide risk factors that are more common in less urban areas, such as limited access to mental healthcare as well as greater social isolation. Bridge to: Although the reasons for the increases in suicide rates are not fully understood, we do know a lot about the circumstances that contribute to suicide risk. It is clear that many factors contribute to suicide beyond mental health factors alone. These factors include such things as relationship problems leg. relationship loss through death, 0 divorce, or break-up; arguments, interpersonal violence], substance use problems, physical health problems, jobi?financial problems, and legal problems. 7. Why are suicide rates increasing more in less urban (or more rural} areas? While there have been increases and deoreases in rates over time, research shows that rates across cities and towns in the United States have been rising, with rural areas exgeriencing the most increases. r: increased rates may be associated with suicide risk factors that are more common in less urban areas, - Limited access to mental healthcare - Greater social isolation. Loss of jobs, homes, and income associated with the Great Recession as we" as the Websicridlsees impact on less urban areas. Urban areas may also experience these risk factors, but to a lesser extentDuring the Great Recession, there was an increase in suicide, but why are rates still going up since the economy has bounced back? Suicide rates have continued to rise after the Great Recession. Comment Do we know this? If we are not sure then I would take this out. l?m concerned that this could be used to frame this as only a rural issue and Ithink it is more widespread than that. Comment This implies that they A previous study found that suicide rates across all urbanization levels in the US. increased over the i are more prevalent in rural areas is that period from 1999?2015, but the gap in rates between less urban and more urban areas widened over this period, and rates in more rural areas increased at a more rapid pace than more urban areas known? beginning in 2007-2008. Fuicide rates in more rural areas may be driving the Increase in suicide rates overall. Ilhe rapid acceleration of increasing suicide rates in more rural areas in 2007-2008 may reflect the corresponding start of the Great Recession at about this same time. The disproportionate impact of the recession on rural areas and the longer economic recovery time in these areas may help to explain why suicide rates have remained high overall. Other common suicide risk factors known to be highly prevalent in rural areas, Euch as mental health and substance abuse probiemsl potentially influenced by the meag?pti?oploid epidemic impacting such areas over made worse by shortages in behavioral health care providers in these areas, and greater social isolation may also continue to impact suicide rates in rural areas and overall. The potential cumulative burden of suicide risk factors in less urban areas may impact not only individuals but relationships. families, and communities as well, suggesting the need for comprehensive suicide prevention measures. 9. Is the opioid epidemic associated with rises in suicide rates? Both suicide and drug overdoses are on the rise. CDC is actively working to analyze and better understand the trends and risk factors for opioid overdose and suicide, and the connections between the two public health challenges. Increased availability and misuse of opioids may be related to increases in suicide rates. Substance abuse itself is an established risk factor for suicide and, therefore! the epidemic of opioid abuse could be driving the suicide rate higher. When we look at who is dying from suicide and who is dying from overdoses involving opioids, we see that there is overlap in the demographics of the populations most highly affected by suicide and opioid overdose deaths. Data also indicate that opioid prescribing rates are higher in counties where there are higher rates ofsuicide. CDC uses several systems to monitor overdoses, overdose deaths SI. suicide: - Deaths - Death certificates, National ?v'iolent Death Reporting System and State Unintentional Drug Overdose Reporting System Nonfatal National Electronic Injury Surveillance System~All Injury Program Healthcare Cost and Utilization Project from AHRQ. and emergency department and I EMS surveillance data from Enhanced State lC'ipiold Overdose Surveillance program 10.Why are suicide rates increasing more among females? This MMWR showed that suicide rates were increasing for females and males. The increases for females were significant in 43 states and the increases for males were significant in 34 states. It is important to note that while the relative increases in rates were higher for females than for males overall, the absolute suicide rates rose faster for males than females. Male suicide rates are consistently 3 to 5 times higher than the suicide rates for females. It is important for suicide prevention strategies to address the needs of males and females. What?s going on globally with respect to suicide rates? 11. How does the U.S. compare to other nations with respect to trends in suicide rates? Globally, suicide rates ha been declining. Global data from the World Health Organization indicates that nearly all European societies experienced rising suicide rates after the Great Recession. However, unlike the U.S., the suicide rate in many European nations stabilized or returned to pre~recession levels after the recession. This may be because the economic recession impacted different countries in different ways, and areas within the U.S. may have taken longer to recover from the recession. Although suicide rates also increased in Canada during the Great Recession, Canada has experienced a fairly level suicide rate over the past 17 years, with a rate between 12.5 to 13.0 per 100,000. Unlike in the U.S., ingestion of pesticide is one of the most common methods of suicide globally. Policies related to the sales and import of pesticides, which have reduced access to this lethal means of suicide, have demonstrated impact in preventing suicide in some countries. For instance, in Sri Lanka, the suicide rate decreased from 4? per 100,000 in 1995 to 30.9 per 100,000 in 2005 after the implementation of such policies. 12.What's going on in the U.S. that?s not occurring in other countries to explain the increase in suicide rates here? The U.S. has good surveillance systems in place to track mortality, allowing us to identify the increases in suicide rates and even which areas of the country, age groups, and racialfethnic groups are most at risk. Unfortunately, these surveillance systems do not assess and track the risk factors that may be contributing to these trends. We know that suicide rates are increasing in most age groups and demographic groups and we are seeing increases across suicide methods. The increases in suicide rates are unlikely to be due to any single factor. Factors at the individual, relationship, and community levels - such as age; substance abuse history; school, job, or legal problems; exposure to another person's suicidal behavior; and the accessibility of assistance in the community all contribute to risk. It is likely that multiple factors are influencing suicide trends. Some potential contributing factors that people are considering include the following: - The role of the great recession in the late 2000?s and subsequent financial challenges and concerns about economic instability. Past research on the association between business cycles and U.S. suicide indicate that the overall suicide rate rises and falls in connection with the 5 Comment I suggest having Malia economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by parents may trickle down resulting in or Erin take a look at this response if YOU vulnerable youth. haven?t yet. 0 Other developed nations also experienced increased suicide rates during the Great Comment This is stronger than Recession, but for the most port, their surcrd'e rates have leveled of since then. .E what we say, in the TP. I think sum edits II Increased availability and misuse of prescription opioids. We know that substance abuse is an are needed. important risk factor for suicide. It is unclear to what extent trends in opioid misuse are l: contributing to suicide rates among adolescents. Adolescents could be at risk due to their own misuse or because of the misuse by family members. 1' 0 Another potentially relevant factor is the role of social media. More research is needed on the impact of social media use on suicide rates. However, changes in social media content or use ii patterns could potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. Firearms and Stiicide 13. Are firearms a major means of suicide globally? Unlike in the U.S., ingestion of pesticide and hanging are the two most common methods of suicide globally. Policies related to the sales and import of pesticides, which have reduced access to this lethal means of II suicide, have demonstrated impact in preventing suicide in some countries. For instance, in Sri Lanka, the suicide rate decreased from 4? per 100,000 in 1995 to 30.9 per 100,000 in 2005 after the implementation of such policies. 14. How many lives are lost to firearm-related suicides per year? In 2015, almost 23,000 lives were lost due to suicides by firearm. This equates to 51% of suicides in the US in 2015. 15. Does the CDC want to restrict access to firearms? The CDC is not suggesting that ?rearms should be taken away from US {esidemj Based on prior research, we know that safe storage practices can help reduce the risk for suicide bv separating vulnerable popylations from easy access to lethal means. . .. "..Thiscan involve safely storing firearms locked and unloaded, which can help to provide a buffer for those who are thinking about suicide and increases the time it takes them to access lethal means. We know from prior research that simply providing a buffer in this critical time period can help reduce risksavealiives. 16.What are the leading ways that people die by suicide? Firearms are the mechanism for about half of all suicides in the United States. The next leading methods are suffocation and poisoning. Reducing access to lethal means of suicide among persons at risk for suicide is an intervention with robust supporting evidence; such intervention includes: I lntervening at suicide hotspots such as bridges I Counseling around safe storage of medications, firearms, or other household products to keep them away from people at I These interventions can be combined with other strategies for a comprehensive approach to prevention. 17.What was the process of obtaining support and resources from the CDC to do this research, given the agency's historical lack of funding for gun violence research? This study used data from existing public health surveillance systems that collect data on many different causes of injury and death. CDC has and continues to support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U5. Understanding the patterns, characteristics, and impacts of firearm?related iniuries?w'roleoee is an important step toward 13.A previous report shows that a substantial number of gun-caused deaths are suicides. What could drive children to take their own lives and how do they access firearms in the first place? When looking at the circumstances surrounding child firearm suicides, while mental health factors are important, firearm suicides are also frequently related to situational life stressors and relationship problems with an intimate partner, friend, or family member. It is important for parents and other adults who interact with children to be aware that life stressors such as these can have a big impact on children and put them at risk for suicide. Other researchers have found that safe storage of firearms (storing firearms locked, unloaded, and separate from ammunition) is associated with reductions in adolescent firearm suicide attempts and also unintentional firearm deaths in children. The Preseot Study MMWR Content and Methods 19. How was the current study conducted? Trends in age?adjusted suicide rates were assessed among people aged :10 years, by state and sex, and across six consecutive three?year periods [19992016], using data from the National Vital Statistics System for 512} states and Washington, DC. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to Examine contributing circumstances among suicide decedents with and without known mental health conditions. 20. What are some of the key findings? I Across the study period, suicide rates increased in all states, except Nevada [which had a consistently high rate throughout). These increases were statistically significant in 44 states. 0 The percentage increases in rates ranged from 5.9% in Delaware to 516% in North Dakota, with increases of more than 30% observed in 25 states. I Suicide rate trends indicated significant increases for males (34 states} and females (43 states}, as well as for the U5. overall. I While all decedents were predominately male and non-Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to: be male (83.6% vs. odds ratio 95% CI 2.2-2.5) be racial/ethnic minorities (OR range: 1.2-2.0} to die by firearms 95% CI: I Overall, the large majority of suicides occurred among people ages of 25-64. I More than half of suicide decedents in (27 states) did not have a known mental health condition. This group suffered more from relationship problems and other life stressors such as criminal? legal matters, eviction/loss of home, and recent or impending crises, however such circumstances were also common in people with mental health conditions. I To address the full range of contributing factors to suicide, comprehensive suicide prevention activities are needed. Such strategies include both upstream prevention to prevent risk from occurring in the first place as well as more activities responsive to the needs of people at increased risk and to prevent re?attempts. The technical package to prevent suicide provides information about evidence-based strategies, as well as information about the need for a broad, comprehensive approach to preventing suicide. 21. For some states, the reported percentage increase in the suicide rate is quite large. Is this due simply to fluctuations in small numbers of suicides? The percentages represent increases in rates between the first three?year reporting period {1999-2001) and the last three?year reporting period (2014?2016]. By aggregating the data into three?year periods, small suicide counts were avoided. The table below provides the beginning and ending suicide counts and rates for the ten states showing the largest percentage rate increases. No suicide count appearing in the table below is less than 200, and some counts range into the thousands. Even after recognizing the growth in state populations and any shifts in their age profiles, changes such as those shown would not typically be expected clue to random fluctuations alone. State Riggilng $9321?" 5:;315 211:3: Rank ND 3333:3333 3:333 333 333 1 33333333 31333 333 3313 48.6% 2 NH 33333333 3333 333 3313 43.3% UT 33333333 3333 1333 333 45.5% ., Ks 3333:3333 3:333 13;: 5 SD 33333333 3333 333 3313 44.5% 5 '0 33333333 33333 1,333 3313 43.23. MN 333323333 3:333 3:333 3313 40.5% 8 WV 33333333 31333 333 333 39.0% 9 SC 33333333 3:333 3:333 3333 33.3% 1., Average population 3: 10 years old during reporting period. 3 Annual age-adjusted rate per 100,000 population a 10 years old. 22.What is known about which groups are experiencing increases? The current study found that rates of suicide are increasing, overall, and for males and females. Rates among females increased significantly in 43 states and rates among males increased significantly in 34 states. I In general, suicide rates in the U.5. have increased by nearly 30% since 1999. i. Increases were observed for both women and men in all age groups under 75. I Certain groups have had particularly high greatest increases since 1999, including: i. Working-age adults 35-64 yrs, ii. Non-Hispanic whites, and non-Hispanic American Indians 1' Alaska Natives and People living in rural areas. iv. Rates have increased for males and female however the rate for males is consistently 3~ 5 times higher than the rate for females 23. How do people with and without mental health conditions differ with respect to suicide? People with and without mental health conditions had similarities and differences 10 I While all decedents were predominately male and non-Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely male {83.6% vs. 68.8%} and racialf'ethnic minorities (OR I Suicide decedents without known mental health conditions also had significantly greater odds of perpetrating homicide-suicide {adjusted odds ratio 2.9, 95% CI Although this represents a small percentage of suicides in both groups. I While firearms were the most common method of suicide used overall and for both groups, decedents without known mental health conditions were more likely to die by firearm (55.3% vs. 40.5%) and less likely to die by ngulation/suffocation {26.9% vs 31.3%) or poisoning [10.4% vs 19.8%) than those with known mental health conditions. (These differences remained significant in the adjusted models}. I Among decedents with toxicology results, decedents without known mental health conditions were less likely to test positive for any substance overall [a0R=0.8, 95% such as opioids 95% but more likely to test positive for alcohol 95% I People without known mental health conditions were less likely to have substance abuse problems 95% I Two?thirds ofthose with known mental health conditions had a history of mental health or substance abuse treatment and just over half were in current treatment. I Decedents without, versus those with, known mental health conditions, had significantly greater likelihood of any relationship problemfloss (45.1% vs. specifically intimate partner problems {30.2% vs. {12.5% vs. and recently perpetrating interpersonal violence vs. They also were more likely to have experienced any life stressors (54.2% vs such as criminal-legal problems [10.7% vs. or evictioniloss of home vs. and were more likely to have had a crisis within the preceding or upcoming two weeks (32.9% vs. All of these differences remained significant in the adjusted models. I Among all people with crises, intimate partner problems were the most common types and did not differ by mental health group status. I Physical health problems {23.2% and 21.4%} and job/financial problems {15.6% and 16.8%) were commonly experienced by both groups [with and without mental health conditions, respectively} I Decedents without known mental health conditions had significantly lower odds of recent release from any institution 95% but among those who were recently released they were significantly more likely to be released from a correctional facility (25.7% vs. hospital {43.7% vs. or other facility alcoholisubstance treatment] laDR=2.5 95% than those with a known mental health conditions. Among decedents with known mental health conditions who were recently released from an institution 46.7% of this group were released from facilities. I Decedents without known mental health conditions, compared to those with mental health conditions, were significantly less likely to have a history of suicidal ideation {23.0% vs. 40.3%} and prior suicide attempts [10.3% vs. More than one in five people in both groups disclosed suicide intent (22.4% vs. 24. Why did Nevada not see an increase in suicide rates? While Nevada?s suicide rate did not increase, it remained consistently high across the study period. 11 25. 26. 27. 23. 29. Why did this study focus on those aged 10 and older? Suicide rates were analyzed for people aged 210 years only, because determining suicidal intent in younger children can be difficult. a. Suicide is defined as self?directed injurious behavior with an intent to die as a result of the behavior, and youth under the age of 10 may not fully understand the implications of their actions. web site} How was ?crisis" defined in this study? For this study, a "crisis? was a current/'acute event that occurred within the 2 weeks of a suicide. Crises are indicated in an source report to have contributed to the suicide. A crisis can precede the death had a bad argument the day before the incident, divorce papers served that day, or victim laid offthe week before) or be an impending event house was to be foreclosed on the day after the incident or court date for a criminal offense three days after the suicide}. Crises are interpreted from the eyes of the victim. This is particularly relevant for young victims whose crises, such as a bad grade or a dispute with parents over a curfew, may appear to others as relatively minor. How did you define a mental health condition? The National Violent Death Reporting System defines a mental health condition as disorders and listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with the exception of alcohol and other substance use disorders, which are captured separately in the system. a. Data on mental health conditions are abstracted from the investigative reports included within and that are associated with each suicide. b. Investigative reports are those filed bylaw enforcement and coronersfmedical examiners. Information obtained from these reports is dependent upon the extent of informant knowledge that may impact data completeness and accuracy. Are the people without mental health conditions just people who haven't been diagnosed with a mental health conditions? it is possible that the people without mental health conditions in this study had a diagnosable mental health conditions but had not been diagnosed, or that their mental health conditions was unknown to informants who provided circumstantial information to law enforcement. Studies including more in- depth interviews with next-of-kin often cite greater attributions to mental disorders, however many methodological variations across studies exist. It is likely that some people without known mental health conditions in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. Nonetheless, the high prevalence of diverse contributing circumstances among those with and without known mental health conditions suggests the importance of addressing the broad range of factors that contribute to suicide. Are suicides by people without mental health conditions considered impulsive? Suicide decedents who do not have mental health conditions should not necessarily be considered impulsive. I As this study demonstrates, there are many reasons, beyond mental health conditions alone, why people take their own lives. 12 I 54% of the study sample did not have a known mental health condition, but people in this group still experienced challenges in their lives that contributed to their suicide. I They may have been experiencing these challenges for an extended period of time and may have had suicidal thoughts leading up to their suicide, which may indicate that the suicide was not impulsive 35% of those without mental health conditions left a suicide note 0 23% were known to have a history of suicidal ideation 22% had disclosed suicidal intent to another person 0 10% had previously attempted suicide 30. How many suicides are considered impulsive? - A previous case-control study of survivors of neoriy iethoi suicide attempts indicates that about 24% of this group acted impulsively on their suicidal thoughts 0 less than 5 minutes passed between their initial thought of suicide and their nearly lethal suicide attempt 76% of attempt survivors did not meet this definition of impulsivity with respect to their suicide attempt. 31.Why does this study find such a low rate of mental health conditions compared to autopsy studies? autopsy studies that utilize in-depth interviewing of surviving friends/family and often include record review typically show that a larger proportion of suicide have a mental health diagnosis. However, variations in the methodology of autopsy studies and the current study may impact the prevalence of mental health conditions identified. It is likely that some people without known mental health conditions in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. Nonetheless, the high prevalence of diverse contributing circumstances among those with and without known mental health conditions suggests the importance of addressing the broad range of factors that contribute to suicide. 32. Why did you only look at suicide circumstances in 27 states? a. In 2015, the National Violent Death Reporting System collected data from 27 states. The data collected from these states were used for the analysis. More current data is not yet available. b. In 2016, collected data from 40 states, D.C. and Puerto Rico however data are not yet available. c. The FY 2013 omnibus appropriation bill provided funding and Congressional direction to expand the program to all 50 states and the District of Columbia. CDC is actively working toward that goal. 33. What are some of the limitations to this study? There are three limitations to the study: First, in the state-level analysis, rankings for four states MA, RI, UT) might have been impacted by large proportions of injury deaths of undetermined intent [potentially biasing 13 reported suicide rates downward), or decreased percentages of such deaths over time [potentially biasing estimated rate trends upward}. Second, is not yet nationally representative; the 27 states included in this study represent 49.6% of the U.S. population Third, abstractors of data are limited to information contained in investigative reports. Therefore, the extent of informant knowledge can affect data completeness and accuracy. Studies including more in-depth interviews with next-of?kin often cite greater attributions to mental disorders, however many methodological variations across studies exist. It is likely that some people without known mental health conditions in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. Nonetheless, the high prevalence of diverse contributing circumstances among those with and without known mental health conditions suggests the importance of addressing the broad range of factors that contribute to suicide. We know that suicides are underreported. It is possible that some suicides were coded as unintentional or deaths of undetermined intent. It is unclear how that could impact estimates of trends or conclusions about circumstances. The National Violent Death Reporting System 34. What is the National Violent Death Reporting System? The National Violent Death Reporting System is a data system that provides states and communities with a clearer understanding of violent deaths. data can be used to guide local decisions about efforts to prevent violence and track progress over time. is the only state-based surveillance {reporting} system that pools data on violent deaths from multiple sources into a usable, anonymous database. These sources include state and local medical examiner, coroner, law enforcement, toxicology, and vital statistics records. Pooling these data can provide CDC with a detailed, comprehensive picture of how and why violent deaths occur. includes over 600 unique data elements that provide valuable context about violent deaths such as Relationship problems; mental health conditions and treatment; toxicology results; and life stressors I including recent problems with a job, finances, or physical health problems. Extensive information about the incidents, such as weapons used, characteristics of suspects, and locations where they occurred are included. Such data are far more comprehensive than what is available elsewhere. can help identify populations particularly affected by fatal violence. The system not only provides details on specific manner of violent death, but also identifies common factors that span multiple types of violence. The page has more details: 35. How does using the National Violent Death Reporting System help to make the statistics more complete? Although limited to the 27 states participating in during the time period of the study, data from provide the only detailed information available on the circumstances surrounding these 14 deaths, therefore taking the findings beyond reporting numbers and rates and providing unique information on the context in which people die from suicide. 36. Is the National Violent Death Reporting System expanding to SD states? We are happy to announce that beginning in FY13, we are able to make funding available to all 50 states for the implementation of the Currently, 4i] states, Washington, DC and Puerto Rico are funded by to 50 states allows us to meet one of the national goals we?set forth for Healthy People East] twp-431] Warning signs of suicide and what to do if you know someone at risk 31A lot of the problems mentioned as contributing to suicide in this study seem very common, how can someone tell who?s at risk? Many people think that suicide is an inexplicable act, when, in reality, many known risk factors exist. These include: - History of previous suicide attempts a Family history of suicide I History of child maltreatment - History of depression or other mental illness I Alcohol or drug abuse - Feelings of hopelessness or isolation I Impulsive or aggressive tendencies - Stressful life event or loss 0 Easy access to lethal methods Exposure to the suicidal behavior of others Isolation, lack of social connectedness Researchers agree that suicidal behavior results from an interaction of factors and is rarely due to a single cause. 38. What are the warning signs for suicide? The warning signs for suicide are: Expressing hopelessness - Increased anger or rage - Extreme mood swings Sleeping too little or too much Making plans for suicide Talking andfor posting about suicide Feeling unbearable pain Increased anxiety Securing lethal means Increased substance use Feeling like a burden 15 {Comment Ithink this is sufficient, {Ful?lment Should we add anything else re: .1 fl i: i" I I?ll I: Comment It might be good to add that you can learn more about these . steps to help by going to - Isolation 39. What should someone do if they believe someone may be suicidal? Ask the question, ?Are you thinking about suicide?" Asking the question won't make someone I suicidal, and instead, may relieve or reduce the feeling. lfthe person says yes, keep them safe. Find out ifthey have a suicide plan. Remove any lethal .- means in the environment, if possible, and do not leave the person alone. Be there and show concern. Don?t act surprised or dismiss their feelings. Take the person I seriously, and do not assume they arejoking. - Help them connect to resources, for example, by calling the National Suicide Prevention Lifeline [3255? or by connecting the person to someone in the community who can help, e.g. emergency department, counselor, pastor. 0 Follow up - After the person is safe, follow up in the days ahead with a phone call, ask them how they are doing. See if there is anything else that you can 40. Where can people go for help? No matter what problems people deal with, we want to help them find a reason to keep living. By calling [3255) people will be connected to a skilled, trained counselor at a crisis center in their area, anytime are many success stories where people in need have reached out to others or family or friends have intervened to get people help. They got the support or treatment they needed and were able to get through a crisis. among Veterans 41. Do you have any information on suicide among Veterans and Military service members? While we did not describe Veteran suicides in this study, here are some key epidemiologic findings from other reports published by the Departments of Veterans Affairs and Defense, as well as the CDC. CDC and its partners are currently doing more research to understand the extent to which the general rise in Suicide rates can be attributed to the rise in suicide rates among Veterans. Veterans: Veterans accounted for 13 percent of adult suicides but constituted only 3.5 percent of the U.5. I adult population [ages An average of 20 Veterans died by suicide each dgy; roughly 14 of these are not using VHA I The overall burden of Veteran suicide is mostly among Veterans of middle to older adult ages. services. An estimated 55% of Veteran suicides occurred among Veterans ages 50 years an older 16 0 Rates dramatically increased from 12f100,000 in 2005 to 110/ 100,000 in 2014 among young Veterans aged 18-24 years who were using VHA services and were in Operations Enduring Freedom, Iraqi Freedom, or New dawn - Suicides among young Veterans aged 1835 years are highly concentrated in a small proportion of counties. I Within 17 states, an estimated 33% of suicides among Veterans aged 18-35 years occurred in just 3% of US. counties and 59% occurred in 13% of U.S. counties. Many of these high burden counties do not have easy access to VHA facilities. Accounting for age and sex, risk for suicide was 21 percent higher among Veterans versus civilians. - Accounting for age, risk for suicide was 2.4 times higher among female Veterans versus female civilians Active duty: - Suicide rates have doubled from 12.5 per 100,000 in 2005 to 30 deaths per 100,000 in 2012. Steady declines in recent years have been observed (although this could be because more service members were recently discharged and therefore their suicides would be reflected in the Veteran population} I Since 2001?2014, 51% of suicide decedents were Army service members; 18% were Air Force service members; 17% were Navy service members; 14% were Marines I Key epidemiological findings include: I 94% were male I 72% were of white race I 87% were of non-Hispanic ethnicity I 83% were under the age of 35 years I 88% were in the enlisted ranks of I 72% only had a high school graduate level of education (or less} I 52% were married I 63% of suicides were the result of firearm injuries I 54% had a history of deployment 42. Do you think the rate increases in suicide across the U.S. is the result of increases in Veteran suicides? For this study, we were unable to explore the reasons why we observed these state increases. Therefore, we are unable to determine the extent to which if the broad increase in suicide rates across the states is the result of increases in the Veteran suicide rate. This question needs further exploration. 43. is CDC engaged in preventing suicides among Military service members and Veterans? CDC has partnered with the Departments of Veterans Affairs and Defense on numerous innovative suicide prevention projects to help address and prevent suicide among active duty service members and Veterans. I The innovations span across public health service. Such efforts are focused to: 17 {Comment Not sure what this i reallymeans. i i' improve surveillance of suicide Increase understanding of the antecedents of suicide and potential factors that might protect against risk ofsuicide 0 Improve early identification of suicide risk and rapid response to those in need of services, and evaluate -key population-level suicide prevention policies and strategies being i i implemented across states and at military installations. The overall portfolio of work embraces the seven key approaches to prevent suicide as outlined in the CDC's technical Fockag? Opioicls and Suicide 44. How are suicide, opioid misuse, and Adverse Childhood Experiences related? We know that adults who experienced Adverse Childhood Experiences, or AEEs, are at risk for both suicide and substance abuse. Additionally. it is important to note that children whose parents are dealing with substance abuse or have overdosed are experiencing ACEs, as are children whose parents attempt or die from eereplete?suicide. So addressing trauma and preventing ACEs can be important to prevention of suicide and opioid misuse as well. 45. Why are opioid overdoses increasing? Drug overdoses killed 53,632 Americans in 2016. Opioids?prescription and illicit?are the main driver of drug overdose deaths. Nearly two-thirds of these deaths involved a prescription or illicit opioid. Overdose deaths increased in all categories of drugs examined for men and women, people ages 15 and older, all races and ethnicities, and across all levels of urbanization. The rise in opioid overdose deaths can be outfitted in three distinct waves: The ?rst wave began with increased prescribing of opioids in the 19905 with overdose deaths I involving prescription opioids {natural and opioids and methadone] increasing since at least 1999. The second wave began in 2010, with rapid increases in overdose deaths involving heroin. The third wave began in 2013, with significant increases in overdose deaths involving opioids particularly those involving illicitly-manufactured fentanyl The IMF market continues to change, and IMF can be found in combination with heroin, counterfeit pills, and cocaine. in Recent CDC data [Seth P, Scholl L, Rudd RA, Bacon 5. Overdose Deaths Involving Dpioids, Cocaine, and United States, 2013.20.15 MMWR Morb Mortal Wkly Rep. ePub: 29 March 2018.] con?rms that increases in drug overdose deaths are being driven by continued sharp increases in deaths involving opioids other than methadone, such as illicitly manufactured fentanyl ilMFi. 46. Does prescribing opioids to patients with chronic health conditions increase suicide risk? Research has shown that chronic health conditions, including painful conditions such as arthritis, migraines, and fibromyalsia, are associated with increased suicide risk. Further, patients receiving opioid therapy for chronic pain are at elevated risk for mental health conditions and suicide attempts. This may reflect an increased likelihood of prescribing opioids by providers to patients with risk factors for 18 suicide, including mental health conditions, chronic pain, and opioid use disorder. Increased opioid availability can also offer greater access to lethal means for suicide. 47.Can the increase in suicides among certain populations be attributed to opioid use, or 48. to chronic pain? A recent study showed that chronic health conditions are associated with increased suicide risk, particularly when multiple chronic conditions are present (Ahmedani et al., 201?}. Opioids can be prescribed for chronic conditions, and patients receiving opioid therapy are at elevated risk of attempting suicide. However, suicide risk might be able to be reduced by improving pain management consistent with prescribing guidelines. For example, in a study of veterans on long?term opioid therapy, approximately 1~2% of patients attempted suicide within 6 months of receiving a prescription. The VA facility engaged in an effort to increase compliance with prescribing guidelines by making more consistent use of drug screening, providing follow?up within 4 weeks for patients initiating new opioid prescriptions, and avoiding co?prescribing of sedatives with opioids. The study found that by providing follow?up as recommended in the guideline, the risk of suicide could be reduced by 5 times {Im et al., 2015). In a second study, researchers found that compliance with the VAlDepartment of Defense guideline improved patient safety for VA opioid~prescribed patients (Bren nan et al 2016). For example, urine drug screening increased significantly, and this was associated with lower risk of suicide among patients. Has the Guideline for Prescribing Opioids caused people suffering in pain to contemplate or die by suicide? Chronic pain can result in considerable suffering. Having a chronic pain condition, compared to no physical pain, is associated with a higher likelihood of suicide, suicidal ideation and suicide attempts, and in many cases this association persists even after controlling for co-morbid mental health andfor substance abuse disorders. This is the finding of a recent meta-analysis of 30 studies that examined the association of physical pain with a range of suicide related outcomes among people with and without pain conditions. {Ref: Calati, FL, Artero, S., Courtet, P., 8t Lopez?Castroman, J. {2016). Framing the impact of physical pain on suicide attempts. A reply to Stubbs. Res, 102-103. - Among patients taking opioids. a recent study suggests that the most important factor that predicts transition from suicidal ideation to suicidal attempt is the belief that pain can't be successfully managed (Le. hopelessness about pain management], rather than factors such as condition or pain severity. - A recent study of US veterans prescribed opioid medications for chronic pain management revealed that a very small percent attempted suicide [less than and that having a mood disorder increased the risk for suicide attempt. lmportantly, use of guideline-recommended practices, including use of urine drug testing, greater-follow?up, and lower co?prescription of sedatives was associated with a lower risk of suicide attempts. Additional research would tell us more about the associations among chronic pain, opioid use, and suicide, and inform prevention efforts. The available evidence highlights the importance of urine drug testing and avoiding co-prescribing of benzodiazepines, whenever possible, and providers remaining alert to signs of anxiety and depression, using validated instruments to assess for mental health 19 conditions, re?evaluating patients with depression or mental health conditions more frequently than every 3 months, considering use of tricyclic or SNRI antidepressants for analgesic as well as antidepressant effects, and considering behavioral health specialist consultation for any patient with a history of suicide attempt or mental health disorder, as recommended in the CDC Guideline. 49.Why doesn?t CDC think chronic pain is important? Why is the prescription drug overdose epidemic the focus? Chronic pain is a public health concern in the United States. Patients with chronic pain deserve safe and effective pain management. it Opioids can help manage some types of pain but also have serious risks ofaddiction and overdose. - While evidence supports short?term effectiveness of opioids, there is insufficient evidence that opioids control chronic pain effectively over the long term, and there is evidence that other treatments can be effective with less harm. I Primary ca re providers are concerned about opioid pain medication misuse, are worried about patient addiction, and want more training in prescribing opioids. role is to tackle the biggest health problems causing death and disability for Americans, putting science and advanced technology into action to prevent disease and promote healthy and safe behaviors, communities and environment. CDC recently played a leading role in getting public health goals pertaining to chronic pain included in Healthy People 2020, and facilitated the inclusion of questions about chronic pain in the 2016?17 National Health Interview Survey. CDC scientific experts also provided review and input regarding the overall National Pain Strategy led by HHS. The NPS outlines a coordinated plan for reducing the burden of chronic pain on the American public. It includes key recommendations in areas including population research, prevention and care, disparities, service delivery and payment, professional education and training, and public education and training. The strategy calls for: - "Developing methods and metrics to monitor and improve the prevention and management of pain. I Supporting the development of a system of patient-centered integrated pain management practices based on a model of care that enables providers and patients to access the full spectrum of pain treatment options. 0 Taking steps to reduce barriers to pain care and improve the quality of pain care for vulnerable, stigmatized and underserved populations. 0 Increasing public awareness of pain, increasing patient knowledge of treatment options and risks, and helping to develop a better informed health care workforce with regard to pain management.? Drug overdose one of the few problems getting worse in US affecting all ages, races, communities. The opioid overdose crisis is being fueled by both prescription opioids and illicit drugs, like heroin and illicitly-manufactured fentanyl. CDC plays an important role in understanding and addressing the causes of the opioid overdose epidemic. Opioids (including prescription opioids, heroin, and fentanyl] killed more than 42,000 people in 2016, more than any year on record. 20 40% of all opioid overdose deaths involve a prescription opioid. The best ways to prevent opioid overdose deaths are to improve opioid prescribing, reduce exposure to opioids, prevent misuse, and treat opioid use disorder. Managing chronic pain is important to the health and well-being of all Americans, and preventing, assessing, and treating chronic pain can be a challenge. Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse, or overdose from these drugs. The CDC guideline provides recommendations to help determine when to initiative and continue opioid prescribing for pain outside of active cancer treatment, palliative care, and end-of-life care to ensure patients have access to safe and effective chronic pain treatment. CDC aims to save lives and prevent prescription opioid overdoses by equipping providers with the knowledge, tools, and guidance they need. Suicide Prevention 50. Did the study provide recommendations for prevention? Comprehensive suicide prevention activities both upstream (before suicide risk begins} and (after people have been identified as at-risk, or have attempted suicide} are needed to address the full range of factors contributing to suicide. II For example, among people with mental health conditions, the study identified a need for additional safety supports, including broader implementation of affordable and effective treatment modalities such as doctor-patient collaborative care models and proven cognitive-behavioral therapies. Additionally, greater access to providers in underserved areas is needed, as is expansion of healthcare systems that integrate physical and behavioral health with a priority on suicide prevention and patient safety, especially through care transitions. I In addition to strategies addressing mental health conditions, the study identified the need for attention to the broader range of circumstances contributing to suicide, including relationship, substance use, physical health, job, financial, and legal problems. Taken, together a comprehensive approach to suicide includes the following strategies: Identifying and supporting people at risk of suicide. Teaching coping and problem-solving skills to help people manage challenges with relationships, jobs, health, or other concerns. 0 Promote safe and supportive environments, including safely storing medications and firearms to reduce access among people at risk. Connecting people to others in their community so they don?t feel alone. Connecting people at risk to effective and coordinated mental and physical healthcare. Expanding options for temporary assistance for those struggling to make ends meet. Preventing future risk of suicide among those who have lost a loved one to suicide 0000 Effective approaches to prevent the many suicide risk factors are available. States and communities can use data from and resources such as 0305 Preventing Suicide: 0 Technicoi Package of Policies, Programs, and Practices, available at: to better understand their suicide problem, prioritize evidence-based comprehensive suicide prevention, and save lives. 51.What can be done to prevent suicide? 21 Comment We need to be sure to Suicide is preventable. use "recom men dations" rather than ?guidelines?. This was a delibErate CDC released a technical package of policies, programs, and practices to prevent suicide to help in how the document was titled. communities focus on a core set of strategies that have the best available evidence and greatest prevention potential. The technical includes examples of programs that local implementers might tailor to fit the needs of their community. The technical package includes 3' strategies designed to work together to achieve the greatest impact possible. I. Strengthen Economic supports Strengthen access and delivery of suicide care Create protective environments Promote connectedness iv. v. Teach coping and problem-solving skills vi. identify and support people at risk vii. Lassen harms and prevent future risk i For example, an evidenced based suicide prevention program called Sources of Strength was developed with rural and tribal communities in North Dakota to promote connectedness between youth and caring ll adults. The program works to understand and respond to underlying causes of suicidal behavior and i promote protective factors against suicidal behavior before the causes result in adverse outcomesDther innovative prevention strategies, such as telebehaviorai health (telephone, video and web?based technologies), are a promising option to increase access to health care and mental health care in rural communities. However, rural communities often have limited access to the internet suggesting a need to increase broadband access and to identify other ways to deliver promising prevention supports, Everyone can playr a role in suicide prevention. Physicians have an important role to play in recognizing and appropriately treating mental 0 health conditions. Other professionals who work with vulnerable populations leg. parole of?cers, teachers, etc.) play an important role in identifying and referring at~risk individuals. I Employers can play a role too. EAP programs can work to reduce stigma about seeking help and improving access to care. There are a'50 News mmendatiu? tests. awareness without increasing the risk of additional suicides among vulnerable populations. We know that risk can increase when the media provides details about the methods used, dramaticl'graphic headlines. or slamorize a death 52. What is a technical package? 0 A technical package is a collection of strategies that represent the best available evidence to prevent or reduce public health problen?rs like violence. They can help improve the health and well? being of communities. CDC's suicide prevention technical package Is intended as a resource to guide decision-making in communities and states. 22 I CDC expert scientists reviewed the literature and summarized the best-available evidence in the technical package. The package has been reviewed by granteeslfunded partners, federal partners, and other audiences. I The technical package highlights seven strategies to prevent suicide. I This technical package ineladesdescribes programs, practices, and policies along with the evidence of their impact on suicide or risk and protective factors for suicide. I The strategies are presented in order from those with the greatest potential to produce broad public health impact on suicide followed by those with potential to impact subsets of the population persons who have already made a suicide attempt). 53. If suicide rates are increasing, does that mean the evidenced-based strategies that have been identified are not working? The evidence tells us that there are strategies that work. I These strategies and approaches do not work if they aren?t properly implemented or expanded to reach larger audiences. I There are many reasons why effective programs are not implemented and expanded, but a lack of funding for suicide prevention has been identified as a contributing factor. The most e?ective strategies are comprehensive and use a public health approach as opposed to focusing exclusively on iast?amental health conditionsappraeeh, to impact a broader audience. There is also the issue of stigma around suicide and mental health care, which discourages people at risk for self-harm from seeking help. Suicide is preventable, but we need sufficient investment and a comprehensive public health approach. 54. Where can people go to get more information about suicide prevention? Visit the CDC Injury Center website at 55. What partnerships or sectors should be involved in suicide prevention? I Public health agencies can play an important role in preventing suicide. They can provide leadership and bring critical resources to address the problem. However, the strategies and approaches outlined in CDC's technical package cannot be accomplished by the public health sector alone and require a collective effort across sectors. I Other sectors vital to prevention efforts include: Education Government (local, state, and federal} Social services Health services Business Labor Justice Housing Media 5- Community organizations le.g., foundations or faith-based and other organizations) I Each sector has an important role: 0 Local and state public health agencies and organizations can work to convene partners, lead efforts, track progress, and help evaluate efforts. 23 Education and the public health sector are vital to supporting the development, evaluation, and adoption of effective programs that promote connectedness or that teach coping and problem-solving skills. Business, workplaces, housing, and local and state government entities are in a position to help implement policies and programs that directly address some of the underlying risks and environments that increase the risk for suicide. The healthcare, public health, justice, and social service sectors can work together to identify and support people at-risk of suicide and their families. Across all strategies - community organizations and other non-governmental organizations are vital to prevention. 56. Is it necessary to monitor and evaluate prevention efforts? It is important to have data to monitor the extent of the problem so you can see if your prevention efforts are producing the desired impact. There are existing data sources for you to consider such as National Vital Statistics System the National Violent Death Reporting System the National Electronic Injury Surveillance System-All injury Program the Youth Risk Behavior Surveillance System and the National Survey on Drug Use and Health (NSDUH). c: If gaps in the data exist, you may want to look for data collected at the local level. provides some local data. You may also want to consider data from state and local Child Death Review teams and Suicide Death Review Teams {where available). The data you collect can be used to identify and address gaps in surveillance systems as well as plan programs and evaluate the impact of your efforts. Talking about suicide 31 suicide contagion 57.Will talking about suicide give peeple the idea to do it? Could we do more harm than good? Talking about suicide does not cause suicide to occur. I In fact, it can be an excellent prevention tool. 0 Talking breaks the secrecy that surrounds suicidal behavior and lets people know that help is available. I By not talking about suicide, we increase the isolation and despair of individuals thinking about it and perpetuate the stigma associated with suicidal ideation and behavior. 58.What is meant by "suicide contagion" or "copy-cat" suicide? 59. These words describe a process by which exposure to suicide or suicidal behavior of one or more persons influences similar behavior by vulnerable individuals. Research has shown that graphic, sensationalized or romanticized descriptions of suicide deaths in the news media can contribute to suicide contagion. Do media reports regarding suicide increase the number of copy-cat suicides? What suggestions does CDC have for news media covering suicide issues in their community? CDC research suggests that stories about suicide can help inform readers and viewers about the likely causes of suicide, its warning signs, trends in suicide rates, and recent treatment advances. They can 24 also highlight opportunities to prevent suicide. Media stories about individual deaths by suicide may be newsworthy, but they also have the potential to do harm. implementation of recommendations for media coverage of suicide has been shown to decrease suicide rates. For more information about these recommendations and tips for covering suicide visit Reporting on Suicide: Recommendations for the Media: 60. What suicide story angles should reporters consider? 0 Trends in suicide rates accompanied by prevention strategies 0 Recent advances in prevention strategies individual stories of how prevention was life-saving Stories of people who overcame desperate circumstances without attempting suicide about suicide Warning signs of suicide Actions that individuals or families can take to prevent suicide by others Actions that communities can take to support connections among people that help to reduce risk What role do the economy and social media play in increasing suicide rates? 61. What role does the economy play in increasing suicide rates? The role of the great recession in the late 2000?s and subsequent financial challenges and concerns about economic instability could have contributed to increases in suicide risk. Past research on the association between business cycles and U.S. suicide indicate that the overall suicide rate rises and falls in connection with the economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by pa rents may trickle down resulting in vulnerable youth. 62. Is social media use to blame for increasing suicide rates? More research is needed on the impact of social media use on suicide rates. However, changes in social media content or use patterns could potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. New opportunities for tracking suicide and understanding comprehensive suicide prevention efforts a Linking with Departments of Defense and Veterans Affairs data on suicide 0 Partners who are working on this project include Department of Veterans Affairs, Department of Defense Suicide Prevention Office, and the Health Center of ExcellencelDefense Health Agency. This project will link pertinent data on active duty Military and Veteran suicide decedents across National Violent Death Reporting System the Department of Defense Suicide Event Reports, and the Veteran Health Administrative databases. 25 0 Provide more information on suicides among active duty Military personnel and Veterans as well as partition study populations in the civilians, active duty, VHA Veterans, non?VHA Veterans}. Help agencies monitor common and unique precipitating factors of suicide captured in by groupipopulation and inform comprehensive community-based efforts to help address specific population needs. All linkages will use a tie-identified matching technique. No personal identifying information will be used. 0 Social media intervention C) The purpose of this project is to implement, test, and refine a web?based peer?to?peer therapeutic support platform for 0.5. Military Veterans aimed at preventing suicide and related problems. This system called TalkVet, has the potential to bridge the gap between the many social media sites that are widely used by Veterans le.g., Facebook, Snapchat, etc.) and the growing number of clinical interventions that are available to Veterans, but currently underrutilized. With the explicit consent of users, we will test the novel features of the TaIkVet platform in three ways: 1. Use an artificial intelligence [All guided system to help identify participating Veterans most in need of help based on their posts and other user activity; 2. Connect Veterans in need of help with other Veterans in TaIkVet who can support them; and 3. Conduct outreach with experimentaily refined methods for Veterans in need of a higher levei of care to encourage them to obtain such care in the form of links and hand-offs provided by the TalkVet system [this phase of the work will include the use of Veteran moderators with training in crisis counseling who will work with our team}. This project includes partners from Harvard University, West Virginia University ICRC, TalkLifeiTalkaet and has been approved by - Colorado Collaborative for a Comprehensive Approach to Suicide Prevention 0 The CDC is collaborating with the Colorado Department of Public Health and Environment, the CDC- funded Injury Control Research Center the Colorado National Collaborative (CNC), and the Colorado Suicide Prevention Commission on the first state?wide, largeascale, population~based initiative to reduce suicide rates 20% by 2024 in CO and to serve as a model for other states to help reduce suicide by 20% by 2025 in the nation. Partners on the CNC also include the Action Alliance, SAMHSA, and AFSP, among others. Through this project we propose to pilot test the impiementation and evaluation of a comprehensive, integrated approach to suicide prevention?guided, in part, by the technical package and the National Action Alliance for Suicide Prevention?s Transforming Communities: Key Elements for the implementation of Comprehensive Community~Bosed Suicide Prevention. Working with to seek external funding Why Colorado? I Colorado consistently ranks among the states with the highest suicide rates in the nation (rate: 19.5 per 100,000 in rate 13.3 per 100,000}. Colorado has sizable populations at increased risk of suicide, including veterans, American IndianlAlaska Natives and people living in rural communities. I Colorado demonstrates readiness as evidenced by a strong state suicide prevention infrastructure, a history of political will, and a proven track record of valuing and implementing public health approaches to prevention. Specifically, the State has: 0 A funded Office of Suicide Prevention legislated in 2000} I Suicide Prevention Commission [legislated in 2014} 0 Colorado National Collaborative (est. 2015} A strong platform of existing suicide prevention activity 0 A commitment to ?connecting the dots?fshared risk and protective factors 26 Select Recent CDC Research In CDC has released several publications recently. Late last year, we released a JAMA article analyzing the number of youth visiting emergency rooms with nonfatal, self-inflicted injuries. I We found that self-inflicted injuries are one of the strongest risk factors for suicide. Our research found that emergency room visits for self?inflicted injuries among young females increased significantly in recent years (ZOUl-ZUISl?particularly among girls 10-14. I And since the risk leads to a potentially fatai outcome, monitoring trends in Self-inflicted injuries is critical to preventing suicide in young people. 0 K, Leemis RVV, Stone Dl?vi, Wang J. Trends in Emergency Department Visits for Nonfatal Self?inflicted Injuries Among Youth Aged 10 to 24 Years in the United States, In February of this year, CDC reieased a Morbidity and Mortality Weekly Report summarizing 2014 data from the 18 states participating in the National Violent Death Reporting System at that time. I Violent deaths due to self-inflicted injury or interpersonal violence disproportionately affected people aged men, and American Indiaanlaska Nativesrand I There were several primary precipitating factors for both homicides and suicides that stood out including: intimate partner problems, interpersonal conflicts, mentai health and substance abuse and recent crises I is currently in 40 states, the District of Columbia, and Puerto Rico, with goals to expand nationally. I Developing and expanding is crucial to public health efforts at the federal, state, and local levels, in order to identify information like precipitating factors and also to target prevention efforts. I Fowler KA, Jack SP, Lyons BH, Bet: Ci, Petrosky E. Surveillance for Violent Deaths National Violent Death Reporting System, 18 States, 2014. MMWR Surveill Summ 2018:67lNo. 0 As part of our commitment to suicide prevention in vulnerable populations, in March of this year, CDC released another MMWR, specifically on suicides among American indian/Alaska Natives. I It showed that the rates of suicide among American IndianiAlaska Natives have been increasing since 2003. I Analysis of the data from 18 states, shoWed that AIXAN people who died by suicide were younger and were more likely to live in a non?metropolitan area than non-Hispanic whites who died by suicide. I The data show a clear need for culturally relevant intervention strategies for this population. Leavitt RA, Ertl A, Sheats K, Petrosky E, lvey?Stephenson A, Fowler KA. Suicides Among American IndianJAlaska Natives National Violent Death Reporting System, 13 States, 2003?2014. MMWR Morb Mortal Wkly Rep Partner Activrties I. What is the Notionai Action Alliance for Suicide Prevention? The National Action Alliance, also referred to as the "Action Alliance" is a public-private partnership that works to advance the National Strategy for Suicide Prevention and make suicide prevention a national priority- 2? 2. What is the Notionoi Strategy for Suicide Prevention? This is a report created by the US. Surgeon General and the Action Alliance. It emphasizes the role everyone can play in protecting their friends, family, and colleagues from suicide. It has been revised to include a decade of research and other advancements in order to provide guidance for several sectors like schools, businesses, and health systems. 3. What is Project 2025 Project 2025 is a collaborative initiative developed by American Foundation of Suicide Prevention (AFSPII. The goal of Project 2025 is to reduce the annual suicide rate 20 percent by year 2025. AFSP has determined a series of actions and critical areas to help reach the goal, which includes approaches that reach across all demographic and sociological groups. 4. What is the Action Zero Suicide Modei? This a key concept of the National Strategy for Suicide Prevention. It requires that health and behavioral health care systems commit to making suicide prevention a core priority and implement processes and strategies that prevent suicide and improve the care oi patients at risk for suicide. Additional Resources Recommendations for Media about Safe Reporting on Suicide, reportingonsuicde.org If you or someone you know is thinking about suicide or needs support, help is always available. Call the National Suicide Prevention Lifeline at 1-800-273-TALK [8255} or visit Preventing Suicide: A Technical Package of Policy, Programs, and Practices: National Strategy for Suicide Prevention, suicide-prevention-D Suicide Prevention Resource Center, 28 From: Black, Erin Sent: 22 Jun 2013 09:10:33 -0400 To: Wilkniss, Sandra Cc: Coleman, Akeiisa;Dennehy, Heather Alexander Deborah Subject: RE: June 22 webinar - CDC introduction slides Thanks for the feedback, will do. From: Wilkniss, Sandra Sent: Friday, June 22, 2018 7:00 AM To: Black, Erin Cc: Coleman, Akeiisa,? Dennehy, Heather Crosby, Alexander Stone, Deborah Subject: Re: June 22 webinar - CDC introduction slides Great. thanks, Erin. Just one note to consider - most on the call likely won?t be familiar with some of' the policy options language (eg alcohol outlet density, greening), but will be very interested in any recommended policy options. So, can you take a minute to explain each in lay terms? thanks! On Jun 21, 2018, at 11:03 AM, Black, Erin (CDCIONDIEHINCIPC) wrote: Attached are the talking points I was thinking of sharing: eln March, in Denver, Colorado, DVP collaborated with the National Governor?s Association and SAM HSA to convene state leaders from 13 states with a high burden of suicide to hear suicide prevention best practices from the Indian Health Service, the VA, SAMHSA, and CO state who is implementing a comprehensive suicide prevention pilot. - CDC specifically sought out this partnership with NGA as a way to leverage their relationship with you, the state health policy advisors and the importance of your role in informing state policy. We want to be a resource for you as you work to reduce the rising suicide rates across the nation. These rising rates are outlined in our recent CDC Vital Signs on state suicide trends. I We want you to know that comprehensive suicide prevention includes policy options, such as unemployment benefits, neighborhood stabilization, mental health parity, alcohol outlet density, and greening polices that can help prevent suicide. These and other best available evidence are outlined in our CDC Suicide Prevention Technical Package for Preventing suicide. - We want to be a resource for you in gathering the suicide prevention data necessary to inform policy decisions. 0 Sandra Wilkniss will be sharing a little bit more about the convening we had in March, and my colleagues from CDC, Deb Stone and Alex Crosby will be talking more about work in suicide prevention, the data from our Vital Signs on suicide prevention, and the strategies and approaches from our suicide prevention technical package that we know work to prevent suicide. From: Stone, Deborah Sent: Wednesday, June 20, 2018 4:58 PM To: Coleman, Akeiisa Crosby, Alexander Cc: Black, Erin Dennehy, Heather Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Here are my slides as well! Thanks! Deb From: Coleman, Akeiisa Sent: IWednesday, June 20, 2018 4:42 PM To: Crosby, Alexander Cc: Black, Erin Dennehy, Heather Stone, Deborah Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Thanks Alex! Akeiisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 I From: Crosby, Alexander (aecl cdc. 0y:- Sent: Wednesday, June 20, 2018 4:39 PM To: Coleman, Akeiisa Cc: Black, Erin Dennehy, Heather Stone, Deborah (CDCKONDIEHKNCIPC) Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Greetings: I have attached the slides. Alex From: Wilkniss, Sandra Sent: Friday, June 15, 2018 11:25 AM To: Crosby, Alexander Cc: Black, Erin Coleman, Akeiisa Richmond-Crum, Malia cdc. ow; Dennehy, Heather Stone, Deborah cdc. oy> Subject: Re: June 22 webinar Wonderful! On Jun 15, 2018, at 9:27 AM, Crosby, Alexander (CDCIONDIEHINCIPC) {aee gt?cdcgoy?e wrote: Greetings: It looks like I am available on the 22nd for the webinar 8: on Weds, 20th for the ore-brief. Alex From: Wilkniss, Sandra <5Wilkniss@NGA.ORG> Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah cdc. ov> Subject: Re: June 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. I could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin Sent: Thursday, June 14, 2018 11:25 PM To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond?Crum, Malia Dennehy, Heather Stone, Deborah Subject: Re: June 22 webinar Hello Erin and Dr Stone. We can be flexible in the federal overview and take your lead on the data to highlight as well as any priority strategies, federal-state partnership aimed at preventing suicide you would like to share. May we schedule a call with the three of you for when Alex returns early next week to plan? Thank you! Sandra On Jun 14, 2018, at 11:19 PM, Black, Erin wrote: Ladies what does the federal overview in the agenda below consist of? As mentioned I plan to be on the call, also the Vital Signs lead author, Deb Stone (copied), will be on the call to present on the Vital Signs. Alex is currently on leave but back next week to discuss his availability. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 1:25 PM To: Black, Erin Cc: Coleman, Akeiisa Subject: June 22 webinar Hi again, Erin. We just discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors (all states and territories invited] 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect - NGA 5-7 min CDC talking about recent data 5-7 min NGA to summarize meeting highlights min state rep from CD to talk about their comprehensive approach 5?7 min rep to talk about prevention or partnership {this is being nailed down in the next couple dayswill be able to show slides. I hope this helps! From: Wilkniss, Sandra Sent: Thursday, June 14, 2013 10:50 AM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HI Erin, it is still being reviewed internally. So, we had hoped to do the webinar after the paper was done. However, the opportunity on the 22""d came up and we thought it more important to capitalize on the momentum of your recent report rather than wait for our paper to be final. We think it critical to get attention to the issue while its top of mind. Sound ok? From: Black, Erin (CDCIONDIEHINCIPC) Sent: Thursday, June 14, 2018 10:25 AM To: Wilkniss, Sandra <5Wilkniss@NGA.ORG> Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Have you sent us a copy of the report yet from the convening that you will be discussing on the call? I will be on the call but also still confirming if others will attend. Alex is out until Monday. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 9:49 AM To: Black, Erin Subject: Re: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data and/or can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin wrote: Sandra I am available that day/time but let me check internally and see who would be best to present on the VS and get back to you. From: Wilkniss, Sandra <5Wilkniss@NGA.DRG> Sent: Tuesday, June 12, 2018 9:00 AM To: Black, Erin (Wis Cc: Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather ckvz? cdc. ov} Subject: RE: EMBARGOED Until 1pm June 2: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Good morning Erin, Alex, Malia and Heather, Thanks again for this terrific report! We are updating the paper now with new stats. in the meantime, we have had an opening for our state leadership calls for June 22 2-3pm eastern which we could use to highlight the findings ofthe Vital Signs report and lessons learned from our meeting and we have a couple of states available to give brief comments about their strategies. I am hoping that it is possible for you all to be available that dayftime for the webinar with governors health policy adyisors? It is usually very well attended and may help perpetuate the momentum around your report. Please let me know if it?s possible and we can jump on a call and sort out details. Thanks! Sandra From: Black, Erin Sent: Thursday, June 7, 2018 1:34 PM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander (CDCIONDIEHINCIPC) Richmond-Crum, Malia Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates I will be on leave July 16-20 and in an all-day meeting July 31. From: Wilkniss, Sandra <5Wilkniss@NGA.ORG> Sent: Thursday, June 7, 2018 1:27 PM To: Black, Erin Coleman, Akeiisa Cc: Crosby, Alexander Richmond?Crum, Malia Dennehy, Heather Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We can?t wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin [mailtozepm7@cdc.goy] Sent: Thursday, June 7, 2013 9:56 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander Richmond-Crum, Malia Dennehv, Heather (CDCIONDIEHINCIPC) Subject: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Sandra and Akeiisa, As we mentioned, our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, will be released later today. The report includes state- Ievel trends in suicide rates from 1999-2015, and, with data from National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. The CDC celebrates the National Governors Association?s commitment to creating safe communities. We hope that this resource can provide state leaders with an increased understanding of the impact of suicide in their states, as well as potential solutions for prevention. I would appreciate it if vou could help disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Also, as discussed we will plan to highlight the Vital Signs on the planned Webinar with State health policy advisers [has a dare been set vet?). Erin The CDC Vitoi Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and DC, examines contributing factors to Suicide in states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vital! Signs materials, including the Morbidity and Mortaiirv Weekly Report (MMWR) article. ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: a In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 1- From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition I A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use. physical health, job, financial, and legal problems. After the embargo is lifted today at 1. pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Sions Webpage to ?nd the MMWR article, fact sheet, and other materials. Take advantage of media tools, such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Hall Teleconference on .lunc 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. 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From: Dennehy, Heather Sent: 21 Jun 2013 14:04:29 0400 To: Coleman, Akeiisa,?Wilkniss, Sandra Cc: Crosby, Alexander Deborah Erin Subject: RE: June 22 webinar - CDC introduction slides Attachments: vs-0618-suicide-H.pdf, Success Stories Examples of Suicide Data From CDC.PDF Hi Akeiisa, We also put together a couple of ?handouts" we thought might be helpful to share with webinar attendees. -The Vital Signs Fact Sheet I Fact Sheet In Stories from the Field (how states are currently using the system) 0 Examples I just pulled to give an idea of the kind of information (maps, cost data, burden data, etc.) that you can access from our CDC web page. Let me know if you have questions on anything. Thanks again for all your help making this happen! Heather From: Coleman, Akeiisa Sent: Thursday, June 21, 2018 1:45 PM To: Black, Erin Wilkniss, Sandra Cc: Dennehy, Heather Crosby, Alexander Stone, Deborah Subject: RE: June 22 webinar CDC introduction slides Thanks Erin! These look great. Akeiisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 acolemanQngaorg From: Black, Erin m? cdc. 0v:- Sent: Thursday, June 21, 2018 11:03 AM To: Coleman, Akeiisa Wilkniss, Sandra Cc: Dennehy, Heather Crosby, Alexander Stone, Deborah <2af9@cdc.gov> Subject: RE: June 22 webinar - CDC introduction slides Attached are the talking points I was thinking of sharing: I In March, in Denver, Colorado, DVP collaborated with the National Governor?s Association and SAMHSA to convene state leaders from 13 states with a high burden of suicide to hear suicide prevention best praCthES from the Indian Health Service, the VA, SAMHSA, and C0 state who is implementing a comprehensive suicide prevention pilot. I CDC speci?cally sought out this partnership with NGA as a way to leverage their relationship with you, the state health policy advisors and the importance of your role in informing state policy. We want to be a resource for you as you work to reduce the rising suicide rates across the nation. These rising rates are outlined in our recent CDC Vital Signs on state suicide trends. We want you to know that comprehensive suicide prevention includes policy options, such as unemployment benefits, neighborhood stabilization, mental health parity, alcohol outlet density, and greening polices that can help prevent suicide. These and other best available evidence are outlined in our CDC Suicide Prevention Technical Package for Preventing suicide. We want to be a resource for you in gathering the suicide prevention data necessary to inform policy decisions. I Sandra Wilkniss will be sharing a little bit more about the convening we had in March, and my colleagues from CDC, Deb Stone and Alex Crosby will be talking more about work in suicide prevention, the data from our Vital Signs on suicide prevention, and the strategies and approaches from our suicide prevention technical package that we know work to prevent suicide. From: Stone, Deborah Sent: Wednesday, June 20, 2018 4:58 PM To: Coleman, Akeiisa Crosby, Alexander Cc: Black, Erin Dennehy, Heather Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Here are my slides as well! Thanks! Deb From: Coleman, Akeiisa Sent: Wednesday, June 20, 2018 4:42 PM To: Crosby, Alexander Cc: Black, Erin Dennehy, Heather Stone, Deborah Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Thanks Alex! Akeiisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 acoleman@nga.org From: Crosby, Alexander Sent: Wednesday, June 20, 2018 4:39 PM To: Coleman, Akeiisa Cc: Black, Erin Dennehy, Heather Stone, Deborah Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Greetings: I have attached the slides. Alex From: Wilkniss, Sandra <5Wilkniss@NGA.ORG> Sent: Friday, June 15, 2018 11:25 AM To: Crosby, Alexander Cc: Black, Erin Coleman, Akeiisa Richmond-Crum, Malia Dennehy, Heather Stone, Deborah (CDCIONDIEHKNCIPCJ <2af9@cdc.gov> Subject: Re: June 22 webinar Wonderful 011 Jun 15., 2018, at 9:27 AM, Crosby, Alexander c?cdc. Iova- wrote: Greetings: It looks like I am available on the 22nd for the webinar on Weds, 20th for the pre-brief. Alex From: Wilkniss, Sandra <5Wilkniss@NGA.ORG> Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin (e m? cdc. ov> Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah <2an cdc. ov> Subject: Re: June 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. I could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin Sent: Thursday, June 14, 2018 11:34:07 PM To: Wilkniss, Sandra Cc: Coleman, Akeiisa; Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Subject: RE: June 22 webinar Yes, it would be helpful if you could schedule a ore-brief next week. From a quick peek at calendars it looks like Alex, Deb and myself might be available Monday 10:30-11 or Wed 3:304. From: Wilkniss, Sandra Sent: Thursday, June 14, 2013 11:25 PM To: Black, Erin Subject: Re: June 22 webinar Hello Erin and Dr Stone. We can be flexible in the federal overview and take your lead on the data to highlight as well as any priority strategies, federal-state partnership aimed at preventing suicide you would like to share. May we schedule a call with the three of you for when Alex returns early next week to plan? Thank you! Sandra On Jun 14, 2018, at 11:19 PM, Black, Erin wrote: Ladies what does the federal overview in the agenda below consist of? As mentioned I plan to be on the call, also the Vital Signs lead author, Deb Stone {copied), will be on the call to present on the Vital Signs. Alex is currently on leave but back next week to discuss his availability. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 1:25 PM To: Black, Erin Cc: Coleman, Akeiisa Subject: June 22 webinar Hi again, Erin. Wejust discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors {all states and territories invited) 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect NGA min CDC talking about recent data min NGA to summarize meeting highlights min state rep from C0 to talk about their comprehensive approach 5?7 min rep to talk about prevention or partnership (this is being nailed down in the next couple dayswill be able to show slides. I hope this helps! From: Wilkniss, Sandra <5Wilkniss?NGADRG> Sent: Thursday, June 14, 2018 10:50 AM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HI Erin, It is still being reviewed internally. So, we had hoped to do the webinar after the paper was done. However, the opportunity on the 22nd came up and we thought it more important to capitalize on the momentum of your recent report rather than wait for our paper to be final. We think it critical to get attention to the issue while its top of mind. Sound ok? From: Black, Erin Sent: Thursday, June 14, 2018 10:25 AM To: Wilkniss, Sandra <5Wi kniss?NGA?RG> Subject: RE: EMBARGUED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Have you sent us a copy of the report yet from the convening that you will be discussing on the call? I will be on the call but also still confirming if others will attend. Alex is out until Monday. From: Wilkniss, Sandra <5Wilkniss@NGA.ORG> Sent: Thursday, June 14, 2018 9:49 AM To: Black, Erin Subject: Re: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data and/or can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin sepm7@cdc.gov> wrote: Sandra ?1 am available that day/time but let me check internally and see who would be best to present on the VS and get back to you. From: Wilkniss, Sandra <5Wilkniss@NGA.0RG> Sent: Tuesday, June 12, 2018 9:00 AM To: Black, Erin Subject: RE: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Good morning Erin, Alex, Malia and Heather, Thanks again for this terrific report! We are updating the paper now with new stats. In the meantime, we have had an opening for our state leadership calls for June 22 2?3pm eastern which we could use to highlight the findings of the Vital Signs report and lessons learned from our meeting and we have a couple of states available to give brief comments about their strategies. I am hoping that it is possible for you all to be available that dayftime for the webinar with governors health policy advisors? It is usually very well attended and may help perpetuate the momentum around your report. Please let me know if it?s possible and we can jump on a call and sort out details. Thanks! Sandra From: Black, Erin [mailtozegmir?t?chcgov] Sent: Thursday, June 17, 2018 1:34 PM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander Sent: Thursday, June 2018 1:27 PM To: Black, Erin ce m7 cdc. our?; Coleman, Akeiisa Cc: Crosby, Alexander ; Richmond-Crum, Malia (CDCIONDIEHINCIPC) <'ry8 cdc. Dennehy, Heather (kyz? cdc. oy> Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We can?t wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin [mailtozeom7@cdc.gov] Sent: Thursday, June 2018 9:56 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander Subject: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Sandra and Akeiisa, As we mentioned, our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, will be released later today. The report includes state? leyel trends in suicide rates from 19992016, and, with data from National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. The CDC celebrates the National Governors Association?s commitment to creating safe communities. We hope that this resource can provide state leaders with an increased understanding of the impact of suicide in their states, as well as potential solutions for prevention. I would appreciate it if you could help disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Also, as discussed we will plan to highlight the Vital Signs on the planned Webinar with State health policy advisors [has a date been set yet?). Erin The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and DC, examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vito! Signs materials, including the Morbidity and Weekiy Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four?page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vita! Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each 0 Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of peeple who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at I pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Sions Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vita! Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vim! Signs is about more than data, it is about action. We look ?n'ward to continuing our work together to prevent suicides and promoting healthier communities. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientts) and may contain information that is privileged, proprietary, and/or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. 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If you have received this communication in error, please immediately notify the sender and delete this message. #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 CDC's National Violent Death Reporting System Violence is a Major Public Health Problem in the United States, seven people per hour die a violent death. lviore than 19,000 people were victims of homicide and almost 45,000 people died by suicide in 2016 aloneThe econon'iic costs are staggering?with suicide costing the US. economy 55? billion and homicide $30 billion and this is just the costs for medical care and lost work. Other costs. including the emotional toll on victims? Families and the costs to the criminal justice system for arrest and incarceration of offenders are substantial and not included in this estimate. .?ilsor many Americans survive violent experiences and are left struggling with long-term physical, and emotional erodes entire communities reducing productivity, decreasing property values. disrupting social services and making people feel unsafe in the places where they live, work, and learn. A Comprehensive Look at Violent Deaths covers all types of violent deaths?including homicides and suicides?in all settings and for all age groups. includes over 600 unique data elements that provide valuable context about violent deaths such as relationship problems; mental health problems and treatment; toxicology results; and life stressors, including recent problems with a job, finances, or physical health problems. Extensive information about the incidents, such as weapons used, characteristics of suspects, and locations where they occurred are included. Such data are far more comprehensive than what is available elsewhere. National Center for Injury Prevention and Control Division of Violence Prevention .. Linking Data to Get the Whole Story To help ?nd answers to prevent violent deaths, we need to know the facts. links information about the "who, when, where, and how" from data on violent deaths and provides insights about "why" they occurred. Frontline investigators including law enforcement. coroner's, and medical examiners collect. valuable information about violent deaths. However, these data are seldom combined in a systematic manner to provide a complete picture. provides a clearer understanding of violent deaths. is the only state?based surveillance {reporting} system that pools data on violent deaths and their circumstances from multiple sources into one anonymous database. No personally identifiable information is collected. The Reach of pulls together data on violent deaths in 40 states, the District of Columbia, and Puerto Rico. if data are not available for your state, you can still use data to better understand general patterns of violent deaths in participating states. l-lovvever, keep in mind that data are not nationallv I rivoas available data representativewie still do not a have a complete picture of violent -6: deaths across the nation. What Can Do i i .. What Makes Unique . Inform decision makers and program planners Other data systems mainly count deaths and provide basic about the magnitude, trends, and characteristics demographic information. In contrast, ofviolent deaths. - - Gathers and Ilnks detailed investigative information - Educate your community about circumstances from several sources, including lavv enforcement, that contribute to violence in your county, state, medical examiners and coroners, toxicology, and or territory. death certi?cates. With this linked information, is able to provide a more complete picture of the DEVEIOP and tailor violence prevention efrorts circumstances that contribute to violent deaths. to maximize benefits. - Helps identify emerging issues, such as - Evaluate the Impact of prevention programs veteran suicide. and strategies. - Combines data about deaths that occurred during the same violent event to help identify circumstances of multiple homicides or homicides followed by the Accessing suicide of the homicide suspect. - Collects information on the suspect and the lnjury Center distributes information from relationship of the victim to the suspect to better at the state and national tevel in both characterire hgrnirjdeg_ summary and reports. data are stored in an incident-based database. Descriptive data can be accessed free of charge from Web-Based Injury Statistics Query And Reporting System For further information on visit CDC provides technical assistance for in the form of manuals and complementary resources. NATIONAL VIOLENT DEATH REPORTING SYSTEM Stories from the Frontlines of Violent Death Surveillance STORIES FROM THE FRONTLINES OF VIOLENT DEATH SURVEILLANCE About the Safe States Alliance Established in 1993, the Safe States Alliance is a national non?profit organization and professional association whose mission is to strengthen the practice of injury and violence prevention. Safe States is the only national non-profit organization and professional association that represents the diverse and ever?expanding group of professionals who comprise the field of injury and violence prevention. Safe States Alliance engages in a variety of activities to advance the organization?s mission, including: 0 Increasing awareness of injury and violence throughout the lifespan as a public health problem; Enhancing the capacity of public health agencies and their partners to ensure effective injury and violence prevention programs by disseminating best practices, setting standards for surveillance, conducting program assessments, and facilitating 'peer-to-peer technical assistance; I Providing educational opportunities, training, and professional development for those within the injury and violence prevention field; 0 Collaborating with other national organizations and federal agencies to achleVe shared goals; - Advocating for public health policies designed to advance injury and violence prevention; 0 Convenlng leaders and serving as the voice of injury'and'violence-prevention programs within state health departments; and 0 Representing the diverse professionals making up the injury and violence prevention field. For more information about the Safe States Alliance, contact the national office: Safe States Alliance 2200 Century Parkway, Suite 700 Atlanta, Georgia 30345 (7 70) 690?9000 (Phone) (Email) VDRS: Stories from the Frontlines of Violent Death Surveillance. (201 Atlanta (GA): Safe States Alliance. The development and publication ofthis document was made possible through funding from the Centers for Disease Control and Prevention (CDC) under the Cooperative Agreement ?Strengthening State and Territorial Public Health lnjury and Violence Prevention Programs." CDC and the U.S. Department of Health and Human Services (DHHS) assume no responsibility for the factual accuracy of the items presented. The selection, omission, or content of items does not imply any endorsement or other position taken by CDC or DHHS. Opinions expressed by and findings and conclusions in this report by the Safe States Alliance are strictly their own and are in no way meant to represent the opinion, views, or policies of CDC or DHHS. References to products, trade names, publications, news sources, and non?CDC websites are provided solely for informational purposes and do not imply endorsement by CDC or DHHS. A 2015 update to this document was made possible through funding from The Joyce Foundation. The Joyce Foundation supports the development ofpolicies that both improve the quality of life for people in the Great Lakes region and serve as models for the rest of the country. The Joyce Foundation?s grant making supports research into Great Lakes protection and restoration, energy efficiency, teacher quality and early reading, workforce development, gun violence prevention, diverse art for diverse audiences, and a strong, thriving democracy. The Foundation encourages innovative and collaborative approaches with a regional focus and the potential fer a national reach. STORIES FROM THE FRONTLINES OF VIOLENT DEATH SURVEILLANCE FOREWORD We are pleased to present, Stories from the Front?nes of Violent Death Survei?ance, a document designed to communicate the unique capacity of the National Violence Death Reporting System and the benefits states gain from participating in this nationwide, state-based surveillance system. The links data from vital statistics, medical examiners and coroners, law enforcement, crime laboratories, and other sources to provide for the first time a more complete understanding of violent deaths in the U.S., states and local communities. It was established in 2002, is funded by CDC and currently operates in 32 states. The goal is to expand participation to all U.S. states and territories. The stories in this document highlight the experience of several states by first telling the story of a typical violent death in the state. Each story is told using the kind of data typically gleaned from sources information about victims and suspects, their relationships, important circumstances contributing to the death, and weapons used. To protect confidentiality, the stories reflect typical information, not real deaths. The document also presents recent rates and trends for specific types of violent deaths valuable data generated by state violent death reporting systems not feasibly collected, linked and analyzed prior to the These data expand our understanding of factors contributing to violent deaths, from homicide- suicides to suicides related to domestic violence and elder abuse. Also included are exciting examples of how states have translated data into actions targeting and informing violence prevention efforts at state and local levels. We hope you find this an engaging, useful tool for demonstrating the unique capacity of the building support for this surveillance-system and helping expand state participation. As this document illustrates, linking data about violence can save lives. Amber Williams Executive Director Safe States Alliance STORIES FROM THE FRONTLINES OF VIOLENT DEATH SURVEILLANCE THE NATIONAL VIOLENT DEATH REPORTING SYSTEM Creating a more complete picture of violent deaths In 2013, a total of 16,121 people were victims of homicide and 41,149 people took their own life, according to the CDC. Valuable information about these and other violent deaths is collected by many sources - law enforcement agents, coroners, medical examiners, crime lab investigators, and state vital records offices. But these data are rarely combined in a systematic way to provide a complete picture of violent incidents - a picture with details about victims and suspects, their relationships, important circumstances contributing to a death, and weapons used. The National Violent Death Reporting System is a nationwide, state-based surveillance system established in 2002 and funded by CDC to collect data on violent deaths from participating states. The CDC currently funds 32 states, who have each established a state vioient death reporting system and voluntarily report state data to CDC. WHAT IS A VIOLENT Linking data from multiple sources According to the coo Aviolent The collects and links data from four major sources about the same violent death death is a death that results from the incident: intentional use of physical force or a Death certificates power, threatened or actual, against oneself, another person, or a group Coroner/medical examiner reports or community. - Law enforcement reports 0 Crime laboratories Some states may incorporate additional data sources, including Child Fatality Reviews or Domestic Violence Fatality Reviews. After all identifying information is removed, these data are linked in an anonymous state database and submitted to the The names of individual victims and suspects are not released, and laws protecting other types of health department records, such as communicable disease records, also apply to files. The power of an incident-based system While some systems - such as vital statistics - count deaths, the collects data on the entire violent incident. A single incident can have one or more victims and/or suspects. The can identify all victims in a multi-homicide, or link victims and a suspect in a homicide-suicide. Linking data into one database places a death into context and provides information not previously possible, such as: 0 the relationship between the victim and perpetrator, including if they knew each other; - information about the perpetrator, including criminal history; - circumstances such as a history of depression or other mental health problems, chronic illness, alcohol or drug use, recent problems with a job, finances or relationships, gang activity, or the recent death of a family member; and - circumdances unique to intimate partner violence, including prior incidents of abuse. Translating data into action The provides the nation, states and communities with a clearer understanding of violent deaths and their circumstances by: - describing the magnitude of and trends for specific types of violence, 0 identifying risk factors associated with violence at state and local levels, and 0 targeting and guiding state and local violence prevention programs, policies and practices. CURRENT STATES Alaska Arizona 0 Colorado Connecticut 0 Georgia Hawaii Illinois Indiana Iowa Kansas Kentucky 0 Maine Maryland 0 Massachusetts 0 Michigan Minnesota - New Hampshire NewJersey New Mexico - NewYork 0 North Carolina - Ohio - Oklahoma . Oregon - Rhode Island 0 South Carolina Utah Vermont Virginia I Washington Wisconsin STORIES FROM THE FRONTLINES OF VIOLENT DEATH SURVEILLANCE TYPICAL DATA FROM SOURCES DEATH CERTIFICATE Age - Gender Residence - Marital status Profession Employment status 0 Veteran status Cause of death 0 Manner of death 0 Time of death 0 Pregnancy status TOXICOLOGY 0 Presence or absence of alcohol or drugs in victimls) MEDICAL CORONER 0 Brief narrative of incident 0 Demographics - Wound location Weapon information, patterns on victim Cause of death Manner of death 0 Current diseasex? health condition Current/recent medical treatment Current medication 0 Relationships among involved persons (if available) - Circumstances relevant to death LAW ENFORCEMENT 1' Narrative on the circumstances of the death - Wound locations - Weapon information - Relationships among victim, perpetrator, others involved Information on suspectls) 0 Potential evidence to substantiate/support conclusion about violent death type (suicide, homicide) - Presence/absence of suicide note - Interviews with any witnesses, family members, others 0 Critical stressors in victim?s life CRIME LAB Firearms involved I Type, make 8: model 0 Caliber or gauge Serial number 0 Importer's name 8: address CHILD FATALITY REVIEW Information on victim's: - Household II Caregivers 0 Supervision 1' Previous contacts with child protective services II Relationship with perpetrator DOMESTIC VIOLENCE FATALITY REVIEW Information on current! former girlfriend, boyfriend, date, spouse Length of relationship - Breakupr'breakup in progress - Court/prosecutor 8: restraining order records I Domestic-violence related services (safety planning, shelter, lethality assessment} - Perpetrator criminal history, charge/conviction of children exposed to homicide DATA ELEMENTS OVERLAP Same information may come from multiple sources ALASKA Violent Death Reporting System Part of CDC ?5 National Violent Death Reporting System Operated by the Alaska Division of Public Health, Injury Surveillance Unit Collecting data since 2003 MEDICAL EXAMINER Died from gunshot wound to the head 9 Victim was seen at ED DEATH within last year for CERTIFICATE domestic violence 1 related injuries 0 26?year?old female . -, LAW ENFORCEMENT 0 Victim?s body found on hiking trial Suicide Suicide note left by victim alludedto dating violence Past suicidial ideations 8: drug use A SUICIDE IN ALASKA To ensure confidentiality, the example below is not the story of an actual death in Alaska. The example was created to illustrate the violent death data typically collected and linked in the Alaska Violent Death Reporting System DEATH CERTIFICATE A 26-year old female was last seen alive by her sister as she left a family event in a small community. Skeletal remains found several months later near a hiking trail were identified as the victim. Victim died from a self-infiicted gunshot wound to the head. The manner of death was suicide. MEDICAL EXAMINER The victim was a 26-year?old female who died from a single gunshot wound to the head. The victim's remains were found next to a small creek. Aforensic odonatologist and a forensic anthropologist were consulted to provide positive identification and assist in identifying the breakage patterns of the skull to determine a probable cause of death. A review ofthe victim's medical reCOrds indicated she had been seen approximately 1i months prior in a local emergency department for domestic violence?related injuries but otherwise had no significant medical or mental health issues. She had no history of drug or alcohol treatment, but court records indicate a previous arrest for possession of narcotics. LAW ENFORCEMENT After being unsuccessful in locating the victima the family contacted 9?11. Troopers issued a missing persons notice and initiated a search. On the third day of the search, troopers found the victim?s vehicle parked at a popular trail head with the keys in the ignition and the victim?s personal belongings inside and untouched. A notebook on the passenger seat contained a suicide note alluding to feeling threatened by her boyfriend and living in fear of his continual ?on again, off again? physical and sexual assaults, as well as her frustration of not being able to stop using heroin and the resulting financial burdens. Hikers found a backpack in a ravine next to a small creek, and upon closer inspection, a portion of the victim?s remains in a face down position a short distance from the backpack. Interviews with family members and friends revealed the victim had made vague suicide ideations in the past, but the family did not think they were serious and did not act. The victim's employer stated that the victim was working as a check?out clerk at a local store and was recently disciplined for poor performance. TOXICO LOGY Postmortem toxicological studies (tissue only) determined the victim had used heroin priorto her demise. ALASKA Violent Death Reporting System fl- xi Part of CDC's National Violent Death Reporting System Operated by the Alaska Division of Public Health, Injury Surveillance Unit Collecting data since 2003 THE BIG PICTURE Alaska Violent Death Reporting System data show that suicide is a significant public and mental health issue in Alaska. I Alaska had the second highest suicide rate in the nation in 2013. During 2009?201 3 in Alaska, suicide was the leading cause of death among Alaskans ages 15-44,the sixth leading cause of death overall, and the most common type of violent death Among the 798 suicide deaths recorded in Alaska during 2009-201 3: 0 Males, young adults, American Indian/Alaska Native people, and persons living in rural regions of the state had the highest suicide rates 0 The vast majority had at least one of the mental health problems and/or other life stressors highly associated with suicide 0 Alcohol intoxication and current depressed mood were the most common suicide characteristics, and 22% had a known alcohol or substance abuse problem (dependency) TRANSLATING DATA INTO ACTION Improving quality of veteran suicide data Collaboration and data sharing between the and Alaska Suicide Prevention programs (municipal, state, tribal, and veteran) resulted in: lmproved identification of suicide victims particularly those individuals qualifying for veteran services, when ?military experience? is reflected on death certi?cates 1' Expanded data on the circumstances around family! domestic violence and veteran suicides, such as if the victim was engaged with mental health services Improving suicide prevention 8: postvention 0 data have been used to develop prevention strategies such as the Alaska State Suicide Prevention Plan, and inform interventions with those most at risk for suicide. These strategies include the Applied Suicide Intervention Skills Training to help caregivers become more willing, ready and able to help persons at risk, and Gatekeeper Training that teaches anyone - public or private - how to determine if a person is at risk and connect them to help. 4- Local and tribal health care facilities serving veterans have used data on veterans' engagement with mental health services to improve these services and - Intimate partner problem was often identified 59 decedents perpetrated intimate partner violence within the past month 26 decedents killed at least one other person before taking hisrher own life, resulting in 14 homicide deaths intimate partner problem identified in 33% Gunshot in?ur wasthe . . I of most common cause of death (males: 427/631, 68%: females: 79f158, followed by hanging/ strangulation/suffocation and poisoning 169 were current or former U.S. military personnel; with about 15% of the Alaska population composed of current orformer U.S. military personnel, this population may be at increased risk for suicide in Alaska suicide prevention efforts. data on suicide circumstances and local suicide patterns help inform state and local "postvention" efforts after a suicide, especially among small villages where suicide may run in families or groups. Expanded data on familyr' domestic violence and veteran suicides data inform state and local postvention after a suicide Postvention is a best practice to document and understand a suicide death, help answer the question of and improve suicide prevention efforts. Postvention supports family, friends and others affected by the suicide, and aims to reduce suicidal behavior among these surviving individuals and break the chain of events that lead to self-harm. Local and tribal health care facilities improved veteran services using data MASSACHUSETTS Violent Death Reporting System Part of CDC ?5 National Violent Death Reporting System Operated by the Massachusetts Department of Public Health, Injury Surveillance Program Collecting data since 2003 DEATH CERTIFICATE 0 Homicide victim: 43?year?old white female II Suicide victim: 52-year old white male MEDICAL EXAMINER Female died from 4 gunshots to torso - Male died from i gunshot to head LAW ENFORCEMENT - (Io-worker stated victim had broken up with suspect it) days ago I No prior reports of domestic violence A HOMICIDE-SUICIDE IN MASSACHUSETTS The example below tells the story of a suicide in Massachusetts, but'to ensure confidentiality, it is not the story of an actual death. The example was created to illustrate the violent death data typically collected and linked in the Massachusetts Violent Death Reporting System (MAVDRS). DEATH CERTIFICATE The victim was a 43-year?old white female. She was injured and died in her residence from gunshot wounds. The manner of death was homicide. She was an office secretary. Another victim was a 52?year?old white male. He died at the scene from a gunshot wound to the head. The manner of death was suicide. He was a laborer working in construction. MEDICAL EXAMINER Police responded to the victim?s residence. The victim, a 43?year?old white female, died from 4 gunshot wounds to her torso. A second victim, a 52-year-old white maler was also at the scene. He died from a self-inflicted gunshot wound to the head. The male is suspected of killing the female, and then killing himself. The victims were intimate partners. TOXICOLOGY Both the victim and the boyfriend had negative toxicology results. LAW ENFORCEMENT When the victim. a 43- year-old white female, did not show up for work, the victim's co?workers called police to assist in a well?being check. Police responded to the victim?s residence and found her on the floor of the living room with gunshot wounds to her torso. Upon further investigation, police discovered the body of a 52?year?old white male in the rear of the home with a gunshot wound to his head. A co?worker on the scene stated that the deceased male was the victim's estranged boyfriend. The co?worker stated the victim had broken up with the boyfriend 10 days prior after a relationship of many years. The victim and the boyfriend had one minor child, a 4?year?old son, between them. The child was not at home at the time of the incident. The child was with his grandmother, the victim's motherr who lives nearby.The victim's mother told law enforcement that the victim had complained to her thatthe boyfriend would get very angry whenever the victim talked about breaking up. According to police reports, there were no prior incidents of domestic violence reported. Family and neighbors also were unaware of any domestic disturbance between the victim and the boyfriend. MASSACHUSETTS Violent Death Reporting System Part of CDC ?5 National Violent Death Reporting System Operated by the Massachusetts Department of Public Health, Injury Surveillance Program Collecting data since 2003 THE BIG PICTURE Homicide-suicide incidents are rare but violent events with long-lasting effects on families and communities. From 2003-2007 in Massachusetts, there were 4i homi- cide-suicide incidents in the state that resulted in 49 homi? cides and 41 suicides, for a total of 90 deaths, per Massachu? setts Violent Death Reporting System (MAVDRS) data. Among the 4i homicide?suicide incidents (in which the fatal injuries were inflicted less than 24 hours apart} during 2003? 2007, most were: intimate partner violence-related, 0 perpetrated by white males, 0 involved the use of a firearm, 0 did not involve an intoxicated perpetrator. 0 had homicide victims who were female and older than all other homicide victims on average. and 41% homicide-suicide incidents resulted in 49 homicides 41 suicides (90 deaths) 0 had perpetrators who were known to the homicide victim. TRANSLATING DATA INTO ACTION Capturing new information Before the MAVDRS, there was no official way to capture information on homicide-suicide incidents because existing surveillance systems were person?based. - The MAVDRS is incident-based, which enables identification of multiple deaths from the same incident or between victims and suspects, and provides a better understanding of the violent deaths. 0 Without the MAVDRS, important differences between homicide?suicides and separate, unrelated homicides or suicides could be missed. Sharing new information New information about violent deaths is available through the MAVDRS, and the injury Surveillance Program has disseminated these findings through 7 annual data reports, 4 special bulletins and many responses to data requests. For example, the program: I identified and disseminated new findings about an increase in suicides among middle aged white males, identified and disseminated new findings about an increase in multiple-victim incidents in general, and particularly among homicide-suicide incidents, - is tracking the emerging issue of suicide by hydrogen sulfide, which results from mixing household chemicals chemicals that can produce fumes dangerous to first responders and other people living in the building where an incident occurs; - analyzed train-related death data for the state suicide prevention program; 0 analyzed youth-related violent death data for the governor's Safe and Successful Youth Program; and 0 regularly responds to a variety of data requests from counties, cities and towns. Improving data quality Because it double checks data from each source and corrects coding mistakes, the MAVDRS has improved the quality of data from Vital Records, medical examiners and law enforcement. Improved collaboration Other benefits of implementing the MAVDRS are improved relationships and data sharing among public health, medical examiners and law enforcement .. agencies. Improved colLalipratlon MAVDRS improved W't_ Boston data sharing between Department public health at Boston 5 has increased Police Department the amount of information on circumstances and suspects that the agency shares with the Injury Surveillance Program. MAVDRS iden??es multiple deaths from the same incident, connects victims suspects MAVDRS can track emerging issues, e.g. suicide by hydrogen sulfide (household chemicals) NORTH CAROLINA Violent Death Reporting System Part of CDC ?5 National Violent Death Reporting System Operated by the North Carolina Division of Public Health, Injury 8: Violence Prevention Branch Collecting data since 2004 LAW ENFORCEMENT DEATH ?Abused methadone, CERTIFICATE used cocaine 0 62?year?old male (I 0 Depressed, financial I Died from intentional overdose of methadone MEDICAL CORON ER Victim?s pain was worsening Treated for bi? polar disorder problems ADULT PROTECTIVE SERVICES (APS) 0 Prior reports due to self-neglect 0 Previous suicide attempt x? - Extensive history, 2 previous suicide attempts by overdose Last contact witl'i APS was 1 year ago AN ELDER ABUSE SUICIDE IN NORTH CAROLINA The example below tells the story of a suicide in North Carolina. butto ensure confidentiality. it is not the story of an actual death. The example was created to illustrate the violent death data typically collected and linked in the North Carolina Violent Death Reporting System DEATH CERTIFICATE The victim was a 62 year old male who died from an intentional overdose of methadone. MEDICAL CORON ER The victim was a 62 year old male who was found unresponsive in his residence by a family member who checked on him every morning. EMS was called and the victim was pronounced dead on the scene. The victim had many health problems which resulted in significant pain. He was prescribed methadone to control the pain. According to his friends, the victim felt his condition was worsening and didn?t feel that he would get any better. The victim also had been diagnosed with bipolar disorder and was receiving treatment. The victim was described as depressed in the weeks leading up to his death due to his health condition and limited finances. There was no information on whether the victim had ever attempted or threatened suicide in the past and he did not leave a note. It was determined that the victim died from an intentional overdose of methadone. LAW ENFORCEMENT The victim was a 62 year old male who was found unresponsive in his residence after a family member requested authorities do a welfare check on the victim. The victim was found lying unresponsive inside his home with an empty medication bottle lying nearby. According to his family, the victim suffered from chronic pain after being injured in a motor vehicle crash several years earlier. He was prescribed methadone to control the pain and was noted to abuse his medication. This addiction to prescription medication led to the victim using crack cocaine as well. The victim had been diagnosed with bipolar disorder and was receiving treatment. He was described as depressed in the weeks leading up to his death due to his addiction, which had resulted in financial problems.The victim had attempted suicide in the past but the method is not known. The victim did not leave a note. ADULT PROTECTIVE SERVICES Several reports were made due to self-neglect and concern from the victim's family. The victim was known to have a long history and was not compliant with his medication. The victim had been involuntarily committed on several occasiOns and attempted suicide twice by overdose. The reports were substantiated and the victim last had contact with the Department of Social Services a year prior to his death. NORTH CAROLINA Violent Death Reporting System Part of ?005 National Violent Death Reporting System Operated by the North Carolina Division of Public Health, Injury Violence Prevention Branch Collecting data since 2004 THE BIG PICTURE Elder maltreatment is an increasing problem across the U.S., and this maltreatment may contribute to suicide and homicide among older adults. Data from the North Carolina Violent Death Reporting System show that for the 652 elder North Carolina residents who died as a result of violence from 2008 to 2009, . 530 were suicide?related, 34% of all elder males and 48% of elder femaies had been characterized as having a current mental health problem by a medical professional, and i 32% of males and 31% of females disclosed their intention to commit suicide to someone else. Older adults, disabled adults and disabled emancipated minors served by North Carolina?s Adult Protective Services may be particularly vul- nerable to abuse and neglect, and at risk for a violent death. 81% of the 652 elder deaths from violence in 2008?2009 were suicide-related TRANSLATING DATA INTO ACTION Few states have surveillance systems which allow them to adequately understand the magnitude of elder maltreatment in their state. North Carolina improved its elder maltreatment surveillance by linking data from the North Carolina Violent Death Reporting System (NC-VDRS) with records from the Division of Aging and Adult Services' Adult Protective Services which works through 100 county social services departments to identify and serve adults in need of protective services. New linked data North Carolina quantified and described -for the first time - violent deaths among persons age 18 and above in care of APS. During 2005-2008: Most APS deaths were among females, but males accounted for over 60% of violence-related APS deaths. . Violence-related APS deaths occurred most often among persons ages 45-54, while all other types of APS deaths occurred most often over age 7?5. I Among adults in APS care who died from suicide, over 70% were identified as having a mental health diagnosis and almost 70% were receiving treatment at the time of their death. Case-level data Linking NC-VDRS and APS data provided important case- ievel information, including if the person had ever been or was currently in APS care at the time of death, and if so, the county social service involved at the time of death, the length of time in this care, and the type of protective services received. Targeted services 8: improved programs The Division of Aging and Adult Services used the linked data to work with APS in counties where these deaths occurred to better target elder maltreatment prevention programs and improve staff training to identify violent death risks, such as indications of suicidal ideation or prior attempts. New adult fatality review process Based on its collaboration with the the Division of Aging and Adult Services is developing an adult fatality case review protocol and data collection process that will be conducted for every adult in APS who dies. NC-VDRS APS data linked for the first time APS can better target elder maltreatment prevention progra ms Adult Fatality Case Review will be conducted for every adult who dies in APS care OHIO Violent Death Reporting System Part of CDC ?5 National Violent Death Reporting System Operated by the Ohio Department of Health, Violence 81: Injury Prevention Program Collecting data since 201 0 ESTABLISHING VIOLENT DEATH REPORTING SYSTEM NO CENTRALIZED SOURCE FOR CORONER 8: LAW ENFORCEMENT DATA I 88 county coroner's 1' 900+ law enforcement agencies EXISTING STATE CONFIDENTIALITY LAWS 0 Public Records Law 8: Open Meeting Acts Parts of Coroner reports considered confidential 0 Law enforcement records confidential while death under investigation {can take years) EASED CONFIDENTIALITY CONCERNS I Law supports when it requests data Ii Law supports coroner's 3c law enforcement when they provide data ESTABLISH ADVISORY BOARD that includes partners who will provide data to 84 use data hem - the state violent death reporting system EDUCATE PARTNERS such as Coroners 8.: Law Enforcement about benefits of a state violent death reporting system 8r. how it works PARTNERS CAN ADVOCATE through their professional organizations for the new system PARTNERSHIPS LINKED DATA in the OH-VDRS provide a more COMPLETE PICTURE of violent deaths in Ohio LEGAL COUNSEL 8: GOVERNMENT AFFAIRS STAFF for the state health department can provide assistance BENEFITS OF LEGISLATION HIGH PARTICIPATION RATES from coroners 8( law enforcement LOCAL-LEVEL VIOLENT DEATH Ensures data will be used for VALID PUBLIC HEALTH REPORTING PURPOSES DATA AVAILABLE for partners to use in their communities OHIO Violent Death Reporting System Part of CDC ?5 National Violent Death Reporting System Operated by the Ohio Department of Health, Violence Injury Prevention Program Collecting data since 201 0 A LEGISLATIVE APPROACH TO ESTABLISHING THE OH-VDRS To establish the Ohio Violent Death Reporting System (OH-VDRS), the Ohio Department of Health determined that legislation that mandates reporting by key data providers - including coroners and law enforcement agencies - was a necessary first step. CHALLENGES Like many states, Ohio has no centralized coroner or law enforcement data systems. Prior to the OH-VDRS, a request for data about a death had to be made to one of 88 county coroners, and at least one of the state?s 900+ local law enforcement agencies. Existing state laws regarding confidentiality presented challenges for establishing the OH-VDRS, including Ohio's Sunshine Laws (Public Records Law 8: Open Meeting Acts}, which allow any person to make a request for information; law enforcement records that remain con?dential while a death is under investigation (for homicides, this may take years); and coroner records, which include investigative notes that may remain confidential, while other coroner data are made public. PARTNERSHIPS Partnerships with coroners, medical examiners and law enforcement agencies and the professional associations representing these partners - were central to the successful passage of the legislation. To educate partners, the Violence 8: Injury Prevention Program (VIPP) provided information about the OH-VDRS to coroners, law enforcement and others. Partners supported the OH-VDRS and recommended a legislative approach once they understood how their data would be kept confidential and used for violence prevention efforts (not typical prior to the They also valued being able to share county-level data from the OH-VDRS with prevention partners in their THE BIG PICTURE Prior to establishing the the Violence 8: Injury Pren vention Program had little data to support its assump? tions about different kinds of violent deaths. Now the state has important information about violent deaths. For example: In 201 0, there were 2,192 violent deaths in Ohio. 65%, or nearly two-thirds, of these violent deaths were suicides. II About 25% ofthese deaths were homicides. data also includes information about the circumstances of violent deaths. With these data, the VIPP has evidence that: communities. The OH-VDRS Advisory Board included representatives from coroner and law enforcement associations, who spoke on behalf of the during legislative hearings. Legal counselfrom the Ohio Department of Health helped the VIPP to draft model language. Staff from the department?s Office of Government Affairs helped to identify potential legislative paths for the OH-VDRS legislation state biennium and mid-biennium budget bills) and respond to requests about the legislation. LEGISLATION After multiple attempts over two years, legislation was passed that (1 established the OH-VDRS, (2) authorized the Ohio Department of Health to study and collect violent death data, mandated reporting from key data sources relevant to the OH-VDRS, and deemed all data collected and subsequent work products to be confidential and exempt from public record requests. IMPACT OF LEGISLATION 8: MANDATED REPORTING 'Ohio's legislation requiring confidential, mandated reporting contributed to the credibility and effectiveness of the OH-VDRS. The legislation: supports the OH-VDRS when it requests data from coroners, medical examiners and law enforcement, and supports coroners and law enforcement when they release data to the 0 ensures that data collected for the OH-VDRS will be used for valid public health reporting purposes; and has resulted in high participation rates - almost 100% among coroners and about 30% among law enforcement - which in turn help ensure OH-VDRS's long-term sustainability. Among women who died from homicide 54.2% of these deaths were related to intimate partner violence. Among persons who died from suicide I 41.3% were currently depressed, 540/ of homicide deaths among women were 0 53.1% had a current mental health problem, 0 21.7% had a previous suicide attempt, and 30.8% had disclosed their intent to someone. related to intimate partner violence OKLAHOMA Violent Death Reporting System Part of CDC ?5 National Violent Death Reporting System Operated by the Oklahoma State Department of Health, Injury Prevention Service Collecting data since 2004 MEDICAL EXAMINER 1' Had been drinking earlier in the day Recent health scare DEATH CERTIFICATE I 47-year?old white male Married 0 History of depression ProblEms at Work Vetera Suicide I. LAW ENFORCEMENT - 9 mm semi-automatic pistol found nearthe victim No suicide note left - Threatened to kill himself during recent argument with wife as he often did A SUICIDE IN OKLAHOMA The example below tells the story of a suicide in Oklahoma. but to ensure confidentiality, it is not the story of an actual death. The example was created to illustrate the violent death data typically collected and linked in the Oklahoma Violent Death Reporting System DEATH CERTIFICATE The victim was a 47?year?old white male who lived in a rural area of eastern Oklahoma. He was a married oilfield worker with a high school diploma. He died at home due to a single gunshot wound to the head. The manner of death was suicide The victim was a veteran of the US. Armed Forces. MEDICAL EXAMINER A 47?year?old white male died from a single gunshot wound to the head. The investigator reports the victim Was found in his bedroom after the victim's son heard a shot. The victim was reported to have been drinking earlier that day and had argued with his wife. The victim had recently been having trouble at work due to layoffs. The victim had a previous medical histOry of depression and had been stressed about a recent health scare. No suicide note was found. LAW ENFORCEMENT Law enforcement responded to the home when the victim?s son called police after hearing a gunshot and finding his father in the bedroom. The victim's wife reported that she and the victim had argued that morning over finances. She said the victim had threatened to kill himself during the argument, but he often threatened to kill himself when they argued and she didn't think anything of it. She said the victim went to a nearby pond to drink alcohol and shoot guns, but he returned later that afternoon and acted normal. An interview with the victim?s son revealed that the victim had seemed stressed lately due to problems at work, concern about losing his job, and a recent diagnosis of cancer with possible related surgeryr and treatment. There was no suicide note left. A C2mm semi?automatic pistol was found near the victim. TOXICOLOGY Toxicology reports showed the victim had a blood alcohol concentration of 0.1 s. OKLAHOMA Violent Death Reporting System Part of CDC '5 National Violent Death Reporting System Operated by the Oklahoma State Department of Health, Injury Prevention Service Collecting data since 2004 THE BIG PICTURE The age-adjusted suicide rate in Oklahoma was 33% higher than the same rate for the U.S. in 201 3. Oklahoma Violent Death Reporting System data illustrate the extent of this problem. Suicide was the third leading cause of death for Oklahomans age 10-34 in 2013, and the most prevalent type of violent death from 2004-2013, accounting for nearly 600 resident deaths each year. Suicides outnumber homicides by about three to one . The Veteran suicide death rate increased by 34% from 2005?2012, with over 1,000 veteran suicides during that time; the suicide rate among veterans was twice that of non-veterans. Among the 5,881 suicide deaths in Oklahoma from 2004- 201 3: - 79% were male, and 21% were female 22% of suicide victims were veterans - 144 victims killed at least one other person before taking hisfher own life, resulting in 173 homicide deaths. of the 5,881 suicide - Firearms (61 were the most prevalent means deaths from 2004- 201 3 were of suicide, followed by vetera ns hanging/strangulation poisoning and other means immediate access to lethal means may increase the risk for suicide. 0 Among suicide victims noted to have a diagnosed mental health problem (2,098}, 62% were currently receiving mental health treatment. Asigni?'cant number of suicides were associated with a dirre-nt depressed mood, intimate partner problem, mental arid/Gr physical health problem, and/or crisis in the past Weeks. TRANSLATING DATA INTO ACTION Informing prevention planning 0 The Oklahoma Injury Prevention Service provides data and statistics and works closely with the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), the Oklahoma Suicide Prevention Cauncil, and other suicide prevention groups. - suicide data informed the Council's 2011 Oklahoma Strategy for Suicide Prevention. Supporting veteran suicide prevention With five military bases in Oklahoma, veterans' health issues impact more than 300,000 Oklahomans. An special study and report on veteran suicides opened doors for collaboration with the Veterans Administration in Oklahoma, and helped illustrate the: - increased risk for suicide among veterans of all ages 0 leading circumstances associated with veteran suicides across the lifespan physical and mental health problems, depressed mood, and intimate partner problems a most common means of suicide (firearms) Expanding the power of data data will be linked to other state databases to better inform suicide prevention, mental health treatment, and problematic drug prescriptions related to suicide. staff worked with law enforcement, the Child Death Review Board, and the Oklahoma Suicide Prevention Council to modify a pocket card that helps law enforcement collect more complete and accurate suicide circumstances data showed increased risk leading cicumstances of suicide among veterans Opened doors data: for collaboration 3T8 used to with the Veterans understand Administration suicide risks, Partnering with - ff law enforcement The Oklahoma Association of Chiefs of Police hosts the Advisory Committee meetings and distributes data reports to its members. Informs statewide Suicide prevention program planning 0 The Oklahoma State Bureau of Investigation maintains a full time program officer to collect law enforcement data tor the through a contract with the injury Prevention Service. RHODE ISLAND Violent Death Reporting System Part of CDC ?5 National Violent Death Reporting System Operated by the Rhode Island Department of Health Center for Health Data and Analysis and Office of State Medical Examiners Collecting data since 2004 TOXICO LOGY 0 Victim had a Blood DEATH Alcohrl Concentration . 1-. CERTIFICATE of 0.32 43?year-old white male victim LAW ENFORCEMENT I Neighbor saw victim hanging in garage I Ex?wife stated victim had history of alcoholism 8: their A SUICIDE IN RHODE ISLAND divorce was finalized one week ago The example below tells the story of a suicide In Rhode Islandl but to ensure confidentiality, it is not the story of an actual death. The example was created to illustrate the violent death data typically collected and linked in the Rhode Island Violent Death Reporting System (RIVDRS). DivorCed, unemployed 1' Died at home due to if from hanging DEATH CERTIFICATE The victim was a 43-year?old white male who lived in a suburb in central Rhode Island. He was a divorced, unemployed machinist. He died at home due to from hanging. The manner of death was suicide. LAW ENFORCEMENT Law enforcement responded to the victim?s home when a neighbor notified law enforcement that when he was returning a tool he borrowed from the victim, he noticed the victim hanging in the victim's garage. While law enforcement were investigating, the victim?s ex? wife arrived on scene and stated that a week prior their divorce had been finalized. The victim's wife also stated that she had left him because he stopped going to treatment for his alcoholism. She stated the victim would become violent when he drank and she thinks his drinking also caused him to lose his job. She said he has a history of depression and had been treated for it in the past. She also stated he had no Past history of suicide attempts or ideation. A note was feund where the victim stated he felt worthless and could not go on without his family. MEDICAL CORONER The 43?year? old, white male vvictim died from due to hanging. He had a tattoo of the Road Runner on his lower left forearm and a tattoo of a knife over his heart. He had ligature marks under and around his neck. The investigator reports the victim was found hanged in his garage where there were numerous empty beer cans scattered around. The victim?s friend reports the victim had recently lost his job and recently been divorced. TOXICO LOGY Toxicology reports showed the victim had a Blood Alcohol Concentration of .32. There were no other drugs in his system. MEDICAL RECORDS The victim had been treated for depression several years earlier and had no history of suicide ideation or attempts. RHODE ISLAND Violent Death Reporting System Part of 5 National Violent Death Reporting System Operated by the Rhode Island Department of Health, Injury 8: Violence Prevention Program Collecting data since 2003 THE BIG PICTURE in Rhode Island during 2010, there were 165 violent deaths: 135 suicides, 2c: homicides and 4 deaths of undetermined manner. The number of suicides in Rhode Island peaked in 2010, declining from 102 suicides in 2011 to 89 in 2012, based on provisional 2012 data. RIVDRS data for 2004-201 0 show that: During this seven year period, there were a total of 731 suicides in Rhode Island. 0 Males were far more likely to commit suicide than females - Male and female suicide deaths peaked in the age group 45-54 years. - There were 18 suicides among those aged less than 18 (15 males, 3 females}. 0 Just over half of those who died by sUicide had a current mental health problem, and 43% were currently receiving mental health treatment. 0 Neariy one in five of those who died by suicide experienced an intimate partner probiem. 0 25% of those who died by suicide experienced a crisis in the two weeks prior to death. Only 37% of those who died by suicide left a note. 25% of those who died by suicide experienced a crisis in the two weeks prior to death. TRANSLATING DATA INTO ACTION Data from the Rhode Island Violent Death Reporting System (RIVDRS) provided new information on suicide and a better understanding of who is at risk. - RIVDRS data were used by the Department of Health's Violence 8( injury Prevention Program and its prevention partners for ground-breaking priority setting and program planning. Using new suicide data from the RIVDRS, the Suicide Prevention Subcommittee of the Rhode island Injury Community Planning Group identified the adult, working age population as being at increased risk for suicide and suicide attempts. I The data were shared with key partners through the subcommittees members, including the State Medical Examiner, RIVDRS Program Manager and Epidemiologist, Violence 8c injury Prevention Program manager, and representatives from the Samaritans, American Foundation for Suicide Prevention, community health and mental health centers, Bradley Children?s HoSpital, Brown University, Coastline Employee Assistance Program, and the Rhode Isiand Student Assistance Program. I An "Economic Impact of Depression and Suicide in the Workplace" symposium, co?sponsored by the Violence 8-: Injury Prevention Program and Coastline Employee Assistance Program, increased awareness of depression and suicide among working age aduits and provided strategies for integrating suicide prevention into worksites. RIVDRS data Show working age adults are at increased risk for suicide . Symposium participants included high-level shares managers and data with suicide human ?Source prevention partners representatives 2 of state 5 largest/ from the two employers largest employers Em Eployeed' in Rhode Island. /assistance r" program adds suicide prevention to its mission, refers at-risk employees to clinical - Coastline Employee Assistance Program integrated suicide prevention into its mission statement and now provides training in early identification and referral of at risk employees to their clinical staff as well as their clients. staii UTAH Violent Death Reporting System Part of CDC 5 National Violent Death Reporting System Operated by the Utah Department of Health. Violence 8: Injury Prevention Program Collecting data since 2005 LAW ENFORCEMENT 54-year-old Hispanic male suspect has history of assaultfdomestic DOMESTIC MEDICAL CORONER Victim' 5 ex? boyfriend/ DEATH CERTIFICATE violence VIOLENCE A FATATLITYREWEW confessed to homicide/ COMMI1TEE 14?year? o?ld daughter Victim referred to victim witnessed homicide advocate after being hos? - 51 ~yearvo d HrspanIc fe- pitalized from injuries male died In her home inflicted by suspect from stab wounds I 2 months ago A DOMESTIC VIOLENCE HOMICIDE IN UTAH The example below tells the story of a suicide in Utah. but to ensure con?dentiality, it is not the story of an actual death. The example was created to illustrate the violent death data typically collected and linked in the Utah Violent Death Reporting System DEATH CERTIFICATE A 51-year-old Hispanic female died at her residence. She was stabbed five times in her abdomen with a large kitchen knife. The manner of death is homicide. MEDICAL The victim was a 51?year?old Hispanic female who died from five stab wounds to her abdomen.The suspect used a kitchen knife to stab the victim. The death was determined to be a homicide. Emergency medical services responded to the victim?s residence early this morning.The call was made by the 14-year old daughter of the victim and the suspect, a 54?year-old Hispanic male. who is the victim?s err-boyfriend. The suspect confessed to their daughter that he had stabbed the victim. The 14?year old daughter indicated that the victim was afraid ofthe suspect and overheard her mother telling a friend that he w0uld kill her One day. The victim was no longer interested in the suspect and was planning on getting married to another man. The victim indicated that this news upset the su5pect, but that he just needed time, would soon accept her decision to re?marry, and would then leave her alone. The victim also had three fractures in her arm and bruises on her back in various stages of healing. Toxicology reports indicate that the victim had no substances present. LAW ENFORCEMENT The suspect is a 54?year?old Hispanic male. The victim and suspect were reported as arguing morning. Witnesses at the scene indicated they saw the suspect at the victim's home several times in the past few days. Once, the victim and suspect were seen fighting in the yard; the suspect slapped the victim and then immediately left. The suspect had a long criminal history with several charges relating to assault and domestic violence in the presence of a child. The suspect's criminal history shows an escalation in violenceArelated charges over the past year. The last incident occurred five weeks prior to the victim's death. Two months prior, the suspect assaulted the victim, who required hospitalization due to the assault. The suspect confessed to clergy that he had assaulted the victim two months prior. DOMESTIC VIOLENCE FATALITY REVIEW COMMI1TEE The suspect stalked and harassed the victim. Two months prior to her death, the victim was referred to a victim advocate after she was hospitalized for injuries inflicted by the suspect. The victim was advised to seek domestic violence shelter services. The victim received relocation funds for a new apartment after the assault. For the homicide, the Office of Crime Victim Reparations paid for counseling and mental health services for the 14?year old daughter and for costs ofthe victim?s funeral. The suspect pleaded down from manslaughter (First Degree Felony} to a Second Degree Felony. UTAH Violent Death Reporting System Part of National Violent Death Reporting System Operated by the Utah Department of Health, Violence 8: Injury Prevention Program Collecting data since 2005 THE BIG PICTURE Domestic violence is one of the fastest growing violent crimes in Utah. Findings from the 2010 publication, Domestic Vio- lance Fatair'ties in Utah, 2003?2008, by the Utah Department of Health?s Violence and injury Prevention Program and the Domestic Violence Fatality Review Committee, include: - 1 out of 3 adult homicides are domestic violence homicides. Females are 10 times more likely than males to die from domestic violence. - The majority of domestic violence homicides are committed by males. While Hispanic persons comprise only 10% of Utah's population, they account for 77% of domestic violence victims. 52% of intimate partner homicides were premeditated. - One?third of domestic violence perpetrators committed suicide after committing a homicide. 91% of the domestic violence?related suicide victims TRANSLATING DATA INTO ACTION Better data provide more complete picture of domestic violence deaths A decade ago, it was difficult to know the extent of domestic violence in Utah because of limited data. The Utah Violent Death Reporting System has developed a more complete picture of domestic violence and its tragic impact on men, women, and Children by: 0 fostering a strong partnership between the Utah Department of Health's Violence and Injury Prevention Program (Vle?l and the state's multidisciplinary Domestic Violence Fatality Review Committee which includes more than 9 agencies, it expanding domestic violence data collection beyond the victim and snapect to include any intimate partner, famiiy member and/or roommate involved in the incident, combining national and state-specific intimate partner violence variables to enable the to collect more and more detailed domestic violence?related data, and . linking data in the to identify and review forthe first time when a domestic violence suspect committed suicide after the homicide. Linking children of victims to needed services Intimate partner violence is particularly damaging to children who witness this violence. They are at greater risk of develop- ing disorders, developmental problems, school failure, violence against others, and low self-esteem, and experienced a crisis prior to the incident or faced an impending crisis the most common of which was facing a criminal legal problem such as a recent or impending arrest, police pursuit, or an impending criminal court date 78% of the 147 children directly exposed to a homicide in 2003?2008 were age 5 or younger - in 44% of intimate partner violence incidents, one or more children under age 18 were living at the victim?s home at the time of the incident (7?6 children total). I 147 children under age 18 were directly exposed to the homicide - they saw it, heard it through the walls, were attacked or threatened during the incident, or discovered the body. Of these children, 78% were 5 years old or youngec data expanded to include any intimate partner, family member or roommate in incident younger children typically display higher levels of distress than do older children. Through their collaboration on the the VIPP and helped inform a policy change to close a gap in services for the children of domestic violence?related homicide victims. - Following recommendations from a Domestic Violence Fatality Recommendations Symposium, the VIPP and worked with the state Department of Children and Family Services (DFCS) to increase immediate referrals to DFCS at the time of a homicide Usually by law enforcement investigating the death if the victim or perpetrator has one or more children in the home, regardless if a child was present during the incident. Worked with state [3ch to close gap in services for Children of victims now connected to mental health other services 0 These referrals enabled these children and their families to receive an assessment and get connected to intervention and follow-up services, such as mental health services, to help cope with the homicide and other domestic violence?related issues. I A referral to DFCS was made in 13 of the 28 intimate partner violence incidents with children in the home during 2003?2008. VIRGINIA Violent Death Reporting System Part of CDC ?5 National Violent Death Reporting System Operated by the Virginia Department of Health, Office of the Chief Medical Examiner Collecting data since 2003 MEDICAL EXAMINER Suffering from lung cancer DEATH Had stopped chemotherapy CERTIFICATE 0 Taking pain medication 82-year-old white male I Widowed veteran LAW Suicide ENFORCEMENT - 2 bottles of prescription pain meds on counter i I Suicide note left by victim ,l - Victim?s daughter said her father would kill himself if cancer got bad again A SUICIDE IN VIRGINIA The example below tells the story of a suicide in Virginia. but to ensure confidentiality, it is not the story of an actual death. The example was created to illustrate the violent death data typically collected and linked in the Virginia Violent Death Reporting System DEATH CERTIFICATE LAW ENFORCEMENT The victim was an 82-year-old white man Law enforcement was called to the victims who lived in a small rural community in home when a neighbor reported that she Southwest Virginia. He was a U.S. citizen had not seen him for a few days. His car born in North Carolina. He was a widowed was in the driveway. Law enforcement veteran and a retired truck driver for a responded for a welfare check and regional supermarket chain. He died at home from a discovered a mildly decomposed body on the living gunshot wound to the head. The manner of death was room floor of the home with a revolver lying near the suicide. right side of his body. The home was locked and secure. Law enforcement described the home as clean and neat with no evidence of foul play or intrusion. Notes on a nearby table provided post-mortem instructions on bills and funeral arrangements and a copy of his will. Two MEDICAL bottles of prescription medicine. one for Oxymorphone CORONER and one for Percocet, were found on the kitchen counter. The victim died from a gunshot wound to Law enforcement interviewed the victim?s daughter the head. Entrance and exit wounds reveal who reported that her father had been diagnosed with a recurrence of lung cancer five months ago and a single intra?oral shot using a revolver. complained about Significant pain. He had told family and Other pathological diagnosis included lesions on his right lung and a history mt surgical removal friends. repeatedly that if his cancer ever got bad again. he ofthe lower lobe ofthe left lung. The victim had a tattoo would end it. The daughter reported that her father with a US. Navy 19494 951 anchor on his right forearm. had no history of mental health problems and that he did Bruising on his forehead at autopsy suggested that he had not like to take pain medications] because it made him fallen and hit his head near the time of his death. Medical sleepy and caused film to lose h?S balance. records revealed that he was suffering from lung cancer. had stopped receiving chemotherapy, and was recently referred to a pain management specialist because he was TOXICOLOGY frustrated with his level of pain. Pill counts revealed he had Toxicology studies revealed that the victim did taken one dose of Oxymorphone and one of Percocet. not have any opiates in his blood. but did have a Blood Alcohol Concentration of ,028. Medical records showed that he had gone to a pain specialist who prescribed Oxymorphone and Percocet. VIRGINIA Violent Death Reporting System Part of National Violent Death Reporting System Operated by the Virginia Department of Health, Office of the Chief Medical Examiner Collecting data since 2003 THE BIG PICTURE Elder suicide is a complex social problem that is often over- elder and non~e der shadowed by a forms on suicide among youth, college suicides differ notably in . 'd students or veterans. Data from the Virginia Violent Death the circumstances and sum? 8 rates Reporting System (WDRS) that: Ilfe events that lead Increase for Elder to suicide, includin - elders have a higher suicide risk (rate of 15.6) than non- the 9 men as they age! bUt presence 0 mental decrease for elder elders (rate of 10.7); and physical health elder men are 6 times more likely than elder Women to die problems. women from suicide, and as elder men age, their suicide rate increases while it decreases for elder women; and TRANSLATING DATA INTO ACTION WDRS data show A new picture of elder suicide Health and - Elder EUiClde Services requested and '5 fundamentally received funding for a state d'?erem non?alder surcrde Combining data sources through the enabled the Virginia Department of Health to: suicide prevention 0 develop a new and more complete picture of elder coordinator to suicide by exploring it as a separate and unique address suicide y? phenomenon; issues across the Siilc'ile . . - l'f prevention . identify what makes elder suicide fundamentally espan. plans different from non-elder suicide - including life altering Educating developed via events such as a change in marital status, onset of illness, loss 7 summits - - - - through data of capacrty for Independent and mental and health problems; 0 in response to frequent media and community- . make recommendations for where to target prevention level requests for data, WDRS efforts, particularly among older men; and 1 staff have provided data, radio conclude, in its report Elder Suicide in Virginia: 2003?2010, and newspaper interviews and that elder suicide is an issue that can only be addressed education around the fact that health agency by treating it as distinct from non-elder suicide. suicide is more common than State suicide prevention coordinator hired by state mental Regional summits increase resources homl?id" l" a lamb? Gite? surprises those requesting the data. 0 Spurred by the release of the WDRS data, the Virginia Department of Behavioral Health and Developmental Services - a key partner and Advisory Committee 0 Since the WDRS began publishing its data, staff has seen a jump in requests a from about 3 to 30 per year. member - funded 7 regional suicide summits to bring With the WDRS, the Department of Health can respond with together mental health, public health and other violence more robust, useful and finely-tuned information including the prevention advocates for a clay of suicide prevention circumstances, methods of fatal injury, and risk factors related planning. to violent deaths that enable communities to hone in on . In each region Department of Health staff used specific local issues and inform the work oftheir prevention data to give a tailored data presentation on suicide- Summit participants then looked at state and local resources I Specialized WDRS reports on the circumstances of a and developed a regional suicide prevention plan to particular type of violent death - such as who dies at work address at?risk populations and the specific circumstances and the issue of suicide among military members - have associated with suicide in their communities. garnered extensive interest from the media, data users and Based on WDRS data and the momentum generated by StakEhOlderS- the regional summits, the Virginia Department of Behavioral WISCONSIN Violent Death Reporting System vi Part of National Violent Death Reporting System Operated by the Wisconsin Department of Health Services, Injury and Violence Prevention Program Collecting data since 2004 DEATH CERTIFICATE 0 16?year-old white male 0 High school student - Suicide A SUICIDE IN WISCONSIN MEDICAL CORONER Died from gunshot wound to the head Suffered from occasional mild depression Teased by classmates LAW ENFORCEMENT No past suicide attempts No suicide note left by victim Gun used was owned by the father and was not locked?up To ensure confidentiality, this is not an actual suicide but the pro?le of a suicide in Wisconsin. The example was created to illustrate the type of violent death data collected and linked in the Wisconsin Violent Death Reporting System DEATH CERTIFICATE The victim was a 16?year-old white male who lived in rural northern Wisconsin. He was a high school student. He died at his residence due to a gunshot wound to the head. The manner of death was suicide. MEDICAL CORONER The io-year-old white male victim died from a self-inflicted gunshot wound to the head. The victim's parents stated that he suffered from mild depression but onlyr occasionally saw a therapist, since she was 30 miles away. They stated he did not have a lot of friends, and one day in the past week he came home from school very upset after being teased by a few classmates for being overweight. LAW ENFORCEMENT The victim told his parents he was going for a walk in the evening. About 15 minutes laterr they heard the sound of a gunshot nearby. They went outside and found their son in a wooded area in their backyard with a gunshot wound to the head. Law enforcement responded upon receiving a call from the parents. The victim was pronounced dead at the scene. The father stated that the gun that was used belonged to him; he kept it hidden (not locked) in the basement. There was no suicide note found, and the parents stated he had not had any past suicidal attempts or ideations. TOXICO LOGY There were no drugs or alcohol found in the victim?s system. Part of CDC's National Violent Death Reporting System Operated by the Wisconsin Department of Health Services, Injury and Violence Prevention Program Collecting data since 2004 WISCONSIN Violent Death Reporting System 1,4 in THE BIG PICTURE The Wisconsin Violent Death Reporting System has provided a better understanding of who is dying, how they are dying, and the circumstances that may be associated with those violent deaths. Among the 249 youth under age 1 8 who died from suicide during 200d?2013: - ?Hit: were male - 103 (41 .493) of the deaths were committed with a firearm; among these cases, the firearm owner was the child's parent in at least 40 cases and the firearm was stored unlocked in at least 22 cases Among the 228 (91 youth suicides where circumstances surrounding the death were known by either the coronen? medical examiner or law entercement: - 9? had a current mental health problem and 104 currently or in the past had treatment for mental illness - 1 19 experienced a crisis in the preceding two weeks (compared to 312% of adult 0 suicides) 4 1 0 70 were experiencing of youth suicide deaths problems at or related to school were committed 'tl f' The highes?f age?adjusted death rates WI 1 a ?Bdrm for youth suicides tend to be in more rural counties, yet Wisconsin?s western and northern rural counties have the lowest number of mental health providers per capita. Groups at higher risk for suicide in Wisconsin include youth in more rural counties, American lndianslAlaska Natives, LGBT persons, and veterans. 0 Whites have the highest suicide rate overall, but non- white students were more likely to report attempting, planning or considering suicide in the past 1 2 months. TRANSLATING DATA INTO ACTION Informing prevention - data were used to develop and inform content of the 2015 Wisconsin Suicide Prevention Strategy, and local-level data can help local coalitions identify how best to target their suicide prevention efforts. Wisconsin's and Maternal Child Health (MCH) program partnered with Mental Health America of Wisconsin to support and advise local health departments in Wi5consin on best practices for adolescent suicide prevention, including coalition development, QPR gatekeeper training, Zero Suicide, and means reduction. Improving access to and quality of mental health services data helped inform the Wisconsin School Mental Health Project, a five?year project launched in 2015 in over 25 school districts that includes youth suicide prevention. The project reflects efforts of Wisconsin's mental health, public health, and education agencies and advocates to reduce per- ceived stigma attached to mental illness and accessing mental health services; train school-community teams; and increase the number of adults who recognize the signs of youth who are having trouble and know how to approach students and their families to access appropriate services. Addressing the how in suicide How persons attempt suicide plays a key role in whether they live or die. "Means reduction" reducing a suicidal person?s access to highly lethal means such as firearms - is recognized as an evidence-based practice that is an important part of a comprehensive approach to suicide prevention. data informed the Wisconsin School The 2015 Msconsin Suicide Mental Health Project Prevention Strategy includes an objective to create suicide? Local- safe environments level data for people at fiSk helps coalitions of suicide through target suicide strategies such as prevention means reduction. etforts I The best-practice program CALM: Counseling on Access to Lethal Creating SUiClde-Sale Means trains providers to environments through implement counseling strategies to means {Edua'on help clients at risk for suicide and '5 part Of the-WI their families reduce access to lethal pgg?ggtlon means, particularly {but not exclusively) gy firearms. - County-level suicide prevention efforts have included offering cable gun locks and providing firearm safety and means restriction/reduction education. Acknowledging that most teens know where their parents keep their guns, messages include storing guns that are locked, unloaded and with ammunition locked and stored separately. ACKNOWLEDGEMENTS STORIES FROM THE FRONTLINES OF VIOLENT DEATH SURVEILLANCE Safe States Alliances thanks the individuals who contributed to Stories from the Frontlines of Violent Death Surveillance. State health department staff from the states below contributed their time to gather and share information, data and their experiences with the and their state violent death reporting systems. Their efforts made this document possible. ALASKA Deborah Hull?Jilly Scott Saxon Injury Surveillance Program Alaska Division of Public Health 3601 Street, Suite 540 PO. Box 240249 Anchorage, AK 99524-0249 (907i 269?8078 dhssalaska.gov/dph/Epi/injury/ Pages/a efault.aspx MASSACHUSETTS Lauren Larochelle Injury Surveillance Program Massachusetts Department of Public Heahh 250 Washington Street, 6th Floor Boston, MA 02103 (617) 624-5664 Iauren.larochelle@state.ma.us NORTH CAROLINA Tammy Norwood Injury and Violence Prevention Branch North Carolina Department of Health and Human Services 5505 Six Forks Road Raleigh, NC 2?069 (919) 707?5432 tammy.norwood@dhhs.nc.gov OHIO Jolene DeFiore-Hyrmer Ohio Violence and Injury Prevention Program Ohio Department of Health 246 N. High Street, 8th Floor Columbus, Ohio 43215 (614) 644-0135 rs. aspx OKLAHOMA Sheryll Brown Brandi Woods?Littlejohn Injury Prevention Service Oklahoma State Department of Health 1000 NE 10th Street Oklahoma City, OK 78111120? 405-271-3430 brandiw?health.ok.gov Preve Preve ntion_Service/Oklahoma_ RHODE ISLAND Samara Viner-Brown Center for Health Data 8: Analysis Rhode Island Department of Health 3 Capitol Hill, Room 40? Providence, RI 02908 (401) 222-5122 healthdataandanaiysisr? UTAH Anna Fondario Trisha Keller Violence and Injury Prevention Program Utah Department of Health PO Box 142106 Salt Lake City, UT 84114-2106 0301) 538-6141 afondario?utah.gov trishakeller@utah.gov Overview. VIRGINIA Virginia Powell Office of the Chief Medical Examiner 737 North 5th Street, Suite 301 Richmond, VA 23219 (804) 205.3856 FatalityReviewSurveillance.htm WISCONSIN Brittany Grogan Hank Weiss Injury and Violence Prevention Program Wisconsin Department of Health Services 1 West Wilson Street, Room 233 Madison,Wl 53703 (608) 267-9008 harold.weiss@dhs.wisconsin.gov Kristen Lindemer of Safe States Alliance compiled and edited the document. Graphic design and layout by Melba Searcy, Creative Director, Toasted Ink (Atlanta). Layout updates in 2015 by Julie Alonso, Safe States Alliance. EXAMPLES OF SUICIDE DATA AVAILABLE FROM WEB SITE EXAMPLE ONE: MAP OF SUICIDE RATES 2008-2014, United States Death Rates per 100,000 Population Suffocetion. Sunczda, All Races. All Ethnicities, Both Sexes, All Ages Annualized Crude Rate for United States 3 i4 2 TEE-2.51 i:l 3 3803.15 3.15?3.29 3.30339 3.40-3.58 3.59-3.82 3.83-4.38 - 4.39-5.48 Reports for All Ages include those of unknown age. Rates based on 20 or fewer deaths my be unstable. States Witt these rates are cross?t?tohed in the map (see legend above). Such Hales have an asterisk. Produced by: the Statistics. Programming E: Eeononlies Branch, National Center for Injury' Prevention 6: Control, CDC Data Sources: NCHS National 1Itital Statistics System for numbers of deaths; US Census Bureau for population estimates. EXAMPLE TWO: MAP OF SUICIDE RATES, AN MALES 2008-2014, United States Death Rates per 100,000 Population All Injury, Suicide. American Indian, All EthnICIties, Makes, All Ages Annualized Crude Rate for United States 16 33 SuppressedenstableIUndef'rned - 0.00-4.65 408-1229 12.30?22.66 - 22 87?6405 Reports for All Ages include those of unknown age. Rae: bated on 20 in fewer deaths may be unstdale. States with these rates are Inthe map (see legend above) Sueh rates have an asterisl . Produced by: the Statintice. Programming .5: Economic: Branch, National Center for Injury Prevention .5: Control, CDC Data Sources: NCHS Natienel Vital Statistics System for numbera of deaths; US Census Bureau for population estimates SAS Output Page 1 of 2 EXAMPLE THREE: CIRCUMSTANCES OF SUICIDE DEATHS, HISPANIC, FEMALES, STATE OF COLORADO 2014, vas StVtes: co Counts by of Suicide AW MechVnisms AW Woes, Hisanic, FemVVes, AW Ages VesidentiW VreleubVic buining, VreV, NVturW VreWcou Other ichuding schoon?sports VreVs {lircur?slance Death Counts Percentage Total number of victims 24 100.00 All victims with unknown circumstances All victims with known circumstances 21 87.50 Current Depressed Mood 11 52.38 Current Mental Health Problem 11 52.38 Current treatment for mental illness 9 42.86 Ever Treated for Mental Problem 12 57.14 Person left a suicide note 7 33.33 Disclosed intent to commit suicide 5 23.81 History of Suicide Attempts 10 47.62 Crisis in past 2 weeks 7 33.33 Intimate partner problem 13 61.90 Eviction or loss of home 0 0.00 Other relationship problem 1 4.?6 Physical health problem 7 33.33 Alcohol Dependence 8 38.10 Other Substance Problem 3 14.29 Recent criminal legal problem 3 14.29 Other legal problems 0 0.00 Job problem 0 0.00 Financial problem 1 4.?6 School problem 2 9.52 Suicide of friend or family in past five years 2 9.52 Other death of friend or family 3 14.29 Other suicide circumstance 0 0.00 Other undetermined circumstance 0 0.00 gov: 8443f Sp 3K1 {1/2017 SAS Output Page 2 of 2 Reports for All Ages include those of unknown age. Manner of death reported here is assigned by the state abstractor based on all available standard data sources. Note1: Victims can have one or more circumstances; therefore, subcategories may not sum to all known circumstances. Notez: Percentages for specific known circumstance categories were computed using the count of victims with known circumstances' as the denominator. Data Sources: National Violent Death Reporting System for Number of Deaths, Bureau of Census for Population Estimates. Produced by: Of?ce of Statistics and Programming, National Center for Injury Prevention and Control, CDC The number of deaths fewer than 10; the number has been suppressed to retain confidentiality. The circumstance 'eviction or loss of horne' was added to in 2010. Counts for this variable prior to 2010 are considered unreliable. gov:8443f Sp 3H 1 OIZO 17 EXAMPLE FOUR: COST OF SUICIDE, MALES, WESTERN REGION Fatal Injuries, Male, All Ages West, 2010 Intenl: Suicide Mechanism: in" Number of Deaths and Estimated Average and Total Lifetime Cosls Classi?ed hy- Hmhanlsm and Il'll?fll Goals Expressed In 201D Hogiond Prices Deaths and Type Of CDSI Deaths -- 7,755 Medical Cost AVerage $3,546 Total $27,497,000 All Mechanisms Work Loss Cost; Average $1,203,154 Total $9,335,186,000 Combined Cost Average - Total InjuryI Classification Scheme: Hechanism by intent o! Injury. Recon: ior All ?ies than of unknown age. Total Ila! He?ma?teo are wi1l'Hn the region. auimam Mud Earl 20 or low dealns tm?ld?e? ?Mlabll. Eslimalu his? 041 20 drains Phi? list! ?13135? d-llt Ill?h Milli" variability oi cleanlml coals. Interpret unstable ?Emilee "Iii! caullon. Hole: For input-related dealt-9. Ilmlme made-oi refer lo Ihe medical coals associated with Iha inlol Injury went. Pmrlumd by: National Banter [or Injury Prevenlion and Control. [Isle Source: NCHS Vllal Slallellcs system for numbers ol deems. REESE All In ury Frograrn operaled by the Ila Consumer Fromm emery Commission (CFSC) for numbera ol? nonlatd Iniu?eu. Paci?c inelitule for Research and Evaluaiim Galleria". MD for unit coal eellmulea. 812172018 WISOARS YPLL Report EXAMPLE FIVE: YEARS OF POTENTIAL LIFE LOST Cause of Death All Causes Unintentional Injury Malignant Neoplasms Heart Disease Suicide Perinatal Period Homicide Congenital Anomalies Liver Disease Diabetes Mellitus Cerebrovascular All Others 11,928,107 2,739,490 1,715,904 1,349,164 895,465 745,134 607,886 421,944 301 ,329 252,804 228,104 2,570,882 Percent Years of Potential Life Lost (YPLL) Before Age 65 2016 United States All Races, Both Sexes All Deaths 100.0% 23.0% 144% 11.3% - 7.5% - 6.2% - 5.1% I 3.5% I 2.5% I 2.1% I 1.9% 22.4% Download Results in a Spreadsheet File Help with Download Produced By: Data Source: Terms for Causes of Death National Center for Injuryr Prevention and Control, CDC National Center for Health Statistics Vital Statistics System. 171 From: Coleman, Akeiisa Sent: 20 Jun 2013 21:02:50 +0000 To: Stone, Deborah Alexander Cc: Black, Erin Heather Sandra Subject: RE: June 22 webinar - CDC introduction slides Thanks Deb! Akeiisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 acolemangriingaorg From: Stone, Deborah (CDCKONDIEHMCIPC) Sent: Wednesday, June 20, 2018 4:58 PM To: Coleman, Akeiisa Crosby, Alexander Cc: Black, Erin Dennehy, Heather Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Here are my slides as well! Thanks! Deb From: Coleman, Akeiisa Sent: Wednesday, June 20, 2018 4:42 PM To: Crosby, Alexander daccl?icdceovl" Cc: Black, Erin Dennehy, Heather Stone, Deborah {:2an (Bede. 0V2 Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Thanks Alex! Akeiisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 acolemangtilngaorg From: Crosby, {aecl (Dede. oy> Sent: Wednesday, June 20, 2018 4:39 PM To: Coleman, Akeiisa Cc: Black, Erin (CDCIONDIEHWCIPC) {epn?l?d?icdogov}; Dennehy, Heather (CDCKONDIEHINCIPC) {kyzol?iedogov}; Stone, Deborah (CDCXONDIEHINCIPC) Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Greetings: I have attached the slides. Alex From: Wilkniss, Sandra <8Wilknisst2?NGADRG> Sent: Friday, June 15, 2018 11:25 AM To: Crosby, Alexander Subject: Re: June 22 webinar Wonderful On Jun 15, 2018, at 9:27 AM, Crosby, Alexander wrote: Greetings: It looks like I am available on the 22nd for the webinar 85 on Weds, 20th for the pre- bne? Alex From: Wilkniss, Sandra Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin (CDCIONDIEHMCIPC) Ce: Coleman, Akeiisa Crosby, Alexander , Richmond?Grunt, Malia Dennehy, Heather Stone, Deborah <2an ov> Subject: Re: one 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. I could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin (CDCIONDIEHWCIPC) {ieom'i'triicdogovl} Sent: Thursday, June 14, 2018 11:34:07 PM To: Wilkniss, Sandra Cc: Coleman, Akeiisa; Crosby, Alexander Richmond-Chum, Malia Dennehy, Heather Stone, Deborah (CDCIONDIEHINCIPC) Subject: RE: June 22 webinar Yes, it would be helpful if you could schedule a ore-brief next week. From a quick peek at calendars it looks like Alex, Deb and myself might be available Monday 10:30-11 or Wed 3:30-11. From: Wilkniss, Sandra <5Wilkniss@NGA.0RG> Sent: Thursday, June 14, 2018 11:25 PM To: Black, Erin wrote: Ladies what does the federal overview in the agenda below consist of? As mentioned I plan to be on the call, also the Vital Signs lead author, Deb Stone (copied), will be on the call to present on the Vital Signs. Alex is currently on leave but back next week to discuss his availability- From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 1:25 PM To: Black, Erin Cc: Coleman, Akeiisa Subject: June 22 webinar Hi again, Erin. We just discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors {all states and territories invited) 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect - NGA min CDC talking about recent data min NGA to summarize meeting highlights min state rep from CD to talk about their comprehensive approach 55- min IDIUT rep to talk about prevention or partnership (this is being nailed down in the next couple days) 15 min (1 A We will be able to show slides. I hope this helps! From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 10:50 AM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HI Erin, It is still being reviewed internally. So, we had hoped to do the webinar after the paper was done. However, the opportunity on the 22"Id came up and we thought it more important to capitalize on the momentum of your recent report rather than wait for our paper to be final. We think it critical to get attention to the issue while its top of mind. Sound ok? From: Black, Erin Sent: Thursday, June 14, 2018 10:25 AM To: Wilkniss, Sandra Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Have you sent us a copy of the report yet from the convening that you will be discussing on the call? I will be on the call but also still confirming if others will attend. Alex is out until Monday. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 9:49 AM To: Black, Erin Subject: Re: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data andfor can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin wrote: Sandra -1 am available that day/time - but let me check internally and see who would be best to present on the VS and get back to you. From: Wilkniss, Sandra Sent: Tuesday, June 12, 2018 9:00 AM To: Black, Erin Cc: Crosby, Alexander ; Richmond?Crum, Malia <'rv8 cdc. Dennehy, Heather ckvz? cdc. ov> Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates I will be on leave July 16-20 and in an all-day meeting July 31. From: Wilkniss, Sandra Sent: Thursday, June 7, 2018 1:27 PM To: Black, Erin Coleman, Akeiisa Cc: Crosby, Alexander ; Richmond-Crum, Malia <'rv8 cdc. ov>; Dennehy, Heather ckvz? cdc. ova Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We ca n't wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin (CDCIONDIEHINCIPC) Sent: Thursday, June 2018 9:55 AM To: Wilkniss, Sandra sSWilkniss??NGADRG); Coleman, Akeiisa Cc: Crosby, Alexander ; Dennehy, Heather ckvz? cdc. ov> Subject: EMBARGOED Until 1pm June 7: Vital Signs. Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Sandra and Akeiisa, As we mentioned, our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, will be released later today. The report includes state? level trends in suicide rates from 1999?2016, and, with data from National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. The CDC celebrates the National Governors Association?s commitment to creating safe communities. We hope that this resource can provide state leaders with an increased understanding of the impact of suicide in their states, as well as potential solutions for prevention. I would appreciate it if you could help disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Also, as discussed we will plan to highlight the Vital Signs on the planned Webinar with State health policy advisors {has a date been set vet?]. Erin The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortality Weekly Report article, "Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm following a media telebriefing at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016. suicide rates increased in nearly eveiy state. with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone. including relationship. substance use, physical health. job. financial. and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of social media tools such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, and/or confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, and/or confidential. Ifthe reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls} and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls] and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. if you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientis) and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. Ifyou have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient{s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. 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From: Stone, Deborah Sent: 20 Jun 2018 20:57:30 +0000 To: Coleman, Akeiisa;Crosby, Alexander Cc: Black, Erin Heather Sandra Subject: RE: June 22 webinar - CDC introduction slides Attachments: Vital Signs NGA Meeting 6.22.18_clean.pptx Here are my slides as well! Thanks! Deb From: Coleman, Akeiisa Sent: Wednesday, June 20, 2018 4:42 PM To: Crosby, Alexander Cc: Black, Erin Dennehy, Stone, Deborah Wilkniss, Sandra Subject: RE: June 22 webinar - CDC introduction slides Thanks Alex! Akeiisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 1 acoleman@nga.org From: Crosby, Alexander saecl cdc. 0% Sent: Wednesday, June 20, 2018 4:39 PM To: Coleman, Akeiisa Cc: Black, Erin Dennehy, Heather Stone, Deborah Wilkniss, Sandra <5Wilkniss?NGADRG> Subject: RE: June 22 webinar CDC introduction slides Greetings: I have attached the slides. Alex From: Wilkniss, Sandra Sent: Friday, June 15, 2018 11:25 AM To: Crosby, Alexander Cc: Black, Erin Coleman, Akeiisa Malia Dennehy, Heather Stone, Deborah <2an cdc. oys- Subject: Re: June 22 webinar Wonderful! On Jun 15, 2018, at 9:27 AM, Crosby, Alexander {aeel diode. voy> Wrote: Greetings: It looks like I am available on the 22nd for the webinar 8: on Weds, 20th for the pre-brief. Alex From: Wilkniss, Sandra Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Subject: Re: June 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. I could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin (e m? cdc. ov> Sent: Thursday, June 14, 2018 11:34:07 PM To: Wilkniss, Sandra Cc: Coleman, Akeiisa; Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Subject: RE: June 22 webinar Yes, it would be helpful if you could schedule a pre-brief next week. From a quick peek at calendars it looks like Alex, Deb and myself might be available Monday 10:30-11 or Wed 3:30-44. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 11:25 PM To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander ; Stone, Deborah cdc. ov> Subject: Re: June 22 webinar Hello Erin and Dr Stone. We can be flexible in the federal overview and take your lead on the data to highlight as well as any priority strategies, federal?state partnership aimed at preventing suicide you would like to share. May we schedule a call with the three of you for when Alex returns early next week to plan? Thank you! Sandra On Jun 14, 2018, at 11:19 PM, Black, Erin wrote: Ladies what does the federal overview in the agenda below consist of? As mentioned I plan to be on the call, also the Vital Signs lead author, Deb Stone (copied), will be on the call to present on the Vital Signs. Alex is currently on leave but back next week to discuss his availability. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 1:25 PM To: Black, Erin Cc: Coleman, Akeiisa Subject: june 22 webinar Hi again, Erin. We just discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors {all states and territories invited) 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect - NGA 5-7 min CDC talking about recent data min NGA to summarize meeting highlights min state rep from C0 to talk about their comprehensive approach min rep to talk about prevention or partnership (this is being nailed down in the next couple dayswill be able to show slides. I hope this helps! From: Wilkniss, Sandra (SWilkniss@NGA.ORGe Sent: Thursday, June 14, 2018 10:50 AM To: Black, Erin (e m? cdc. ov> Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HI Erin, It is still being reviewed internally. So, we had hoped to do the webinar after the paper was done. However, the opportunity on the 22'?d came up and we thought it more important to capitalize on the momentum of your recent report rather than wait for our paper to be final. We think it critical to get attention to the issue while its top of mind. Sound ok? From: Black, Erin Sent: Thursday, June 14, 2018 10:25 AM To: Wilkniss, Sandra Subject: RE: EMBARGCIED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Have you sent us a copy of the report yet from the convening that you will be discussing on the call? I will be on the call but also still confirming if others will attend. Alex is out until Monday. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 9:49 AM To: Black, Erin Subject: Re: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data andlor can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin wrote: Sandra 2 I am available that day/time but let me check internally and see who would be best to present on the VS and get back to you. From: Wilkniss, Sandra Sent: Tuesday, June 12, 2013 9:00 AM To: Black, Erin m? cdc. ov> Cc: Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather ckvz? cdc. ov?a Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing lCircumstances to Suicide and Increasing Trends in State Suicide Rates Good morning Erin, Alex, Malia and Heather, Thanks again for this terrific report! We are updating the paper now with new stats. In the meantime, we have had an opening for our state leadership calls for June 22 2-3pm eastern which we could use to highlight the findings of the Vital Signs report and lessons learned from our meeting and we have a couple of states available to give brief comments about their strategies. I am hoping that it is possible for you all to be available that dayftime for the webinar with governors health policy advisers? It is usually very well attended and may help perpetuate the momentum around your report. Please let me know if it's possible and we can jump on a call and sort out details. Thanks! Sandra From: Black, Erin Sent: Thursday, June 2018 1:34 PM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander ; Dennehy, Heather Subject: RE: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates 1 will be on leave July 16?20 and in an all?day meeting July 31. From: Wilkniss, Sandra Sent: Thursday, June 2, 2018 1:27 PM To: Black, Erin Coleman, Akeiisa Cc: Crosby, Alexander Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We ca n?t wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin Sent: Thursday, June T, 2018 9:55 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Subject: Re: June 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. i could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin Sent: Thursday, June 14, 2018 11:25 PM To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Crum, Malia <'rv8 cdc. Dennehy, Heather Stone, Deborah <2af9@cdc.gov> Subject: Re: June 22 webinar Hello Erin and Dr Stone. We can be flexible in the federal overview and take your lead on the data to highlight as well as any priority strategies, federal-state partnership aimed at preventing suicide you would like to share. May we schedule a call with the three of you for when Alex returns early next week to plan? Thank you! Sandra On Jun 14, 2018, at 11:19 PM, Black, Erin Cc: Coleman, Akeiisa Subject: June 22 webinar Hi again, Erin. We just discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors {all states and territories invited) 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect NGA 5-7 min CDC talking about recent data min NGA to summarize meeting highlights min state rep from CD to talk about their comprehensive approach min rep to talk about prevention or partnership (this is being nailed down in the next couple days) 15 min (1 A We will be able to show slides. I hope this helps! From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 10:50 AM To: Black, Erin Subject: RE: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HI Erin, It is still being reviewed internally. So, we had hoped to do the webinar after the paper was done. However, the opportunity thought it more important to capitalize on the momentum of your recent report rather than wait for our paper to be final. We think it critical to get attention to the issue while its top of mind. Sound ok? From: Black, Erin Sent: Thursday, June 14, 2018 10:25 AM To: Wilkniss, Sandra Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Have you sent us a copy ofthe report yet from the convening that you will be discussing on the ca 1? will be on the call but also still confirming if others will attend. Alex is out until Monday. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 9:49 AM To: Black, Erin Subject: Re: EMBARGOED Until 1pm June 7: lv'ital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data and/or can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin wrote: Sandra ?l am available that dayftime but let me check internally and see who would be best to present on the V5 and get back to you. From: Wilkniss, Sandra Sent: Tuesday, June 12, 2018 9:00 AM To: Black, Erin (CDCXONDIEHXNCIPCJI Cc: Crosby, Alexander ; Dennehy, Heather Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Good morning Erin, Alex, Malia and Heather, Thanks again for this terrific report! We are updating the paper now with new stats. In the meantime, we have had an opening for our state leadership calls for June 22 2-3pm eastern which we could use to highlight the findings of the Vital Signs report and lessons learned from our meeting and we have a couple of states available to give brief comments about their strategies. I am hoping that it is possible for you all to be available that dayj?time for the webinar with governors health policy advisers? it is usually very well attended and may help perpetuate the momentum around your report. Please let me know if it?s possible and we can jump on a call and sort out details. Thanks! Sandra From: Black, Erin Sent: Thursday, June 7, 2018 1:34 PM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander ; Richmond-Crum, Malia Dennehy, Heather Subject: EMBARGOED Until 1pm June 7: lu?ital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Sandra and Akeiisa, As we mentioned, our new Vital Signs, Contributing Circumstances ta Suicide and increasing Trends in State Suicide Rates, will be released later today. The report includes state- level trends in suicide rates from 1999-2016, and, with data from National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. The CDC celebrates the National Governors Association?s commitment to creating safe communities. We hope that this resource can provide state leaders with an increased understanding of the impact of suicide in their states, as well as potential solutions for prevention. i would appreciate it if you could help disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Also, as discussed we will plan to highlight the Vital Signs on the planned Webinar with State health policy advisors [has a date been set yeti]. Erin The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Viiai Signs materials. including the Morbidity and Mortuary Weekiy Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm (EST) following a media talc-brie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vita! Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each - Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than halfof people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, ?nancial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webnage to find the article, fact sheet, and other materials. Take advantage of social media tools, such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you tojoin us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andror con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientis} and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andior con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. National Center for Injury Prevention and Control Support for states to prevent suicidal behavior National Governors Association Center for Best Practices Webinar June 2018 "The findings and conclusions in this presentation are those of the authorls) and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agencyr for Toxic Substances and Disease Registry.? Alex Crosby, MDDivision of Violence PreventionCenters for Disease Control and Prevention Supporting State Health Departments urveillance Colorado VDRS, National Environmental ESSENCE Collaborative Scan DVP SUICIDE PREVENTION FFORTS Response to Technical events package Examples of available resources - Surveillance . .. Preventing connecting_the_dots- packages.html#suicide ll you. um um 3m .4: uleueumnv sudden! 11W nitride I It" numb innl?mn titular".- Age-adjusted suicide rates among all persons by state -- United States, 2016 (U.S. avg 13.5) i Rate per 100,000 13.51191 National Center for Injury Prevention and Control Thank You Being a Suicide Prevention Champion! From: Stone, Deborah Sent: 21 Jun 2018 14:58:09 +0000 To: Crosby, Alexander Erin Cc: Dennehy, Heather Malia Subject: RE: June 22 webinar Looks good to me too! Thanks, Deb From: Crosby, Alexander Sent: Thursday, June 21, 2018 10:52 AM To: Black, Erin Cc: Dennehy, Heather Stone, Deborah Richmond?Crum, Malia Subject: RE: June 22 webinar Greetings: Looks good. Just a couple of suggestions. Please see below. Alex From: Black, Erin (CDCIDNDIEHINCIPQ Sent: Thursday, June 21, 2018 10:47 AM To: Stone, Deborah Richmond-Crum, Malia Crosby, Alexander Cc: Dennehy, Heather Subject: RE: June 22 webinar Here are the TPs Heather and were thinking for my portion, let me know what you think before I send to NBA. I In March, in Denver, Colorado, DVP collaborated with the National Governor?s Association and SAMHSA to convene state leaders from 13 states with a high burden of suicide to hear suicide prevention best practices from the Indian Health Service, the VA, SAMHSA, and C0 state who is implementing a comprehensive suicide prevention pilot. 0 CDC specifically sought out this partnership with NGA as a way to leverage their relationship with you, the state health policy advisors and the importance of your role in informing state policy. We want to be a resource for you as you work to reduce the rising suicide rates across the nation. These rising rates are outlined in our recent CDC Vital Signs on state suicide trends. 0We want you to know that comprehensive suicide prevention includes policy options, such as unemployment benefits, neighborhood stabilization, mental health parity, alcohol outlet density, and greening polices that can help prevent suicide. These and other best available evidence are outlined in our CDC Suicide Prevention Technical Package for Preventing suicide. 0We want to be a resource for you in gathering the suicide prevention data necessary to inform policy decisions. ISandra Wilkniss will be sharing a little bit more about the convening we had in March, and my colleagues from CDC, Deb Stone and Alex Crosby will be talking more about work in suicide prevention, the latest data from our Vital Signs on suicide prevention, and the strategies and approaches from our suicide prevention technical package that we know work to prevent suicide. From: Stone, Deborah Sent: Wednesday, June 20, 2018 4:52 PM To: Richmond-Crum, Malia Crosby, Alexander Cc: Dennehy. Heather Black. Erin Subject: RE: June 22 webinar No, nothing changed. Ijust streamlined the talking points a bit. Deb From: Richmond-Crum, Malia Sent: Wednesday, June 20, 2018 4:42 PM To: Stone, Deborah Crosby, Alexander Cc: Dennehy, Heather Black, Erin Subject: RE: June 22 webinar Hi Deb? Did anything change from the VS Town Hall? From: Stone, Deborah Sent: Wednesday, June 20, 201B 4:40 PM To: Crosby, Alexander (CDCIDNDIEHINCIPC) caecl cdc. ov> Cc: Richmond?Crum, Malia Dennehy, Heather Black, Erin Subject: RE: June 22 webinar Thanks, Alex. I?m going to go ahead and send them in a few mins. Deb From: Crosby, Alexander Sent: Wednesday, June 20, 2013 4:39 PM To: Stone, Deborah <2af9@cdc.govb Cc: Richmond?Crum, Malia Dennehy, Heather Black, Erin Subject: RE: June 22 webinar Greetings: I think those look good. Alex From: Stone, Deborah Sent: Wednesday, June 20, 2018 3:58 PM To: Black, Erin Cc: Richmond-Crum, Malia Dennehy, Heather (CDCXONDIEHINCIPC) Subject: RE: June 22 webinar Hi Guys. These are the slides and talking points I had. Do you think these are ok? Deb From: Coleman, Akeiisa Sent: Monday, June 18, 2018 11:0? AM To: Black, Erin Wilkniss, Sandra Cc: Richmond-Crum, Malia Dennehv, Heather Stone, Deborah Crosby, Alexander (CDCXONDIEHXNCIPC) Picher, Caroline Sent: Monday, June 18, 2018 10:42 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Crosby, Alexander Subject: RE: June 22 webinar Can vou please forward the invitation for the webinar on Friday so that we have it on our calendars and have the call-in information. Thank vou. From: Wilkniss, Sandra Sent: Friday, June 15, 2018 11:25 AM To: Crosby, Alexander Cc: Black, Erin Coleman, Akeiisa Richmond-Crum, Malia Dennehv, Heather Stone, Deborah <2af9 cdc. ova Subject: Re: June 22 webinar Wonderful! On Jun 15., 2018, at 9:27 AM, Crosby, Alexander wrote: Greetings: It looks like I am available on the 22nd for the webinar 8; on Weds, 20th for the ore-brief. Alex From: Wilkniss, Sandra Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Subject: Re: June 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. I could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin (e m? cdc. ov> Sent: Thursday, June 14, 2018 11:34:07 PM To: Wilkniss, Sandra Cc: Coleman, Akeiisa; Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Subject: RE: June 22 webinar Yes, it would be helpful if you could schedule a ore-brief next week. From a quick peek at calendars it looks like Alex, Deb and myself might be available Monday 10:30-11 or Wed 3:30-4. From: Wilkniss, Sandra <5Wilkniss@NGA.0RG> Sent: Thursday, June 14, 2018 11:25 PM To: Black, Erin m7 cdc. ova Cc: Coleman, Akeiisa Crosby, Alexander ; Dennehy, Heather Stone, Deborah cdc. ov> Subject: Re: June 22 webinar Hello Erin and Dr Stone. We can be flexible in the federal overview and take your lead on the data to highlight as well as any priority strategies, federal-state partnership aimed at preventing suicide you would like to share. May we schedule a call with the three of you for when Alex returns early next week to plan? Thank you! Sandra On Jun 14, 2018, at 11:19 PM, Black, Erin wrote: Ladies what does the federal overview in the agenda below consist of? As mentioned I plan to be on the call, also the Vital Signs lead author, Deb Stone (copied), will be on the call to present on the Vital Signs. Alex is currently on leave but back next week to discuss his availability. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 1:25 PM To: Black, Erin Cc: Coleman, Akeiisa Subject: June 22 webinar Hi again, Erin. Wejust discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors {all states and territories invited) 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect NGA min CDC talking about recent data min NGA to summarize meeting highlights min state rep from C0 to talk about their comprehensive approach min rep to talk about prevention or partnership (this is being nailed down in the next couple dayswill be able to show slides. I hope this helps! From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 10:50 AM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June lv?ital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HI Erin, It is still being reviewed internally. So, we had hoped to do the webinar after the paper was done. However, the opportunity on the 22Hid came up and we thought it more important to capitalize on the momentum of your recent report rather than wait for our paper to be final. We think it critical to get attention to the issue while its top of mind. Sound ok? From: Black, Erin Sent: Thursday, June 14, 2018 10:25 AM To: Wilkniss, Sandra Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Have you sent us a copy of the report yet from the convening that you will be discussing on the call? I will be on the call but also still confirming if others will attend. Alex is out until Monday. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 9:49 AM To: Black, Erin Subject: Re: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data and/or can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin (CDCIONDIEHINCIPG wrote: Sandra ?1 am available that davftime but let me check internally and see who would be best to present on the V5 and get back to you. From: Wilkniss, Sandra Sent: Tuesday, June 12, 2013 9:00 AM To: Black, Erin Cc: Crosby, Alexander Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Good morning Erin, Alex, Malia and Heather, Thanks again for this terrific report! We are updating the paper now with new stats. In the meantime, we have had an opening for our state leadership calls for June 22 2-3pm eastern which we could use to highlight the findings of the Vital Signs report and lessons learned from our meeting and we have a couple of states available to give brief comments about their strategies. I am hoping that it is possible for you all to be available that dayftime for the webinar with governors health policy advisers? lt is usually very well attended and may help perpetuate the momentum around your report. Please let me know if it's possible and we can jump on a call and sort out details. Thanks! Sandra From: Black, Erin Sent: Thursday, June 2018 1:32;l PM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We can?t wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin Sent: Thursday, June 7, 2018 9:56 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander Subject: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Sandra and Akeiisa, As we mentioned, our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, will be released later today. The report includes state- level trends in suicide rates from 1999-2016, and, with data from National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. The CDC celebrates the National Governors Association?s commitment to creating safe communities. We hope that this resoarce can provide state leaders with an increased understanding of the impact of suicide in their states, as well as potential solutions for prevention. I would appreciate it if you could help disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Also, as discussed we will plan to highlight the Vital Signs on the planned Webinar with State health policy advisers [has a date been set yet?). Erin The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month's edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vitai Signs materials, including the Morbidity and .Mor?iaiity Weekb.? Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: I In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of peOple who died by suicide did not have a known mental health condition I A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vital Signs buttons and email updates. Visit CDC ?5 Public Health Media Library at and search on the term Vital Signs. We also invite you tojoin us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andr?or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, yen are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, and/or confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient{s) and may contain information that is privileged, proprietary, andz?or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. From: Coleman, Akeiisa Sent: 18 Jun 2013 21:09:55 +0000 To: Black, Erin Sandra Cc: Richmond-Crum, Malia Heather Deborah Alexander Caroline Subject: RE: June 22 webinar Aftemoon all! I know we're talking on Wednesday to prep for Friday's webinar. If anyone plans to use a couple slides for their piece, we?d appreciate it if you could send these by the end of the day Wednesday. Additionally, Caroline, who is handling the webinar logistics, would like to do a quick check to make sure everyone?s comfortable using Go To Meeting. Thanks, Akeiisa Akciisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 From: Coleman, Akeiisa Sent: Monday, June 18, 2013 11:07 AM To: ?Blaek, Erin Wilkniss, Sandra Cc: Richmond-Cram, Malia DEnnehy, Heather Stone. Deborah Crosby, Alexander Picher, Caroline Subject: RE: June 22 webinar Attached is a calendar invite that was shared with governors? stafiC and health secretaries. Also, here is the link to register for the webinar: Akeiisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 acolemangi?ngabrg From: Black, Erin Sent: Monday, June 18, 2018 10:42 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Richmond-Cram, Malia Dennehy, Heather (CDCIONDIEHWCIPC) ; Crosby, Alexander {aecl ov> Subject: RE: June 22 webinar Can you please forward the invitation for the webinar on Friday so that we have it on our calendars and have the call-in information. Thank you. From: Wilkniss. Sandra Sent: Friday, June 15, 2018 11:25 AM To: Crosby, Alexander (CDCIONDIEHINCIPO Cc: Black, Erin (CDCIONDIEHFNCIPC) Coleman, Akeiisa Richmond-Cram, Malia Subject: Re: June 22 wcbinar Wonderful I On Jun 15, 2018, at 9:27 AM, Crosby, Alexander wrote: Greetings: It looks like I am available on the 22nd for the webinar 85 on Weds, 20th for the pre- bne? Alex From: Wilkniss, Sandra Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin (CDCIONDIEHMCIPC) Ce: Coleman, Alceiisa Crosby, Alexander (CDCIONDIEHXNCIPC) , Richmond?Cram, Malia Dennehy, Heather Stone, Deborah (CDCKONDIEHINCIPC) <2an ov> Subject: Re: one 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. I could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin {iepm'l'i?riicdcgov} Sent: Thursday, June 14, 2018 11:34:07 PM To: Wilkniss, Sandra Cc: Coleman, Akeiisa; Crosby, Alexander Richmond-Chum, Malia Dennehy, Heather Stone, Deborah (CDCIONDIEHINCIPC) Subject: RE: June 22 webinar Yes, it would be helpful if you could schedule a ore-brief next week. From a ourck peek at calendars it looks like Alex, Deb and myself might be available Monday 10:30-11 or Wed 3:30-41. From: Wilkniss, Sandra <5Wilkniss@NGA.0RG> Sent: Thursday, June 14, 2018 11:25 PM To: Black, Erin wrote: Ladies what does the federal overview in the agenda below consist of? As mentioned I plan to be on the call, also the Vital Signs lead author, Deb Stone (copied), will be on the call to present on the Vital Signs. Alex is currently on leave but back next week to discuss his availability- From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 1:25 PM To: Black, Erin Cc: Coleman, Akeiisa Subject: June 22 webinar Hi again, Erin. We just discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors {all states and territories invited) 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect - NGA min CDC talking about recent data min NGA to summarize meeting highlights min state rep from CD to talk about their comprehensive approach 55- min IDIUT rep to talk about prevention or partnership (this is being nailed down in the next couple days) 15 min (1 A We will be able to show slides. I hope this helps! From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 10:50 AM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HI Erin, It is still being reviewed internally. So, we had hoped to do the webinar after the paper was done. However, the opportunity on the 22"Id came up and we thought it more important to capitalize on the momentum of your recent report rather than wait for our paper to be final. We think it critical to get attention to the issue while its top of mind. Sound ok? From: Black, Erin Sent: Thursday, June 14, 2018 10:25 AM To: Wilkniss, Sandra Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Have you sent us a copy of the report yet from the convening that you will be discussing on the call? I will be on the call but also still confirming if others will attend. Alex is out until Monday. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 9:49 AM To: Black, Erin Subject: Re: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data andfor can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin wrote: Sandra -1 am available that day/time - but let me check internally and see who would be best to present on the VS and get back to you. From: Wilkniss, Sandra Sent: Tuesday, June 12, 2018 9:00 AM To: Black, Erin Cc: Crosby, Alexander ; Richmond?Crum, Malia <'rv8 cdc. Dennehy, Heather ckvz? cdc. ov> Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates I will be on leave July 16-20 and in an all-day meeting July 31. From: Wilkniss, Sandra Sent: Thursday, June 7, 2018 1:27 PM To: Black, Erin Coleman, Akeiisa Cc: Crosby, Alexander ; Richmond-Crum, Malia <'rv8 cdc. ov>; Dennehy, Heather ckvz? cdc. ova Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We ca n't wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin (CDCIONDIEHINCIPC) Sent: Thursday, June 2018 9:55 AM To: Wilkniss, Sandra sSWilkniss??NGADRG); Coleman, Akeiisa Cc: Crosby, Alexander ; Dennehy, Heather ckvz? cdc. ov> Subject: EMBARGOED Until 1pm June 7: Vital Signs. Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Sandra and Akeiisa, As we mentioned, our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, will be released later today. The report includes state? level trends in suicide rates from 1999?2016, and, with data from National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. The CDC celebrates the National Governors Association?s commitment to creating safe communities. We hope that this resource can provide state leaders with an increased understanding of the impact of suicide in their states, as well as potential solutions for prevention. I would appreciate it if you could help disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Also, as discussed we will plan to highlight the Vital Signs on the planned Webinar with State health policy advisors {has a date been set vet?]. Erin The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortality Weekly Report article, "Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm following a media telebriefing at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vital Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016. suicide rates increased in nearly eveiy state. with 25 states experiencing increases of more than 30% each I Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone. including relationship. substance use, physical health. job. financial. and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of social media tools such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, and/or confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, and/or confidential. Ifthe reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls} and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls] and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. if you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientis) and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. Ifyou have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient{s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain inibrmation that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. From: Coleman, Akeiisa Sent: 18 Jun 2013 15:07:01 +0000 To: Black, Erin Sandra Cc: Richmond-Crum, Malia Heather Deborah Alexander Caroline Subject: RE: June 22 webinar Attachments: Governors' Health Ca re Leadership Webinar on State Strategies for Suicide Preventionmsg Attached is a calendar invite that was shared with governors? staff and health secretaries. Also, here is the link to register for the webinar: Akeiisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 acolemangr?ngaorg From: Black, Erin Sent: Monday, June 18, 2018 l0:42 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Richmond-Calm, Malia Dennehy, Heather (CDCHONDIEHINCIPC) Stone, Deborah Crosby, Alexander Subject: RE: June 22 wehinar Can you please forward the invitation for the webinar on Friday so that we have it on our calendars and have the call-in information. Thank you. From: Wilkniss, Sandra Sent: Friday, June 15, 2018 11:25 AM To: Crosby, Alexander {aecl wedeaov> Cc: Black, Erin (CDCIONDIEHFNCIPC) ; Coleman, Akeiisa (AColeman??lNGADRGa; Richmonderum, Malia Dennehy, Heather Stone, Deborah {2:an diode. ov> Subject: Re: June 22 webinar Wonderful! On Jun 15, 2018, at 9:27 AM, Crosby, Alexander wrote: Greetings: It looks like I am available on the 22nd for the webinar on Weds, 20th for the pre- brief. Alex From: Wilkniss, Sandra Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Cram, Malia Subject: Re: June 22 webinar Great. Will send and invitation for Wednesday at 3:304. I could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin (CDCIONDIEHINCIPC) Sent: Thursday, June 14,2018 11:34:07 PM To: Wilkniss, Sandra Cc: Coleman, Akeiisa; Crosby, Alexander Richmond-Cram, Malia Dennehy, Heather Stone, Deborah (CDCXONDIEHFNCIPC) Subject: RE: June 22 webinar Yes, it would be helpful if you could schedule a pre?brief next week. From a quick peek at calendars it looks like Alex, Deb and myself might be available Monday 10:30?11 or Wed 3:304. From: Wilkniss, Sandra <5Wilkniss@NGA.ORG> Sent: Thursday, June 14, 2018 11:25 PM To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah <2af9@cdc.gov> Subject: Re: June 22 webinar Hello Erin and Dr Stone. We can be flexible in the federal overview and take your lead on the data to highlight as well as any priority strategies, federal-state partnership aimed at preventing suicide you would like to share. May we schedule a call with the three of you for when Alex returns early next week to plan? Thank you! Sandra On Jun 14, 2018, at 11:19 PM, Black, Erin wrote: Ladies - what does the federal overview in the agenda below consist of? As mentioned I plan to be on the call, also the Vital Signs lead author, Deb Stone (copied), will be on the call to present on the Vital Signs. Alex is currently on leave but back next week to discuss his availability. From: Wilkniss, Sandra <5Wilkniss@NGA.0RG> Sent: Thursday, June 14, 2018 1:25 PM To: Black, Erin m7 cdc. ov> Cc: Coleman, Akeiisa Subject: June 22 webinar Hi again, Erin. Wejust discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors {all states and territories invited) 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect NGA min CDC talking about recent data min NGA to summarize meeting highlights min state rep from C0 to talk about their comprehensive approach 5-7 min rep to talk about prevention or partnership (this is being nailed down in the next couple clayswill be able to show slides. I hope this helps! From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 10:50 AM To: Black, Erin Subject: Re: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data andx'or can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin wrote: Sandra ?1 am available that day/time but let me check internally and see who would be best to present on the V5 and get back to you. From: Wilkniss, Sandra Sent: Tuesday, June 12, 2018 9:00 AM To: Black, Erin Cc: Crosby, Alexander ; Dennehy, Heather Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Good morning Erin, Alex, Malia and Heather, Thanks again for this terrific report! We are updating the paper now with new stats. In the meantime, we have had an opening for our state leadership calls for June 22 2-3pm eastern which we could use to highlight the findings of the Vital Signs report and lessons learned from our meeting and we have a couple of states available to give brief comments about their strategies. I am hoping that it is possible for you all to be available that dayftime for the webinar with governors health policy advisors? it is usually very well attended and may help perpetuate the momentum around your report. Please let me know if it?s possible and we can jump on a call and sort out details. Thanks! Sandra From: Black, Erin (CDCKONDIEHINCIPC) [mailtozepm7@cdc.gov] Sent: Thursday, June 7, 2018 1:34 PM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander ; Richmond?Crum, Malia ; Dennehy, Heather Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates i will be on leave July 16?20 and in an all?day meeting July 31. From: Wilkniss, Sandra Sent: Thursday, June 7, 2018 1:27 PM To: Black, Erin (CDCXONDIEHXNCIPC) ; Dennehy, Heather ckvz? cdc. ova- Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We can?t wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin Sent: Thursday, June 7, 2018 9:56 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander ; Dennehy, Heather Subject: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Sandra and Akeiisa, As we mentioned, our new Vital Signs, Contributing Circumstances ta Suicide and increasing Trends in State Suicide Rates, will be released later today. The report includes state- level trends in suicide rates from 1999?2016, and, with data from (3005 National Violent Death Reporting System, looks at the circumstances of suicide among peeple with and without known mental health conditions. The CDC celebrates the National Governors Association?s commitment to creating safe communities. We hope that this resource can provide state leaders with an increased understanding of the impact of suicide in their states, as well as potential soluticms for prevention. I would appreciate it if you could help disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Also, as discussed we will plan to highlight the Vital Signs on the planned Webinar with State health policy advisors {has a date been set yet?l. Erin The CDC Vitai Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 2? states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Vitai Signs materials, including the Morbidity and Mortality Weekiy Report article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates," and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2013, at 1:00 pm following a media telebriefing at noon; all attached materials are EMBARGDED until 1pm EST. Key points in the 1Mital Signs report include: I In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older 0 From 1999-2016, suicide rates increased in nearly every state. with '25 states experiencing increases of more than 30% each 0 Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than halfo?f people who died by suicide did not have a known mental health condition I A range of factors contributes to suicide beyond mental health conditions alone, including relationship= substance use, physical health, job, financial. and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of social media tools such as the Vital Signs buttons and email updates. Visit CDC's Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientis) and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, and/or confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls) and may contain information that is privileged, proprietary, and/or confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, and/or confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientis} and may contain information that is privileged, proprietary, and/or confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andr?or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, and/or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. From: Picher, Caroline Sent: 14 Jun 2018 22:32:29 +0000 To: Picher, Caroline Subject: Governors' Health Care Leadership Webinar on State Strategies for Suicide Prevention Please register for Gevernors? Health Care Leadership Call on State Strategies for Suicide Prevention on Jun 212018 2:00 PM EDT at: w: 717" ?4 After registering, you will receive a confirmation email containing information about joining the webinar. Agenda TBD From: Richmond-Crum, Malia (CDCIDNDIEHINCIPC) Sent: 21 Jun 2018 07:43:35 -O400 To: Stone, Deborah Alexander Cc: Dennehy, Heather Erin Subject: RE: June 22 webinar Got it. Thanks. From: Stone, Deborah (CDCIDNDIEHXNCIPC) Sent: Wednesday, June 20, 2018 4:52 PM To: Richmond-Crum, Malia Crosby, Alexander Cc: Dennehy, Heather Black, Erin Subject: RE: June 22 webinar No, nothing changed. I just streamlined the talking points a bit. Deb From: Richmond-Crum, Malia Sent: Wednesday, lune 20, 2018 4:42 PM To: Stone, Deborah Crosby, Alexander Cc: Dennehy, Heather (kvz? cdc. ova; Black, Erin Subject: RE: June 22 webinar Hi Deb- Did anything change from the VS Town Hall? From: Stone, Deborah Sent: Wednesday, June 20, 2018 4:40 PM To: Crosby, Alexander (aecl@cdc.goy> Cc: Richmond-Crum, Malia Dennehy, Heather Black, Erin (CDCIONDIEHINCIPC) m? cdc. ova- Subject: RE: June 22 webinar Thanks, Alex. I?m going to go ahead and send them in a few mins. Deb From: Crosby, Alexander Sent: Wednesday, June 20, 2018 4:39 PM To: Stone, Deborah (CDCIONDIEHXNCIPQ <2an cdc. ow? Cc: Richmond?Crum, Malia Dennehy, Heather ckyz? cdc. one; Black, Erin ce m7 cdc. 0y} Subject: RE: June 22 webinar Greetings: I think those look good. Alex From: Stone, Deborah Sent: Wednesday, June 20, 2018 3:58 PM To: Black, Erin Cc: Richmond?Crum, Malia Subject: RE: June 22 1webinar Hi Guys, These are the slides and talking points I had. Do you think these are ok? Deb From: Coleman, Akeiisa Sent: Monday, June 18, 2018 11:07 AM To: Black, Erin Wilkniss, Sandra <5Wilkniss@NGA.ORGa Cc: Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Crosby, Alexander Picher, Caroline Sent: Monday, June 18, 2018 10:42 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Richmond-Crum, Malia Dennehy, Heather Stone, Deborah ?:2an cdc. ov>; Crosby, Alexander Subject: RE: June 22 webinar Can you please forward the invitation for the webinar on Friday so that we have it on our calendars and have the call-in information. Thank you. From: Wilkniss, Sandra Sent: Friday, June 15, 2018 11:25 AM To: Crosby, Alexander (aecl cdc. ova Cc: Black, Erin Coleman, Akeiisa Richmond-Crum, Malia Dennehy, Heather Stone, Deborah <2:an cdc. ov> Subject: Re: June 22 webinar Wonderful! On Jun 15, 2018, at 9:27 AM, Crosby, Alexander siaeel Erode. ov> wrote: Greetings: It looks like I am available on the 22nd for the webinar 8: on Weds, 20th for the ore-brief. Alex From: Wilkniss, Sandra Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Subject: Re: June 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. i could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin Sent: Thursday, June 1d, 2018 11:34:07 PM To: Wilkniss, Sandra Cc: Coleman, Akeiisa; Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Subject: RE: June 22 webinar Yes, it would be helpful if you could schedule a ore-brief next week. From a quick peek at calendars it looks like Alex, Deb and myself might be available Monday 10:30?11 or Wed 3:30-4. From: Wilkniss, Sandra Sent: Thursday, June 14, 2013 11:25 PM To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond?Crum, Malia Dennehy, Heather Stone, Deborah cdc. ov> Subject: Re: June 22 webinar Hello Erin and Dr Stone. We can be flexible in the federal overview and take your lead on the data to highlight as well as any priority strategies, federal-state partnership aimed at preventing suicide you would like to share. May we schedule a call with the three of you for when Alex returns early next week to plan? Thank you! Sandra On Jun 14, 2018, at 11:19 PM, Black, Erin wrote: Ladies what does the federal overview in the agenda below consist of? As mentioned I plan to be on the call, also the Vital Signs lead author, Deb Stone {copiedL will be on the call to present on the Vital Signs. Alex is currently on leave but back next week to discuss his availability. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 1:25 PM To: Black, Erin (e m? cdc. ov> Cc: Coleman, Akeiisa Subject: June 22 webinar Hi again, Erin. Wejust discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors {all states and territories invited) 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect NGA min CDC talking about recent data min NGA to summarize meeting highlights min state rep from C0 to talk about their comprehensive approach 5-7 min rep to talk about prevention or partnership (this is being nailed down in the next couple clayswill be able to show slides. I hope this helps! From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 10:50 AM To: Black, Erin Subject: Re: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data andx'or can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin wrote: Sandra ?1 am available that day/time but let me check internally and see who would be best to present on the V5 and get back to you. From: Wilkniss, Sandra Sent: Tuesday, June 12, 2018 9:00 AM To: Black, Erin Cc: Crosby, Alexander ; Dennehy, Heather Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Good morning Erin, Alex, Malia and Heather, Thanks again for this terrific report! We are updating the paper now with new stats. In the meantime, we have had an opening for our state leadership calls for June 22 2-3pm eastern which we could use to highlight the findings of the Vital Signs report and lessons learned from our meeting and we have a couple of states available to give brief comments about their strategies. I am hoping that it is possible for you all to be available that dayftime for the webinar with governors health policy advisors? it is usually very well attended and may help perpetuate the momentum around your report. Please let me know if it?s possible and we can jump on a call and sort out details. Thanks! Sandra From: Black, Erin (CDCKONDIEHINCIPC) [mailtozepm7@cdc.gov] Sent: Thursday, June 7, 2018 1:34 PM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander ; Richmond?Crum, Malia ; Dennehy, Heather Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates i will be on leave July 16?20 and in an all?day meeting July 31. From: Wilkniss, Sandra Sent: Thursday, June 7, 2018 1:27 PM To: Black, Erin (CDCXONDIEHXNCIPC) ; Dennehy, Heather ckvz? cdc. ova- Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We can?t wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin Sent: Thursday, June 7, 2018 9:56 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander Subject: EMBARGDED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Sandra and Akeiisa, As we mentioned, our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in State Suicide Rates, will be released later today. The report includes state- level trends in suicide rates from 1999?2016, and, with data from CDC's National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. The CDC celebrates the National Governors Association?s commitment to creating safe communities. We hope that this resource can provide state leaders with an increased understanding of the impact of suicide in their states, as well as potential solutions for prevention. I would appreciate it if you could help disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Also, as discussed we will plan to highlight the Vital Signs on the planned Webinar with State health policy advisors {has a date been set yet?). Erin The CDC Vita! Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e-mail contains advance copies of several Viiai Signs materials. including the Morbidity and Mortality Weekiv Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vita! Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older I From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each 0 Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition a A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, ?nancial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vital Signs Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of social media tools, such as the Vita! Signs buttons and email updates. Visit CDC's Public Health Media Library at and search on the term Vital Signs. We also invite you tojoin us for the Vita! Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Vital Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andior con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, and/or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, and! or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientis} and may contain information that is privileged, proprietary, and/or confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, and/or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. From: Dennehy, Heather Sent: 20 Jun 2018 16:39:55 0400 To: Crosby, Alexander Deborah (CDCIONDIEHINCIPQ Cc: Richmond-Crum, Malia Erin Subject: RE: June 22 webinar Agreed! They look great to me! From: Crosby, Alexander Sent: Wednesday, June 20, 2018 4:39 PM To: Stone, Deborah (CDCIONDIEHKNCIPQ Cc: Richmond-Crum, Malia Dennehy, Heather Black, Erin Subject: RE: June 22 webinar Greetings: I think those look good. Alex From: Stone, Deborah Sent: Wednesday, June 20, 2018 3:58 PM To: Black, Erin (e m? cdc. oy> Cc: Richmond-Crum, Malia Dennehy, Heather Crosby, Alexander Cc: Richmond~Crum, Malia Dennehy, Heather Stone, Deborah <2an cdc. ow; Crosby, Alexander Picher, Caroline wrote: Greetings: It looks like I am available on the 22nd for the webinar 81 on Weds, 20th for the pre-brief. Alex From: Wilkniss, Sandra Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander (CDCIONDIEHINCIPC) Richmond-(2mm, Malia Dennehy, Heather Stone, Deborah <2an cdc. ova Subject: Re: June 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. i could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin Sent: Thursday, June 14, 2018 11:34:07 PM To: Wilkniss, Sandra Cc: Coleman, Akeiisa; Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah (CDCJONDIEHINCIPC) Subject: RE: June 22 webinar Yes, it would be helpful if you could schedule a ore-brief next week, From a quick peek at calendars it looks like Alex, Deb and myself might be available Monday 10:30-11 or Wed 3:30-4. From: Will-miss, Sandra <5Wilkniss@NGA.0RG> Sent: Thursday, June 14, 2018 11:25 PM To: Black, Erin Subject: Re: June 22 webinar Hello Erin and Dr Stone. We can be flexible in the federal overview and take your lead on the data to highlight as well as any priority strategies, federal-state partnership aimed at preventing suicide you would like to share. May we schedule a call with the three of you for when Alex returns early next week to plan? Thank you! Sandra On Jun 14, 2013, at 11:19 PM, Black, Erin Subject: RE: EMBARGOED Until 1pm June 7: Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HI Erin, It is still being reviewed internally. So, we had hoped to do the webinar after the paper was done. However, the opportunity on the came up and we thought it more important to capitalize on the momentum of your recent report rather than wait for our paper to be final. We think it critical to get attention to the issue while its top of mind. Sound ok? From: Black, Erin Sent: Thursday, June 14, 2018 10:25 AM To: Wilkniss, Sandra Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Have you sent us a copy of the report yet from the convening that you will be discussing on the call? I will be on the call but also still confirming if others will attend. Alex is out until Monday. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 9:49 AM To: Black, Erin Subject: Re: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data and/or can others join the call? We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin Cc: Crosby, Alexander Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Good morning Erin, Alex, Malia and Heather, Thanks again for this terrific report! We are updating the paper now with new stats. In the meantime, we have had an opening for our state leadership calls for June 22 2-3pm eastern which we could use to highlight the findings of the Vital Signs report and lessons learned from our meeting and we have a couple of states available to give brief comments about their strategies. I am hoping that it is possible for you all to be available that dayftime for the webinar with governors health policy advisers? It is usually very well attended and may help perpetuate the momentum around your report. Please let me know if it?s possible and we can jump on a call and sort out details. Thanks! Sandra From: Black, Erin [mailtozepm? @_cdc.gov] Sent: Thursday, June 7, 2018 1:34 PM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Crosby, Alexander Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates I will be on leave July 16-20 and in an all-day meeting July 31. From: Wilkniss, Sandra Sent: Thursday, June 7, 2018 1:27 PM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We ca n?t wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin (CDCKONDIEHXNCIPC) Sent: Thursday, June 2018 9:56 AM To: Wilkniss, Sandra ; Richmond?(2mm, Malia Subject: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Sandra and Akeiisa, As we mentioned, our new Vital Signs, Contributing Circumstances to Suicide and increasing Trends in Store Suicide Rates, will be released later today. The report includes state level trends in suicide rates from 1999?2016, and, with data from CDC's National Violent Death Reporting System, looks at the circumstances of suicide among people with and without known mental health conditions. The CDC celebrates the National Governors Association?s commitment to creating safe communities. We hope that this resource can provide state leaders with an increased understanding of the impact of suicide in their states, as well as potential solutions for prevention. I would appreciate it if you could help disseminate the Vital Signs to your networks once the embargo lifts at 1:00 pm. Also, as discussed we will plan to highlight the Vital Signs on the planned Webinar with State health policy advisors (has a date been set vet?]. Erin The CDC Vital Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and DC, examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e?mail contains advance copies of several itai Signs materials, including the Morbidity and Moi-ioii'iy Weekiy Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four?page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Thursday, June 7, 2018, at 1:00 pm (EST) following a media tale-brie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vita! Signs report include: In 2016, nearly 45,000 suicides occmred in the US among people 10 years and older 0 From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each 0 Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vita! Sions Webpage to find the MMWR article, fact sheet, and other materials. Take advantage of CDC ?5 social media tools, such as the Hm! Signs buttons and email updates. Visit CDC's Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vito! Signs Town Hall Teleconference on June 12 at 2:00 pm Vital Signs is about more than data, it is about action, We look forward to continuing our work together to prevent suicides and promoting healthier communities. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient{s) and may contain information that is privileged, proprietary, and/or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The infonnation contained in this electronic transmission, including any attachments, is for the exclusive use of the intended reeipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andfor con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, and? or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient{s) and may contain information that is privileged, proprietary, andi?or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipientls} and may contain information that is privileged, proprietary, and/or confidential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient(s) and may contain information that is privileged, proprietary, andi?or con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. The information contained in this electronic transmission, including any attachments, is for the exclusive use of the intended recipient{s) and may contain information that is privileged, proprietary, andior con?dential. If the reader of this transmission is not an intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby noti?ed that any review, dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify the sender and delete this message. From: Stone, Deborah Sent: 20 Jun 2018 19:58:10 +0000 To: Black, Erin Cc: Richmond-Crum, Malia Heather Alexander Subject: RE: June 22 webinar Attachments: Vital Signs NGA Meeting 6.22.1841:th Hi Guys, These are the slides and talking points I had. Do you think these are ok? Deb From: Coleman, Akeiisa Sent: Monday, June 18, 2018 11:07 AM To: Black, Erin Wilkniss, Sandra Cc: Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Crosby, Alexander Picher, Caroline Subject: RE: June 22 webinar Attached is a calendar invite that was shared with governors' staff and health secretaries. Also, here is the link to register for the webinar: Akeiisa Coleman, MSW Senior Policy Analyst, Health Division National Governors Association 202.624.5344 acoleman@nga.org From: Black, Erin Sent: Monday, June 18, 2018 10:42 AM To: Wilkniss, Sandra Coleman, Akeiisa Cc: Richmond-Crum, Malia <'rv8 cdc. 0v}; Dennehy, Heather Stone, Deborah <7.an cdc. ov>; Crosby, Alexander Subject: RE: June 22 webinar Can you please forward the invitation for the webinar on Friday so that we have it on our calendars and have the call?in information. Thank you. From: Wilkniss, Sandra <5Wilkniss@NGA.ORG> Sent: Friday, June 15, 2018 11:25 AM To: Crosby, Alexander (aecl cdc. ov> Cc: Black, Erin Coleman, Akeiisa Richmond?(2mm, Malia Dennehy, Heather Stone, Deborah (CDCIONDIEHINCIPC) <2an cdc. ov> Subject: Re: June 22 webinar Wonderful! On Jun 15, 2018, at 9:27 AM, Crosby, Alexander siaecl wrote: Greetings: It looks like I am available on the 22nd for the webinar 81. on Weds, 20th for the ore-brief. Alex From: Wilkniss, Sandra Date: June 15, 2018 at 6:45:31 AM EDT To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander Richmond-Crum, Malia Dennehy, Heather Stone, Deborah Subject: Re: June 22 webinar Great. Will send and invitation for Wednesday at 3:30-4. I could talk later in the day on Monday if you want to do it sooner, but am stuck before noon. thanks! Sandra From: Black, Erin Sent: Thursday, June 14, 2018 11:34:01 PM To: Wilkniss, Sandra Cc: Coleman, Akeiisa; Crosby, Alexander Malia Dennehy, Heather Stone, Deborah Subiect: RE: June 22 webinar Yes, it would be helpful if you could schedule a ore-brief next week. From a quick peek at calendars it looks like Alex, Deb and myself might be available Monday 10:30?11 or Wed 3230?4. From: Wilkniss, Sandra Sent: Thursday, June 14, 2013 11:25 PM To: Black, Erin Cc: Coleman, Akeiisa Crosby, Alexander (CDCIONDIEHINCIPCJ Richmond?Crum, Malia Subject: Re: June 22 webinar Hello Erin and Dr Stone. We can be flexible in the federal overview and take your lead on the data to highlight as well as any priority strategies, federal-state partnership aimed at preventing suicide you would like to share. May we schedule a call with the three of you for when Alex returns early next week to plan? Thank you! Sandra On Jun 14, 2018, at 11:19 PM, Black, Erin wrote: Ladies 1 what does the federal overview in the agenda below consist of? As mentioned I plan to be on the call, also the Vital Signs lead author, Deb Stone (copied), will be on the call to present on the Vital Signs. Alex is currently on leave but back next week to discuss his availability. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 1:25 PM To: Black, Erin Cc: Coleman, Akeiisa Subject: June 22 webinar Hi again, Erin. Wejust discussed the layout for this webinar and wanted to bullet it out for you for discussion you are having at CDC: Call is June 22 from 2 3pm eastern with governors health policy adivisors (all states and territories invited) 5 minutes flex time for people to get on the call and announce themselves 10 min federal overview 2 min overview of what to expect - NBA min CDC talking about recent data min NGA to summarize meeting highlights min state rep from CD to talk about their comprehensive approach min rep to talk about prevention or partnership (this is being nailed down in the next couple dayswill be able to show slides. I hope this helps! From: Wilkniss, Sandra <5Wilkniss@NGA.DRGe Sent: Thursday, June 14, 2018 10:50 AM To: Black, Erin Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates HI Erin, It is still being reviewed internally. So, we had hoped to do the webinar after the paper was done. However, the opportunity on the 22'? came up and we thought it more important to capitalize on the momentum of your recent report rather than wait for our paper to be final. We think it critical to get attention to the issue while its top of mind. Sound ok? From: Black, Erin Sent: Thursday, June 14, 2018 10:25 AM To: Wilkniss, Sandra cSWilkniss@NGA.DRG> Subject: RE: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Have you sent us a copy of the report yet from the convening that you will be discussing on the call? I will be on the call but also still confirming if others will attend. Alex is out until Monday. From: Wilkniss, Sandra Sent: Thursday, June 14, 2018 9:49 AM To: Black, Erin Subject: Re: EMBARGOED Until 1pm June 7: Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hi Erin - We have all things ready to go for the webinar next Friday. Are you ok to cover the new data and/'or can others join the call?I We are super excited to highlight and get the info to all governors. Thanks! On Jun 12, 2018, at 1:30 PM, Black, Erin wrote: Sandra 1 I am available that dayftime but let me check internally and see who would be best to present on the V5 and get back to you. From: Wilkniss, Sandra <5Wilkniss@NGA.ORG> Sent: Tuesday, June 12, 2018 9:00 AM To: Black, Erin Cc: Crosby, Alexander ; Richmond-Crum, Malia Dennehy, Heather Sent: Thursday, June 17, 2018 1:27 PM To: Black, Erin Coleman, Akeiisa Cc: Crosby, Alexander ; Richmond-Crum, Malia Dennehy, Heather (kvz? cdc. ova Subject: RE: EMBARGOED Until 1pm June Vital Signs, Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates Hello Erin and Team. Congratulations! We can?t wait to review and will incorporate into the white paper and will share with our folks. The date for the webinar has not yet but set, but we are looking at July. Would it be possible for you to let us know of dates that do not work in July for at least one of your team to join and share the Vital Signs highlights? Thanks! Sandra From: Black, Erin Sent: Thursday, June 2018 9:55 AM To: Wilkniss, Sandra Coleman, Akeiisa sAColemani?i?NGADRG) Cc: Crosby, Alexander (aecl cdc. ova; Richmond?Cram, Malia ; Dennehy, Heather Cc: Simon, Thomas Peaker, Brandy Subject: RE: June Vital Signs - Suicide Prevention - MMWR early draft Just to clarify - Dr. Redfield did not review your MMWR when it was sent for review with the FS because he had just started as Director. As Dr. Redfield learns more about the agency, we?ll get more guidance from DD on how he wants to engage with Vital Signs. Since he has requested a copy of your MMWR, if he has comments at this point, we will not expect you to incorporate them by the time the MMWR is due to ScholarOne on 4/25. We will work with the MMWR editors to let them know that his comments were just received and that you all will incorporate his requested changes in the first round of edits with the MMWR editors. Thanks, Brandy From: Peaker, Brandy Sent: Friday, April 20, 2018 3:59 PM To: Sokler, Stone, Deborah (CDCIDNDIEHXNCIPQ ; Schieber, Richard A. Omisore, Shannon L. (h l5 cdc. ov> Subject: RE: June Vital Signs - Suicide Prevention - MMWR early draft Hi Deb CDCXOD had the opportunity to review your MMWR when they reviewed the FS. They will review it again after it is submitted to ScholarOne. You may get more comments from them at that point. No need to worry. They have already seen it once when reviewing the FS, they will see again during MMWR production, and then before the prebrief. They may not have many comments because it is written so well. Brandy From: Sokler, Sent: Friday, April 20, 2018 3:36 PM To: Stone, Deborah Schieber, Richard A. Peaker, Brandy Dmisore, Shannon L. (CDCIDDIOADQ Cc: Sokler, cdc. ov> Subject: RE: June Vital Signs Suicide Prevention - MMWR early draft Hi Deb, Didn't want you fretting over the weekend. Rich is out today and Rich andfor Brandy will get back to you probably on Monday. Thanks and have a good weekend. From: Stone, Deborah Sent: Friday, April 20, 2018 3:08 PM To: Sokler, Schieber, Richard A. Peaker, Brandy Omisore, Shannon L. Subject: RE: June Vital Signs - Suicide Prevention - MMWR early draft Hello VS team. I?m concerned that i haven't gotten any comments back on our MMWR yet and revisions are due back on the 25th. Do you have any information about this you can provide? Thank you, Deb From: Sokler, Sent: Friday, April 20, 2013 2:26 PM To: Simon, Thomas Stone, Deborah Cc: Sokler, (CDCIDDXOADC) Schieber, Richard A. Peaker, Brandy Dmisore, Shannon L. Subject: FW: June Vital Signs - Suicide Prevention - MMWR early draft Hi Folks, Just wanted you to know that Dr. Redfield asked for a copy of the MMWR now so that he can determine whether he or Anne Schuchat will do the Telebriefing. Either one is probably a good thing! Will keep you posted. From: Sokler, Sent: Friday, April 20, 2013 2:21 PM To: Daniel, Katherine Lyon Subject: June Vital Signs - Suicide Prevention - MMWR early draft This is an early draft of the MMWR. Currently, the pre-brief with Anne accommodate her travel schedule we set up the media telebrief and launch ofthe Vital Signs for Thursday, June 7. Invites have been issued. If Dr. Redfield is able to and wants to do this one, is it possible to change to our normal Tuesday, June 5 schedule? FYI and isn?t any deciding factor at all, but I am on leave and on a plane on June 7, but I am here on June 5. Please let us know, Thanks, From: Peaker, Brandy Sent: 20 Apr 2018 16:18:24 -0400 To: Sokler, Deborah Richard A. Shannon L. Cc: Simon, Thomas Subject: RE: June Vital Signs - Suicide Prevention - MMWR early draft Meant to add - Dr. Schuchat did review the MMWR when reviewing the FS and she did not have any comments. We don?t expect any more comments from her until after the MMWR is submitted to ScholarOne. From: Peaker, Brandy Sent: Friday, April 20, 2013 4:13 PM To: Sokler, (CDCIDDIOADC) Stone, Deborah Schieber, Richard A. Omisore, Shannon L. (CDCJUDKDADQ Cc: Simon, Thomas Peaker, Brandy Subject: RE: June Vital Signs - Suicide Prevention - MMWR early draft Just to clarify Dr. Redfield did not review your MMWR when it was sent for review with the FS because he had just started as Director. As Dr. Redfield learns more about the agency, we?ll get more guidance from OD on how he wants to engage with Vital Signs. Since he has requested a copy of your MMWR, if he has comments at this point, we will not expect you to incorporate them by the time the MMWR is due to Scholaane on 4,!25. We will work with the MMWR editors to let them know that his comments were just received and that you all will incorporate his requested changes in the first round of edits with the MMWR editors. Thanks, Brandy From: Peaker, Brandy Sent: Friday, April 20, 2018 3:59 PM To: Sokler, (CDCIODJDADC) Subject: RE: June Vital Signs - Suicide Prevention - MMWR early draft Hi Deb had the opportunity to review your MMWR when they reviewed the FS. They will review it again after it is submitted to Scholaane. You may get more comments from them at that point. No need to worry. They have already seen it once when reviewing the FS, they will see again during MMWR production, and then before the prebrief. They may not have many comments because it is written so well. Brandy From: Solder, Sent: Friday, April 20, 2018 3:36 PM To: Stone, Deborah Schieber, Richard A. Peaker, Brandy Omisore, Shannon L. Cc: Sokler, <2520@cdc.gov> Subject: RE: June vital Signs - Suicide Prevention - MMWR early draft Hi Deb, Didn?t want you fretting over the weekend. Rich is out today and Rich andfor Brandy will get back to you - probably on Monday. Thanks and have a good weekend. From: Stone, Deborah (CDCIONDIEHINCIPC) Sent: Friday, April 20, 2018 3:03 PM To: Sokler, Schieber, Richard A. Peaker, Brandy Dmisore, Shannon L. Subject: RE: June Vital Signs - Suicide Prevention - MMWR early draft Hello VS team. I?m concerned that I haven?t gotten any comments back on our MMWR yet and revisions are due back on the 25th. Do you have any information about this you can provide? Thank you, Deb From: Sokler, Sent: Friday, April 20, 2018 2:26 PM To: Simon, Thomas (CDCIONDIEHINCIPC) Stone, Deborah <2af9@cdc.gov> Cc: Solder, Schieber, Richard A. Peaker, Brandy Dmisore, Shannon L. Subject: FW: June Vital Signs Suicide Prevention - MMWR early draft Hi Folks, Just wanted you to know that Dr. Redfield asked for a copy of the MMWR now so that he can determine whether he or Anne Schuchat will do the Telebriefing. Either one is probably a good thing! Will keep you posted. From: Solder, Sent: Friday, April 20, 2013 2:21 PM To: Daniel, Katherine Lyon Subject: June Vital Signs - Suicide Prevention - MMWR early draft This is an early draft of the MMWR. Currently, the pre-brief with Anne accommodate her travel schedule we set up the media telebrief and launch ofthe Vital Signs for Thursday, June 7. Invites have been issued. If Dr. Redfield is able to and wants to do this one, is it possible to change to our normal Tuesday, June 5 schedule? FYI and isn?t any deciding factor at all, but i am on leave and on a plane on June 7, but I am here on June 5. Please let us know, Thanks, From: Black, Erin Sent: 7 Jun 2018 09:09:09 -0400 To: Crosby, Alexander Kristin Deborah Cc: Bruce, lv'alerie M. Molly Regina Malia Marie R. Thomas (CDCXONDIEHINCIPC) Subject: RE: Media Messaging Work Group Call Attachments: FINAL MATERIALS FOR June - Vital Signs Suicide Preventionmsg Looks like you guys are all on the invite for the call with the Action Alliance Messaging Work Group today. Per Sokler?s email attached we can distribute VS materials to key partners and constituents as of Elam today. Are you all ok with sharing an embargoed copy of the Fact Sheet with those on the invite in advance of the call this afternoon with the stipulation that it is embargoed until 1pm and cannot be shared or forwarded? On the call I will plan to briefly highlight the fact sheet and Molly will discuss our messaging plans. From: Torguson, Kimberly Sent: Monday, May 14, 2018 6:59 PM To:Torguson, Kimberly; Belyeu, Black, Erin Bray, Miranda Bruce, Carr, Colleen; SCoggin@afsp.org; ccreighton@suicidology.org; Crosby, Alexander Curtin, Sally C. Daniel, Valerie M. mgdyak@eiconline.org; Johno@mhaofnyc.org; fgonzalez@mhaofnyc.org; Gass, Jesse; Hausman, Bridgette; Hedegaard, Holly Holland, Kristin ajkulp@suicidology.org; Kurnit, Molly Regina wendy.e.lakso.civ@mailmil; plauricella@reingold.com; cmaxwell@suicidology.org; McElroy, James McShane, Kristen eneely@reingold.com; AOBrien@afsp.org; O'Keefe, Lindsey (NIHINIMH) jpearson@nih.gov; Pearson, Jane Reed, Jerry; dreidenberg@save.org; Richmond~ Crum, Malia mrosen@mhaofnyc.org; michaelle.scanlon@nih.gov; Sobottka, Linda; Stone, Deborah Stout, Elly; AVactor@mhaofnyc.org; Warner, Margaret Wright, James Subject: Media Messaging Work Group Call When: Thursday, June 2018 11:00 AM Eastern Time at Canada). Where: Phone Number: 365-370-2808 {access code Phone Number: 866-370?2808 (access code Email Context (From 5/14): Hello Media Messaging Work Group (MMWG), Following the email below, we wanted to let you know that the CDC data expected to be released on June 5 will now be released on June 7. Additionally, we received word that we will not be receiving an embargoed copy so we'll be rescheduling our MMWG group call (originally scheduled for Thursday, May 31) to Thursday, June 7 at 11:00 a.m. The goal of this call is to convene our partners to: 1) discuss the data, and 2) develop consensus on our messaging that will be used to craft a statement. If you are unable to join the call, you will still have the opportunity to weigh in on the statement via email. We hope you can join us on Thursday, June 7 at 11:00 am. Lastly, we want to thank CDC for giving us the heads up about the data. Best, Hello Media Messaging Work Group, We wanted to call to your attention to a just-released article published in the American Journal of Preventive Medicine that looks at county?specific estimates of suicide rates. The paper titled "County- level Trends in Surcide Rates in the U.S., 2005-2015" was written by our Partner, CDC {authors include: Lauren M. Rossen, Holly Hedegaard, Diba Khan and Margaret Warner from Key findings include: I Posterior predicted mean county-level suicide rates increased by >10% from 2005 to 2015 for 99% of counties in the U.S., with 87% of counties showing increases of I Counties with the highest model-based suicide rates were consistently located across the western and northwestern U.S., with the exception of southern California and parts of Washington. I Compared with more urban counties, more rural counties had the highest estimated suicide rates from 2005 to 2015, and also the largest increases over time. Overall the data underscores the importance of looking at geographic areas to identify high risk and need for more coordinated and comprehensive community-based suicide prevention efforts in the U.S. While the Action Alliance does notplan to put out a formal statement about the data at this time, we encourage you to reference our past collective statement (written in collaboration with the MMWG partners} released last year that looks at suicide rates in urban and rural areas. ?rou?ll notice much of the information is very relevant and timely as it relates to the county-level trends data. Please find below some tailorable social media posts to help further promote the data: I Data released by featured in @AmJPrevMed shows county-level trends in suicide rates in the US I New article featured in @AmJPrevMed underscores need for coordinated and comprehensive community-based suicide prevention efforts I Trends about suicide, like geographic patterns, helps us develop more targeted community-based #suicideprevention strategies so we can reduce annual suicide rate 20% by 2025 I Rural counties in the U.S. had the highest estimated suicide rates from 2005-2015 according to just-released @AmlPrevMed I Tracking county-level suicide rates helps our field to better understand changes in suicide rates over time and develop more targeted suicide prevention efforts I Together we can reduce the annual suicide rate 20 percent by 2025 but we need continued research on community-level risk and protective factors as shown in recent data by @CDCinjury When posting, please consider incorporating Media Messaging Work Group Partner Twitter handles: I Mion Alliance I @AASuicidology - (afafsgnational I @CDCIniury I I mtofDe-ferg I @DeptVetAffairs I @EDCTweets . I @NiMHgov I I @samhsagg I @SAVEvoicesofedu I I @TrevorProiect I Some resources that you may also find helpful as you promote the data include: I Action Alliance's Transforming Communities: Key Elements for the implementation of Comprehensive Community-Based Suicide Prevention A resource that outlines strategic components that should guide program planning and implementation at the community level. I Preven tingSuicide: A Technical Package oLPolicyirogramsLand Practices A resourcethat helps states and communities prioritize efforts to prevent suicide. We wanted to give you all the heads up that CDC is also expected to release additional relevant data to inform suicide prevention efforts on or around June 5th. The Action Alliance Secretariat does plan to convene this groUp to develop consensus messaging around this impending data release. In preparation for this larger data release, we?ll be convening the MMWG for a call in late May to discuss the data and our collective statement. REQUEST: Please join us Jfor a planning call on Thursday, May 31 at 2:00 p.m. ET to plan ahead for collective statement about CDC data. We will send you a calendar invite (containing callrin information) to you shortly. If you are unable to participate on this call, you?ll have the opportunity to weigh in on the statement electronically. Lastly, we wanted to thank CDC for giving us the heads up about the data. Thank you. From: Sokler, Sent: 6 Jun 2018 14:32:49 43400 To: Houry, Debra E. Courtney Leslie Deborah James Alexander Malia Katherine A. Thomas Erin McCollom, Molly Daniel (CTR};Grusich, Katherina {Kate} Sharon Dontae Lina Michelle E. Anstice M. Renee Stefanie Bernadette Annina Julia K. Carol Y. Katherine Lyon Mansi S. Jay H. Shelly S. Kimberly C. lCDC};Dunn, Evelyn Kate Belsie nt, Llelwyn Hugh Megan Amy B. Jarrad Elizabeth Michael Tonya Alison Charlotte Dianna Ashley Seth Kenzie, William Fl. Laura Yerdon Robert (Kyle) Dagny Sapana Stacey M. lCTR);Payne, Chelsea C. Ami D. Sonja Stephen Robert R. Aimee Jessica Anne MD Gia M. Patti Marjorie J. (CDCIODJOCSj;Stanojevich, Joel G. Nina Douglas Kelly Michelle lcocrocooxom/oril Cc: Solder, Richard A. Brandy Shannon L. Cheryl L. {CTR};Guest, Megan Delaney Ursula (CTR) Subject: FINAL MATERIALS FDR DISTRIBUTION: June 7 - Vital Signs Suicide Prevention Attachments: DEAR PRESS _Final.docx, FACT SHEET_?v?ital TELEBRIEF ck_Final.docx, QA Document Suicide Vital Signs 6.5.1B.docx, Signs_ Hi Folks, This month?s issue of Vital Signs is on Suicide Rates Rising across the U.S. and releases Thursday. June with a Media Telebriefing at noon. All materials go live on the CDC website at 1 pm. Here are the key materials to use to distribute to stakeholders and partners: The Dear Colleague letter, MMWR, Fact Sheet. Press Release and Graphic. For those distributing to media. please send the MMWR. Fact Sheet. Press Release and Graphic. Dr. Schuchat will be the primary spokesperson for this Vital Signs. For those of you distributing out to partners and other constituents Thursday morning at 9 am. please make sure they know these are advance copies only. These materials are embargoed until 7 at 1 pm. Please adjust the Dear Colleague letter forthose people to which you send. Also please send Rich and me a copy when you email this out to your groups. We will also have the press release on CDC en Espanol and available through the Vital Signs website. For those attending the media telebriefing. have also attached the Telebrie?ng Script and the DEA document. These do not get distributed externally. For each Vital Signs issue. we track and report on results two times a after 24 hours and after 30 days. We track the number of audiences reached {from all media and web sources}. of stories and type of media. the dollar value of the media coverage if CDC had to purchase it as advertising. social media use and reuse. and of people looking at Vital Signs on our web pages. Vital Signs reaches out to a lot of different people with our topics and. from our evaluation surveys. the uptake out in the field is impressive. In a survey. an astounding 95% of state health of?cers and state epidemiologists were aware of and used VS issues. with about 3 in 4 using V3 in the past year. All shared the material with their constituents via conference call. e?mail. newsletter. or mailing for topics appropriate to their members. A stratified random sample survey. used with NACCHO member organizations. reported that 74% of all county or local health departments had heard of or used VS in the past year to educate staff. improve programs. and guide policy formation. As well. a 201? internal evaluation showed that most program staff involved believe the value derived from it is worth the work. although producing Vital Signs takes a lot of effort. I want to thank everyone who has worked on this issue for all their extra efforts. It?s a very important topic and will be valuable information for many people. We hope that program continues to use this Vital Signs to promote its messages and the recommended actions in it to achieve new results. Cheers. A. r11.? i.]lL' :iil'l?jli (fritters l'ntr' 'l'rirxeiisi? ("Hi'ilml fin-:I 1mm Horn". filS?i'o?wtil of?ce- ,iilrs?. 4r .tu q?pati-u m4". I I Saving Lwh. 7 Protenurg Pmpie' Dear Colleague: The CDC Viroi Signs series, launched in 2010, addresses a single, important public health topic each month. This month?s edition presents trends in suicide rates across all states and D.C., examines contributing factors to suicide in 27 states, and highlights strategies for comprehensive suicide prevention. We also highlight strategies for state public health departments and others working to help reduce suicides. This e?mail contains advance copies of several Vital Signs materials, including the Morbidity and Mortality Weekiv Report (MMWR) article, ?Vital Signs: Contributing Circumstances to Suicide and Increasing Trends in State Suicide Rates,? and a four-page consumer fact sheet. This latest edition of CDC Vital Signs will be released today, Tuesday, one 7, 2018, at 1:00 pm (EST) following a media telebrie?ng at noon; all attached materials are EMBARGOED until 1pm EST. Key points in the Vita} Signs report include: In 2016, nearly 45,000 suicides occurred in the US among people 10 years and older - From 1999-2016, suicide rates increased in nearly every state, with 25 states experiencing increases of more than 30% each Ir Data from 27 states participating in the National Violent Death Reporting System in 2015 indicate that more than half of people who died by suicide did not have a known mental health condition 0 A range of factors contributes to suicide beyond mental health conditions alone, including relationship, substance use, physical health, job, financial, and legal problems. After the embargo is lifted today at 1 pm (EDT), please share the CDC Vital Signs information broadly with your colleagues and partners. Visit the Vita! Signs Web page to ?nd the article, fact sheet, and other materials. Take advantage of social media tools, such as the Vital Signs buttons and email updates. Visit Public Health Media Library at and search on the term Vital Signs. We also invite you to join us for the Vital Signs Town Hall Teleconference on June 12 at 2:00 pm (EST). Viiai Signs is about more than data, it is about action. We look forward to continuing our work together to prevent suicides and promoting healthier communities. Thank you for your support. Debra Houry, MD, MPH James A. Mercy, Director Director National Center for Injury Prevention and Control Division of Violence Prevention National Center for Injury Prevention and Control Press Release Embargoed until 1:00 pm ET 'I'hursday, June 7, 2018 Contact: CDC Media Relations 404-639-3286 Suicide rates rising across the US. Comprehensive prevention goes beyond ofoetis on mental health concerns Suicide rates have been rising in nearly every state, according to the latest l?"imi Siam report by the Centers for Disease Control and Prevention (CDC). In 2016, nearly 45,000 Americans age 10 or older died by suicide. Suicide is the 1001 leading cause of death and is one of just three leading causes that are on the rise. Suicide is rarely caused by a single factor. Although suicide prevention efforts largely focus on identifying and providing treatment for people with mental health conditions, there are many additional opportunities for prevention. ?Suicide is a leading cause of death for Americans and it?s a tragedy for families and communities across the country,? said CDC Principal Deputy Director Anne Schuchat, MD. ?From individuals and communities to employers and healthcare professionals, everyone can play a role in efforts to help save lives and reverse this troubling rise in suicide." Many factors contribute to suicide For this Vital Signs report, CDC researchers examined state-level trends in suicide rates from 1999- 2016. In addition, they used 2015 data from ?ctional Violent Death Reporting System, which covered 27 states, to look at the circumstances of suicide among people with and without known mental health conditions. Researchers found that more than half of people who died by suicide did not have a known diagnosed mental health condition at the time of death. Relationship problems or loss, substance misuse; physical health problems; and job, money, legal or housing stress often contributed to risk for suicide. Firearms were the most common method of suicide used by those with and without a known diagnosed mental health condition. State suicide rates vary widely The most recent overall suicide rates (2014-2016) varied four-fold; from 6.9 per 100,000 residents per year in Washington, DC to 29.2 per 100,000 residents in Montana. Across the study period, rates increased in nearly all states. Percentage increases in suicide rates ranged from just under 6 percent in Delaware to over 57 percent in North Dakota. Twenty-five states had suicide rate increases of more than 30 percent. Wide range of prevention activities needed The report recommends that states take a comprehensive public health approach to suicide prevention and address the range of factors contributing to suicide. This requires coordination and cooperation from every sector of society: government, public health, healthcare, employers, education, media and community organizations. To help states with this important work, in 2017 CDC released a technical package on suicide prevention that describes strategies and approaches based on the best available evidence. This can help inform states and communities as they make decisions about prevention activities and priorities. Everyone can help prevent suicide: I Learn the warning signs of suicide to identify and appropriately respond to people at risk. Find out how this can save a life by visiting: - Reduce access to lethal means - Such as medications and firearms among people at risk of suicide. I Contact the National Suicide Prevention Lifeline for help: (8255). onli felineorg The media can avoid increasing risk when reporting on suicide by: 0 Following and sharing recommendations available at (for example, avoiding dramatic headlines or explicit details on suicide methods); 0 Providing information on suicide warning signs and suicide prevention resources; and . Sharing stories of hope and healing. Hm." Signs is a CDC report that typically appears on the ?rst Tuesday of the month as part of the CDC journal Mmmrim and H?eelrlr Report. The report provides the latest data and information on key health indicators, and what can be done to drive down these health threats. US. DEPARTMENT OF HEALTH AND HUMAN SERVICES #vitalsigns JUN 201 8 Vitalsignsw WW Suicide risin across the US 45K 'd 2016. 5' More than a mental health concern Suicide is a leading cauSe of death in the US. Suicide rates increased in neariy every state from 199?? through 2016. Mental health conditions are often seen as the cause of suicide. but suicide is rarely caused by any single factor. In fact, many people who die by suicide are not known to have a diagnosed mental health condition at the time of a Suicide rates went up death. Other problems often contribute to suicide, such as those /0 more than 30% in half related to relationships, substance use, physical health, and job, Of states since 1999' money, legal, or housing stress. Making sure government, public health, healthcare, employers, education, the media and community organizations are working together is important for preventing suicide. Public health departments can bring together these partners to focus on comprehensive state and community efforts with the greatest More than half of people likelihood of preventing suicide. 540/ who died by suicide did 0 have 3 mam] States and communities can health condition. - Identify and support people at risk of suicide. I I i I Teach coping and problemasolving skills to help people manage challenges With their relationships, health, or other concerns. Promote safe and supportive environments. This includes safely storing medications and firearms to reduce access among people at risk. 1 Offer activities that bring people together so they feel connected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. I Expand options for temporary help for those struggling to make ends meet. Prevent future risk of suicide among those who have lost a friend or loved one to suicide. Centers for Disease Control and Prevention National Center for Injury Prevention and Control Want to learn more? Visit: PROBLEM: Suicide rates increased in almost every state. Suicide rates rose across the US from 1999 to 2016. Increase 38 - 58% Increase 31 - 31% Increase 19 - 30% Increase 6 - 1 8% Decrease 1% Hill" SOURCE: National Iov'ital Statistics System, CDC Vital Signs, June- 2018. Differences exist among those with and without mental health conditions. People without known mental health conditions were more likely to be male and to die by firearm. No known mental health conditions Known mental health conditions Sex Method Sex Method Poisoning Female Other Female Other was c, 31% . 3% 162i: 326 Poisoning . l7 20% if Firearm Firearm 41% 55% Suf?location SuI?Iocation 27% 31% t' h' Many factors contribute to surerrle among those With and wrthout known mental health Problematic substance use Crisis in the past or upcoming two weeks (290/6) Note: Persons who died by suicide may have had health multiple circumstances. Data on mental health Jobl'FinanciaI problem conditions and other factors are from coroneri' (1 69/ problem medical examiner and law enforcement re orts possible that mental health conditions or other circumstances could have been present and not . . d' cl, cl. Loss of Criminal legal 'agmse know" 0' "3pm 9 I problem SOURCE: CDC's National Violent Death Reporting (9V0) System, data from 2? states participating in 2015. WHAT CAN WE 00 T0 PREVENT Preventing Suicide: A Technical Package of Policy, Programs, and Practices Preventing suicide involves Knowthe Suicide everyone in the community. WARNING SIGNS Feeling like a burden Provide financial support to individuals in need. 39mg States can help ease unemployment and housing stress . . . - Increased anmety temporary help. - Feeling trapped or in unbearable pain Increased substance use Health care systems can offer treatment options by phone or online where services are not widely available. Looking for a way to access lethal means - Increased anger or rage Empioyers can apply policies that create a healthy Extreme mood swings environment and reduce stigma about seeking help. Expressing hopelessness Connect people \Nltl?lln thelr communrtles. 5139ng too little or too much Cummunities can offer programs and events to increase a sense of belonging among residents. 0 Talking or posting about wanting to diel Teach coping and problem-solving skills. - Making plans ?lOr suicide Schools can teach students skills to manage challenges like relationship and school problems. 5 STEPS To HELP SOMEONE AT RISK 1. Ask. 2. Keep them safe. Media can describe helping resources and avoid headlines or details that increase risk. 3? Be there' 4. Help them connect. Identify and support people at risk. 5. Follow up. Find out why this can save a life by visiting: Everyone can learn the warning signs for suicide, how to respond. and where to get help. SOURCE. iTo.com WHAT CAN BE DDNE THE FEDERAL DDVERNMENT IS EMPEDTEHS DAN - Tracking the problem to understand trends and the - Promote employee health and well-being, support groups at greatest risk {for example, see employees at risk, and have plans in place to respond to people showing warning signs. 0 Developing, implementing, and evaluating suicide - Encourage employees to seek help, and provide prevention strategies. referrals to mental health, substance use, legal, or financial counseling services as needed. I Supporting local, state, tribal, national, and other partners to prevent suicide (for example, see CAN - Ask someone you are worried about if they're STATES AND DAN thinking about suicide. Oldentify and support people at risk of suicide. Keep them safe. Reduce access to lethal means for those at risk. - Teach coping and problem-solving skills to help people manage challenges with relationships, jobs, 0 Be there with them. Listen to what they need. health, or other concerns. . - Help them connect ongoing support. You can Promote safe and supportive environments. This start with the Lifeline (1-800-273-8255). includes safely storing medications and ?rearms to reduce access among people at risk. . Follow up to see how they re domg. - Find out why this can save a life by visiting: Offer activities that bring people together so they feel cennected and not alone. Connect people at risk to effective and coordinated mental and physical healthcare. The media can avoid increasing suicide risk Expand options for temporary assistance for those (egg by not using dramatic headlines or sr lintmkensmeeprowding expliut details)and encourage - Prevent future risk of suicide among those who have people to seek help. lost a friend or loved one to suicide. View recommendations at: HEALTH CARE SYSTEMS DAN 0 Provide high-quality, ongoing care focused on patient safety and suicide prevention. If you need help for yourself or someone else, please contact the National Suicide Prevention Lifeline Talk: 1-300-273-TALK {3255) Chat: - Make sure affordable and effective mental and physical healthcare is available where people live. Train providers in adopting proven treatments for patients at risk of suicide. For more information, please contact Telephone: T-BDO-CDC-INFO (232-4636) . . . . WY: 1-888-232-6348 13: W. cl . 9 Cgov Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Suicide rates ruse across the US from 1999 to 2016. SOURCE: Nationa! Vita! Statistics SystemTelebrief Vital Signs Rising Suicide Rates Across U.S. June 7, 201B Desired Headlines Nearly 45,000 lives lost to suicide in 2016, but suicide is preventable. Suicide rates up in almost all states, but suicide is preventable. Suicide rates went up more than 30% in half of US. states between 1999 and 2016. Many factors contribute to suicide, beyond mental health conditions alone. Moderator: Thank you NAME). And thank you all for joining us todavr for the release of a new CDC Vital Signs report on Trends in Suicide Rates and contributing circumstances to suicide. We are joined by Dr. Anne Schuchat, Principal Deputy Director and Dr. Deb Stone, lead author of the studv. Following opening remarks, Drs. Schuchat and Stone will respond to questions. I?ll turn the call over now to Dr. Anne Schuchat. Dr. Schuchat: I Good afternoon and thank you forjoining us today. 0 CDC works 24/? to protect Americans against health threats. Each month in Vito! Signs report, we focus on one of these threats and what can be done about it. Telebrief Script_V6_6.6.2018_206pm_FinaI Today?s report contains new information about state suicide trends, the factors that contribute to suicide, and the implications for prevention. In 2016 alone, 45,000 people in the U.S. lost their lives to suicide. Unfortunately, our data show that the problem is getting worse. Suicide is one ofjust three leading causes of death that are on the rise. And these statistics don?t begin to reveal the emotional, social and financial toll that suicide exacts on individuals, families and communities who are left devastated. Many of us have lost friends, neighbors and family members to suicide or have loved ones who have considered or attempted it. Between 1999 and 2016, suicide rates increased among all age groups younger than 75 years. During that period, middle-aged adults had the largest number of suicides and particularly high increases in rates. We found that suicide rates increased in nearly every state across the nation. These findings are disturbing. Suicide is a public health problem that can be prevented. For this Vital Signs report, we first analyzed data from the National Vital Statistics System to look at trends in suicide rates for all 50 states and Washington, DC. We then looked at data from National Violent Death Reporting System (the which included information for 27 states in 2015, and looked at Telebrief Script_V6_6.6.2018_206pm_FinaI circumstances around suicides among people with and without known mental health conditions. 0 [As a side note, CDC is now collecting data in 40 states, D.C. and Puerto Rico. And Congress has provided additional funding in the fiscal year 2018 omnibus so that CDC can expand the system to all 50 states]. I Suicide is often attributed solely to a mental health concern. But, according to our data fewer than half of the people who died by suicide had a known mental health condition. I Our research found that those people who died by suicide and did not have a diagnosed mental health condition were somewhat more likely than those with a mental health condition to struggle with relationship problems or loss, other life stressors, and experience recent or impending crises. However, and importantly, these circumstances were likely to occur in all people who died by suicide, regardless of whether or not they had a diagnosed mental health condition. - Suicide IS preventable. - That?s why it?s so important to understand the range of factors and circumstances that contribute to suicide risk, including relationship problems, substance misuse, physical and mental health conditions, job issues, financial troubles, and legal problems. Telebrief Script_V6_6.6.2018_206pm_FinaI With this information in mind, states and communities can develop a comprehensive approach to suicide prevention. One example of a successful program is The United States Air Force Suicide Prevention Program. This program, (which includes 11 policy and education initiatives designed to increase social support, social skills, and help-seeking) shifted the culture of the Air Force away from viewing suicide as an individual-oriented mental health concern to a larger, service-wide problem impacting the whole community. After the program was begun, the Air Force saw a 33% reduction in suicide as well as reductions in other related problems, such as severe fa milv violence and homicide Bv increasing awareness of the range of circumstances contributing to suicide risk, and acting to address them through a comprehensive approach, we could reach our national goal of reducing the annual suicide rate by 20 percent by 2025. Today?s report suggests we have a lot of important work to do to reach this goal. Nearly all states had increasing suicide rates between 1999 and 2016, and 25 states had rate increases of more than 30 percent. So how do we work together to reverse these numbers and help save lives? On the Federal level, government agencies are tracking the problem of suicide to understand trends and groups at greatest risk; developing, implementing, and Telebrief Script_V6_6.6.2018_206pm_FinaI evaluating what works to prevent suicide in communities; supporting local, territorial, state, tribal, and other partners to prevent suicide; and working with public and private partners to advance the National Strategy for Suicide Prevention. 0 In states and communities, close coordination of activities between public health agencies and other sectors of society is critical for preventing suicide. Necessary partners include health and mental healthcare providers, social services, first responders, educators, faith communities, and the media. - States and communities can and should take action now. I To help prioritize prevention, CDC developed Preventing Suicide: A Technicalr Package of Policy, Programs, and Practices. It features the best available evidence for states and communities to guide their prevention activities. Some of the strategies are designed to prevent suicide risk before it emerges in the first place. These strategies include teaching coping and problem-solving skills to help people manage life challenges; promoting safe and supportive environments, including safe storage of medications and firearms among people at risk; providing temporary help for people struggling to make ends meet; and encouraging connectedness so people are less likely to feel alone or isolated. Telebrief Script_V6_6.6.2018_206pm_FinaI I Other strategies in the technical package are designed to support people who may already be struggling, by providing effective treatment and crisis intervention strategies. I Health and behavioral health care providers have an important role to play in suicide prevention as well, so that nobody in these systems falls through the cracks. Policies and protocols that prioritize patient safety and that help get people into ongoing care, especially during care transitions, can help prevent suicide. It Last and very important, the technical package describes approaches to prevent future suicide risk among people who have attempted suicide or have lost a friend or loved one to suicide. 0 You can find the link to the technical package is on our Vital Signs website. - Preventing suicide takes everyone. Parents, employers, teachers, coaches, religious leaders, healthcare providers, and people affected by suicide everyone in the community can help prevent suicide risk by learning the warning signs of suicide and how best to respond effectively. Together we can work to bring hope and save lives. Suicide Prevention Vital Signs For internal use only. Contents General Background on the Problem of Suicide 1 What was the impetus for this study? 2 What is CDC doing to prevent suicide? 2 Why are suicide rates increasing? 5 What?s going on globally with respect to suicide rates? 9 Firearms and Suicide 11 The Present Study - MMWR Content and Methods 12 The National Violent Death Reporting System 18 Warning signs of suicide and what to do if you know someone at risk 19 Suicide among Youth 21 Suicide among Veterans 23 Opioids and Suicide 24 Adverse Childhood Experiences and Suicide 27 Suicide Prevention 29 Talking about suicide suicide contagion 32 What role do the economy and social media play in increasing suicide rates? 33 Select Recent CDC Research 33 Partner Activities 35 Additional Resources 35 General Background on the Problem of Suicide I Suicide is a public health problem. 0 Nearly 45,000 lives were lost to suicide in 2016, which is approximately one suicide every 12 minutes. 0 Rates have increased by nearly 30% from 1999-2016 Suicide rates vary by racefethnicity, age, and other population characteristics, with the highest rates across the lifespan occurring among non-Hispanic American lndiaanlaska Native (AIIAN) and non-Hispanic White population groups, middle-aged adults, veterans and active duty personnel, certain occupational groups, and sexual minority youth. More than half ofsuicide deaths occur among adults in the prime of their lives, ages 35-64. Suicide rates in rural areas are consistently higher than rates in more urban areas. Suicide and nonfatal self-harm injuries cost more than $69 billion annually in direct medical and work loss costs. O- Decades of research have shown that suicide is preventable. What was the impetus for this study? 1. What was the impetus for this study? The CDC has a strong portfolio of research describing the increasing trends in suicide as well as rich data on circumstances contributing to suicide from the National Violent Death Reporting System. CDC also has a technical package geared towards states and communities that provides what works to prevent suicide based on the best available evidence. With all of this information in hand and in the context of increasing national suicide rates, the present study was motivated to support states and our nation as we seek to meet the national goal of reducing annual suicide rates 20% by 2025. 2. A CDC employee went missing in February and was later found deceased. His death was determined to be suicide. Is that why you?re publishing this study now? The CDC community continues to be deeply saddened and impacted by the death of Commander Cunningham. As you correctly state, his death was recently ruled a suicide by the Medical Examiner?s office. While it?s true the timing of our study is close to Commander Cunnigham?s death, this study began many months before Commander Cunningham disappeared. CDC has worked to prevent suicide for many years and suicide prevention is currently a priority area. We have a strong portfolio of research describing the increasing trends in suicide and rich data on circumstances contributing to suicide from the National Violent Death Reporting System. CDC also has a technical package geared towards states and communities that provides what works to prevent suicide based on the best available evidence. With all of this information in hand and in the context of increasing national suicide rates, the present study was motivated to support states and our nation as we seek to meet the national goal of reducing annual suicide rates 20% by 2025. What is CDC doing to prevent suicide? 3. Has CDC provided states resources to prevent suicide? Who in the state does this work? CBC does not provide direct funding to states to conduct suicide prevention work specificaiiy, us CDC has no appropriation for suicide prevention. However, the Substance Abuse and Mental Health Services Administration (SAMHSAJ provides grants to states, tribal communities, and campuses through its Garrett Lee Smith, National Strategy, and Zero Suicide grant programs. CDC funds 23 state health departments through the Core State Violence and Injury Prevention Program, which helps states implement, evaluate, and disseminate strategies to prevent injuries and violence. Some of the states funded under this initiative are focusing their efforts on suicide prevention. The CDC also funds ten Injury Control Research Centers These centers study ways to prevent injuries and violence and work with community partners to out research findings into action. Four of the currently funded ICRCs are working to prevent suicide through research, training, or outreach activities: University of lowa, University of North Carolina at Chapel Hill, University of Rochester, and West Virginia University. CDC has aiso created a technical package for suicide prevention that states and communities can use to inform and guide their prevention e?orts. 4. What is CDC doing to prevent suicide? The CDC takes a public health approach to preventing suicide, which involves a number of steps. CDC is: I Tracking and monitoring trends in suicide and suicide attempts to inform prevention policies and programs {for example") 9 Leavitt RA, Ertl A, Sheats K, Petrosky E, lvey?Stephenson A, Fowler KA. Suicides Among American lndiaanlaska Natives National Violent Death Reporting System, 18 States, 20034014. MMWR Morb Mortal Wkly Rep . Identifying risk and protective factors; and developing evidence?based prevention programs. 0 Developing an environmental scan of all 50 states, D.C., territories, and select tribes [511's] to gain a greater understanding of what factors at the STT-level may be associated with rising suicide rates lack of suicide prevention infrastructure, prevention activities, legislation passed, partnerships/collaborations, barriers 8r. facilitators to suicide prevention). I Evaluating programs, policies, practices to determine if they prevent suicide risk. Currently evaluating two RCTS with interventions focused on middle-aged males. These projects are in year 3 of 4 currently so results are not yet available. One project uses a multi?media program in the waiting room to help men at high-risk to raise their suicidal thoughts with their primary care clinicians. The second project evaluates the impact of mantherapy an intervention designed specifically males that uses humor and male stereotypes to get across messages on suicide prevention, plus screening for mental health resources compared to just screening for mental health resources - Sharing information about the best available evidence (for example, the suicide prevention technical package}. New projects (Also included on page 32-33} I Linking with Departments of Defense and Veterans Affairs data on suicide Partners who are working on this project include Department of Veterans Affairs, Department of Defense Suicide Prevention Office, and the Health Center of ExcellenceiDefense Health Agency. This project will link pertinent data on active duty Military and Veteran suicide decedents across CDC's National Violent Death Reporting System the Department of Defense Suicide Event Reports, and the Veteran Health Administrative databases. Provide more information on suicides among active duty Military personnel and Veterans as well as partition study populations in the civilians, active duty, VHA Veterans, non?VHA Veterans}. Help agencies monitor common and unique precipitating factors of suicide captured in by groupipopulation and inform comprehensive community-based efforts to help address specific population needs. All linkages will use a de?identified matching technique. No personal identifying information will be used. 0 Social media intervention 0 The purpose ofthis project is to implement, test, and refine a web-based peer?to-peer therapeutic support platform for U.S. Military Veterans aimed at preventing suicide and related problems. This system called TalkVet, has the potential to bridge the gap between the many social media sites that are widely used by Veterans Facebook, Snapchat, etc.) and the growing number of clinical interventions that are available to Veterans, but currently under-utilized. With the explicit consent of users, we will test the novel features of the TalkVet platform in three ways: 1. Use an artificial intelligence (AI) guided system to help identify participating Veterans most in need of help based on their posts and other user activity; 2. Connect Veterans in need of help with other Veterans in TalkVet who can support them; and 3. Conduct outreach with experimentally refined methods for Veterans in need of a higher level of care to encourage them to obtain such care in the form of links and hand-offs provided by the TalkVet system (this phase of the work will include the use of Veteran moderators with training in crisis counseling who will work with our team). This project includes partners from Harvard University, West Virginia University ICRC, TalkLifefTalk/Vet and has been approved by CDC-F. . Colorado Collaborative for a Comprehensive Approach to Suicide Prevention The CDC is collaborating with the Colorado Department of Public Health and Environment, the CDC-funded Injury Control Research Center the Colorado National Collaborative (CNC), and the Colorado Suicide Prevention Commission on the first state-wide, large-scale, population-based initiative to reduce suicide rates 20% by 202:3r in CO and to serve as a model for other states to help reduce suicide by 20% by 2025 in the nation. Partners on the CNC also include the Action Alliance, SAMHSA, and AFSP, among others. Through this project we propose to pilot test the implementation and evaluation of a comprehensive, integrated approach to suicide prevention?guided, in part, by the technical package and the National Action Alliance for Suicide Prevention's Transforming Communities: Key Eiements for the implementation of Comprehensive Community- Bosed Suicide Prevention. Working with to seek external funding Why Colorado? Colorado consistently ranks among the states with the highest suicide rates in the nation (rate: 19.5 per 100,000 in rate 13.3 per 100,000). I Colorado has sizable populations at increased risk of suicide, including veterans, American lndiaanlaska Natives (AMANJ, and people living in rural communities. I Colorado demonstrates readiness as evidenced by a strong state suicide prevention infrastructure, a history of political will, and a proven track record of valuing and implementing public health approaches to prevention. Specifically, the State has: I A funded Office of Suicide Prevention legislated in 2000} I Suicide Prevention Commission {legislated in 2014] I Colorado National Collaborative (est. 2015) I A strong platform of existing suicide prevention activity - A commitment to ?connecting the dots/shared risk and protective factors *The CDC Foundation is seeking funds from donors to support this work. It is also partially funded by a grant from SAMHSA and other state and local resources {to a small degree}. Why are suicide rates increasing? 5. Why are suicide rates increasing? While the Vital Statistics data are great for describing trends they don?t tell us about the causal factors that are driving the increases. We do know that suicide is not caused by one factor, but instead, it is typically caused by a combination of individual, relationship, community, and societal factors. Several such factors could be contributing to the increases: Economic conditions The role of the great recession in the late 2000?s and subsequent financial challenges and concerns about economic instability could have contributed to increases in suicide risk. Past research on the association between business cycles and U.S. suicide rates indicates that the overall suicide rate rises and falls in connection with the economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by parents may trickle down resulting in vulnerable youth. Opioid epidemic increased availability and misuse of prescription opioids may be related to increases in suicide rates. Substance misuse itself is an established risk factor for suicide and, therefore, opioid misuse associated with the opioid overdose epidemic could be driving the suicide rate higher. When we look at who is dying from suicide and who is dying from unintentional overdoses involving opioids, we see that there is overlap in the demographics of the populations most highly affected by suicide and unintended opioid overdose deaths. Data also indicate that opioid prescribing rates are higher in counties where there are higher rates of suicide. Social media More research is needed on the impact of social media use on suicide rates. However, changes in social media content or use patterns could potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. Rural While there have been increases and decreases in rates over time, research shows that rates across cities and towns in the United States have been rising, with rural areas experiencing the most increases. The increased rates may be associated with suicide risk factors that are more common in less urban areas, such as limited access to mental healthcare as well as greater social isolation. Bridge to: Although the reasons for the increases in suicide rates are not fully understood, we do know a lot about the circumstances that contribute to suicide risk. It is clear that many factors contribute to suicide beyond mental health factors alone. 0 These factors include such things as relationship problems relationship loss through death, divorce, or break-up; arguments, interpersonal violence), problematic substance, physical health problems, jobffinancial problems, and legal problems. Why are suicide rates increasing so much in Western states? Suicide rates have consistently been higher in Western states and these data show that several Western states have seen substantial increases in suicide rates. While the reasons for this need additional study, research has shown that suicide rates have increased faster in rural areas, which may explain some of the difference. Also, the timing of the increase seems to coincide with the Great Recession. Though the recession is over, rural areas were disproportionately impacted and have had a slower recovery time. Others have also pointed to social isolation and access to mental and behavioral health treatment as potential contributing factors to the higher suicide rates in Western states. Why are suicide rates increasing more in less urban (or more rural) areas? While there have been increases and decreases in rates over time, research shows that rates across cities and towns in the United States have been rising, with rural areas experiencing the greatest increases. Increased rates may be associated with suicide risk factors that are more common in less urban areas, I Limited access to mental healthcare . Greater social isolation. 8. - Loss of jobs, homes, and income associated with the Great Recession as well as the prescription opioid overdose epidemic, which has had a greater impact on less urban areas. 0 Urban areas may also experience these risk factors, but to a lesser extent. During the Great Recession, there was an increase in suicide, but why are rates still going up since the economy has bounced back? Suicide rates have continued to rise after the Great Recession. A previous study found that suicide rates across all urbanization levels in the U.S. increased over the period from 1999-2015, but the gap in rates between less urban and more urban areas widened over this period, and rates in more rural areas increased at a more rapid pace than more urban areas beginning in 2007-2008. The rapid acceleration of increasing suicide rates in more rural areas in 2007?2008 may reflect the corresponding start of the Great Recession at about this same time. The disproportionate impact of the recession on rural areas and the longer economic recovery time in these areas may help to explain why suicide rates have remained high overall. 0 Other common suicide risk factors including mental health and substance use problems may be exacerbated in rural areas potentially influenced by the prescription opioid overdose epidemic poor access to mental healthcare, made worse by shortages in behavioral health care providers in rural areas, and greater social isolation in rural areas. The potential cumulative burden of suicide risk factors in less urban areas may impact not only individuals but relationships, families, and communities as well, suggesting the need for comprehensive suicide prevention measures. Is the opioid overdose epidemic associated with rises in suicide rates? Both suicide and drug overdoses are on the rise. CDC is actively working to analyze and better understand the trends and risk factors for opioid overdose and suicide, and the connections between the two public health challenges. Increased availability and misuse of opioids may be related to increases in suicide rates. Substance misuse itself is an established risk factor for suicide and, therefore, opioid misuse associated with the opioid overdose epidemic could be driving the suicide rate higher. When we look at who is dying from suicide and who is dying from unintentional overdoses involving opioids, we see that there is overlap in the demographics of the populations most highly affected by suicide and unintended opioid overdose deaths. Data also indicate that opioid prescribing rates are higher in counties where there are higher rates of suicide. CDC uses several systems to monitor overdoses, overdose deaths 8: suicide: 7 I Deaths Death certificates, National Violent Death Reporting System and State Unintentional Drug Overdose Reporting System I Nonfatal National Electronic Injury Surveillance SystemdAll Injury Program (NEISS-AIP), Healthcare Cost and Utilization Project from AHRQ, and emergency department claims and EMS surveillance data from Enhanced State Opioid Dverdose Surveillance program 10.Why are suicide rates increasing more among females? This study showed that suicide rates were increasing for females and males. The increases for females were significant in 43 states and the increases for males were significant in 34 states. It is important to note that while the relative increases in rates were higher for females than for males overall, the absolute suicide rates rose faster for males than females. Male suicide rates are consistently 3 to 5 times higher than the suicide rates for females. It is important for suicide prevention strategies to address the needs of males and females. While the Vital Statistics data can be used to describe such trends, these data cannot tell us about the causal factors that are driving the increases. We do know that suicide is not caused by one factor, but instead, it is typically caused by a combination of individual, relationship, community, and societal factors. 11. A paper came out recently about county-level trends in suicide rates in the US from 2005-2015, how do the results of that study compare with the results from the Vital Signs? That paper and the VS both look at trends in suicide rates over time, however, this month?s VS examines statenlevel trends in suicide rates whereas the other examines county?level trends. Despite this difference in the level of analysis undertaken {state vs county), both articles point to the same sobering conclusion that rates of suicide at both the state and county level have increased. States may use both sets of findings to tailor comprehensive suicide prevention to areas most impacted by suicide. CDC's technical package inclusive of the best available evidence to prevent suicide is an important resource that can benefit both states and local communities. Note: Some counties with the highest and lowest rates of suicide do not align with our map, and in some cases, they contradict each other. This is because our map shows percentage increases in suicide rates over time at the state level vs. aggregated average rates of suicide over time at the county level as presented in the study by Rossen and colleagues. County level suicide prevention paper {Rossen et al., 2018) compared to US County paper VS Dates for analysis 2005-2015 1999-2016 Level of a Increases Regions Rural vs Rates Highest El! Lowest ra ups of counties D. County-laud modal-hand estimates, 2015 lumen-d 4 . t' i, - ill-10-1Idl 7 m-iu van: am d? - -ing driven, or impacted, by cases of physician assisted-suicide? No. The suicide rates increases observed in this study are not related to cases of physician-assisted suicide. Physician-assisted suicide is currently legal in just a handful of states and such deaths are not classified as suicide. 13. Does CDC endorse or support physician-assisted suicide? CDC does not take a stand, either for or against, physician-assisted suicide. What?s going on globally with respect to suicide rates? 14. How does the U.5. compare to other nations with respect to trends in suicide rates? 15. 16. Globally, suicide rates have been declining. Global data from the World Health Organization indicates that nearly all European societies experienced rising suicide rates after the Great Recession. However, unlike the U.S., the suicide rate in many European nations stabilized or returned to pre-recession levels after the recession. This may be because the economic recession impacted different countries in different ways, and areas within the U.S. may have ta ken longer to recover from the recession. Although suicide rates also increased in Canada during the Great Recession, Canada has experienced a fairly level suicide rate over the past 1? years, with a rate between 12.5 to 13.0 per 100,000. Unlike in the U.S., ingestion of pesticide is one of the most common methods of suicide globally. Policies related to the sales and import of pesticides, which have reduced access to this lethal means of suicide, have demonstrated impact in preventing suicide in some countries. For instance, in Sri Lanka, the suicide rate decreased from 47 per 100,000 in 1995 to 30.9 per 100,000 in 2005 after the implementation of such policies. What?s going on in the U.S. that?s not occurring in other countries to explain the increase in suicide rates here? The U.S. has good surveillance systems in place to track mortality, allowing us to identify the increases in suicide rates and even which areas of the country, age groups, and racialg'ethnic groups are most at risk. Unfortunately, these surveillance systems do not assess and track the risk factors that may be contributing to these trends. We know that suicide rates are increasing in most age groups and demographic groups and we are seeing increases across suicide methods. The increases in suicide rates are unlikely to be due to any single factor. Factors at the individual, relationship, and community levels such as a prior suicide attempt, age; substance abuse history; school, job, or legal problems; exposure to another person?s suicidal behavior; and the accessibility of assistance in the community all contribute to risk. It is likely that multiple factors are influencing suicide trends. Last year, Hurricanes Irrna and Maria caused a great deal of both distress and fatalities in PR. Do we know how many of these deaths were suicide? How can we prevent these in the future? Final data from Puerto Rico on the number of suicides is not yet available. CDC is collaborating with the Commission for Suicide Prevention at the Puerto Rico Department of Health in an effort to prevent suicide, increase awareness about factors that increase and decrease suicide risk, and to conduct training of healthcare providers and others in the community. CDC is also translating Preventing Suicide: A Technical Package of Policy, Programs, and Practices into Spanish. This document helps communities to prioritize prevention activities based on the best available evidence. 10 Firearms and Solclde 17. 18. 19. Are firearms a major means of suicide globally? Unlike in the 0.5., ingestion of pesticide and hanging are the two most common methods of suicide globally. Policies related to the sales and import of pesticides, which have reduced access to this lethal means of suicide, have demonstrated impact in preventing suicide in some countries. For instance, in Sri Lanka, the suicide rate decreased from 47 per 100,000 in 1995 to 30.9 per 100,000 in 2005 after the implementation of such policies. How many lives are lost to firearm-related suicides per year? In 2016, almost 23,000 lives were lost due to suicides by firearm. This equates to 51% ofsuicides in the 0.5. in 2016. Does the CDC want to restrict access to firearms? The CDC is not suggesting that firearms should be taken away from U.S. residents. An important function of public health is to prevent injury and death. Given the lethality of firearms, it is important to identify ways to prevent them from being used for self~harm. Based on prior research, we know that safe storage practices can help reduce the risk for suicide by separating people at?risk, or who have made prior attempts, from easy access to lethal means. This can involve safely storing firearms locked and unloaded in a secure place gun safe or lock box] and separate from ammunition. This can help to provide a buffer for those who are thinking about suicide and increases the time it takes them to access lethal means. We know from prior research that simply providing a buffer in this critical time period can help reduce risk. 20. What are the leading ways that people die by suicide? Firearms are the mechanism for about half of all suicides in the United States. The nest leading methods are suffocation and poisoning. Reducing access to lethal means of suicide among persons at risk for suicide is an intervention with robust supporting evidence: such intervention includes: - Intervening at suicide hotspots such as bridges - Counseling around safe storage of medications, firearms, or other household products to keep them away from people at risk. a These interventions can be combined with other strategies for a comprehensive approach to prevention. 11 21. What was the process of obtaining support and resources from the CDC to do this research, given the agency's historical lack of funding for gun violence research? This study used data from existing public health surveillance systems that collect data on many different causes of injury and death. CDC has, and continues to, support surveillance activities and analyses of surveillance and other data to document the public health burden of firearm injuries in the U.S. Understanding the patterns, characteristics, and impacts of firearm-related injuries is an important step toward prevention. 22.A previous report shows that a substantial number of gun-caused deaths are suicides. What could drive children to take their own lives and how do they access firearms in the first place? When looking at the circumstances surrounding child firearm suicides, while mental health factors are important, firearm suicides are also frequently related to situational life stressors and relationship problems with an intimate partner, friend, or family member. It is important for parents and other adults who interact with children to be aware that life stressors such as these can have a big impact on children and put them at risk for suicide. Other researchers have found that safe storage of firearms (storing firearms locked, unloaded, and separate from ammunition) is associated with reductions in adolescent firearm suicide attempts and also unintentional firearm deaths in children. The PreSEnt Study MMWR Content and Methods 23. How was the current study conducted? Trends in age-adjusted suicide rates were assessed among people aged 210 years, by state and sex, and across six consecutive threeayear periods (1999-2016}, using data from the National Vital Statistics System for SD states and Washington, DC. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among suicide decedents with and without known mental health conditions. 24. What are some of the key findings? I Across the study period, suicide rates increased in all states, except Nevada [which had a consistently high rate throughout}. 0 These increases were statistically significant in 44 states. 0 The percentage increases in rates ranged from 5.9% in Delaware to 57.5% in North Dakota, with increases of more than 30% observed in 25 states. I Suicide rate trends indicated significant increases for males (34 states} and females (43 states}, as well as for the U.S. overall. 12 I While all decedents were predominately male and non-Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to: be male (83.6% vs. odds ratio 95% CI 2.24.5) be raciallethnic minorities (OR range: 1.2?2.0} to die by firearms 95% - Overall, the large majority of suicides occurred among people ages of 25-64. More than half of suicide decedents in (27 states) did not have a known mental health condition. 0 This group suffered more from relationship problems and other life stressors such as criminal legal matters, eviction/loss of home, and recent or impending crises, however such circumstances were also common in people with mental health conditions. i To address the full range of contributing factors to suicide, comprehensive suicide prevention activities are needed. 0 Such strategies include both upstream prevention to prevent risk from occurring in the first place as well as more activities responsive to the needs of people at increased risk and to prevent re-attempts. The technical package to prevent suicide provides information about evidence-based strategies, as well as information about the need for a broad, comprehensive approach to preventing suicide. 25. For some states, the reported percentage increase in the suicide rate is quite large. Is this clue simply to fluctuations in small numbers of suicides? The percentages represent increases in rates between the first three-year reporting period {1999-2001) and the last three-year reporting period (2014-2016]. By aggregating the data into three-year periods, small suicide counts were avoided. The table below provides the beginning and ending suicide counts and rates for the ten states showing the largest percentage rate increases. No suicide count appearing in the table below is less than 200, and some counts range into the thousands. Even after recognizing the growth in state populations and any shifts in their age profiles, changes such as those shown would not typically be expected clue to random fluctuations alone. ?$33333 ?33.33? 53:33. 33:3 33:33:? ND 3333:3333 3:333 333 33:: 1 3333:3333 3:333 333 2 .. 3333:3333 3:333 33: 33:3 3 3333:3333 3:333 .333 33;: . 13 1999?2001 2.31 917 13.3 0 KS 2014-2016 2.51 1,446 19.4 45'0 l6 5 1999-2001 0.65 303 15.7 SD 44.5 ?u 6 2014-2016 0.74 477 22.6 1999-2001 1.10 558 17.3 ID 2014-2016 1.42 1,030 24.7 43'2 A ll 19992001 4.25 1,357 10.7 MN 201432016 4.77 2,161 15.0 40'6 3 1999?2001 0.43 264 20.7 WY 2014-2016 0.51 421 28.8 39'0 9 1999-2001 3.47 1 328 12.8 SC 38.3 9/ 10 2014-2016 4.29 2,310 17.7 Average population a 10 years old during reporting period. Annual age-adjusted rate per 100,000 population a 10 years old. 26. What is known about which groups are experiencing increases? The current study found that rates of suicide are increasing, overall, and for males and females. Rates among females increased significantly in 43 states and rates among males increased significantly in 34 states. I In general, suicide rates in the U.5. have increased by nearly 30% since 1999. i. Increases were observed for both women and men in all age groups under 75. 0 Certain groups have had particularly high greatest increases since 1999, including: i. Working?age adults 35434 ii. Non?Hispanic whites, and non?Hispanic American Indians 1' Alaska Natives and People living in rural areas. iv. Rates have increased for males and female however the rate for males is consistently 31 5 times higher than the rate for females 27. How do people with and without mental health conditions differ with respect to suicide? People with and without mental health conditions had similarities and differences a While all decedents were predominately male and non?Hispa nic white those without known mental health conditions, relative to those with mental health conditions, were more likely male {83.6% vs. 68896;} and racial/'ethnic minorities (OR range: 122.0). I Suicide decedents without known mental health conditions also had significantly greater odds of perpetrating homicide-suicide {adjusted odds ratio 2.9, 95% CI Although this represents a small percentage of suicides in both groups. 0 While firearms were the most common method of suicide used overall and for both groups, decedents without known mental health conditions were more likely to die by firearm {55.3% vs. 40.6%) and less likely to die by ngulationfsuffocation {26.9% vs 31.3%) or poisoning {10.4% vs 19.8%) than those with known mental health conditions. {These differences remained significant in the adjusted models]. 14 I Among decedents with toxicology results, decedents without known mental health conditions were less likely to test positive for any substance overall 95% such as opioids 95% but more likely to test positive for alcohol 95% I People without known mental health conditions were less likely to have substance abuse problems 95% I Two-thirds ofthose with known mental health conditions had a history of mental health or substance abuse treatment and just over half were in current treatment. I Decedents without, versus those with, known mental health conditions, had significantly greater likelihood of any relationship problem/loss (45.1% vs. specifically intimate partner problems (30.2% vs. (12.5% vs. and recently perpetrating interpersonal violence vs. They also were more likely to have experienced any life stressors (50.5% vs such as criminalslegal problems (10.7% vs. or evictionfloss of home vs. and were more likely to have had a crisis within the preceding or upcoming two weeks (32.9% vs. All of these differences remained significant in the adjusted models. I Among all people with crises, intimate partner problems were the most common types and did not differ by mental health group status. I Physical health problems {23.2% and 21.4%} and joblfinancial problems {15.6% and 16.8%} were commonly experienced by both groups (with and without mental health conditions, respectively} I Decedents without known mental health conditions had significantly lower odds of recent release from any institution 95% but among those who were recently released they were significantly more likely to be released from a correctional facility (25.2% vs. hospital (43.7% vs. or other facility alcohol/substance treatment} 95% than those with a known mental health conditions. Among decedents with known mental health conditions who were recently released from an institution 46.7% of this group were released from facilities. I Decedents without known mental health conditions, compared to those with mental health conditions, were significantly less likely to have a history of suicidal ideation {23.0% vs. 40.8%} and prior suicide attempts (10.3% vs. More than one in five people in both groups disclosed suicide intent (22.4% vs. 28.Why did Nevada not see an increase in suicide rates? While Nevada?s suicide rate did not increase, it remained consistently high across the study period. 29.Why did this study focus on those aged 10 and older? Suicide rates were analyzed for people aged 210 years only, because determining suicidal intent in younger children can be difficult. a. Suicide is defined as self?directed injurious behavior with an intent to die as a result of the behavior, and youth under the age of 10 may not fully understand the implications of their actions. (CDC web site} 30. How was "crisis? defined in this study? For this study, a "crisis? was a currentlacute event that occurred within the 2 weeks of a suicide. Crises are indicated in an s0urce report to have contributed to the suicide. A crisis can precede the death had a bad argument the day before the incident, divorce papers served that day, or victim laid off the week before} or be an impending event house was to be foreclosed on the day after 15 31. the incident or court date for a criminal offense three days after the suicide). Crises are interpreted from the eyes of the victim. This is particularly relevant for young victims whose crises, such as a bad grade or a dispute with parents over a curfew, may appear to others as relatively minor. How did you define a mental health condition? The National Violent Death Reporting System defines a mental health condition as disorders and listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (9), with the exception of alcohol and other substance use problems, which are captured separately in the system. a. Data on mental health conditions are abstracted from the investigative reports included within and that are associated with each suicide. b. Investigative reports are those filed by law enforcement and coroners/medical examiners which reflect information provided by family and friends. c. Information obtained from these reports is dependent upon the extent of informant knowledge that may impact data completeness and accuracy. Some decedents might have mental health conditions that were not diagnosed or reported. The high prevalence of diverse contributing circumstances among those with and without known mental health conditions suggests the importance of addressing the broad range of factors that contribute to suicide. 32.Are the people without mental health conditions just people who haven?t been diagnosed with a mental health conditions? It is possible that the people without mental health conditions in this study had a diagnosable mental health condition but had not been diagnosed, or that their mental health conditions was unknown to informants who provided circumstantial information to law enforcement. Studies including more in? depth interviews with next?of-kin often cite greater attributions to mental disorders, however many methodological variations across studies exist. It is likely that some people without known mental health conditions in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. Nonetheless, the high prevalence of diverse contributing circumstances among those with and without known mental health conditions suggests the importance of addressing the broad range of factors that contribute to suicide. 33.Are suicides by people without mental health conditions considered impulsive? Suicide decedents who do not have mental health conditions should not necessarily be considered impulsive. - As this study demonstrates, there are many reasons, beyond mental health conditions alone, why people take their own lives. - 54% of the study sample did not have a known mental health condition, but people in this group still experienced challenges in their lives that contributed to their suicide. 0 They may have been experiencing these challenges for an extended period of time and may have had suicidal thoughts leading up to their suicide, which may indicate that the suicide was not impulsive 35% of those without mental health conditions left a suicide note 23% were known to have a history of suicidal ideation 22% had disclosed suicidal intent to another person 10% had previously attempted suicide 0000 34. How many suicides are considered impulsive? 16 35. 36. 37. I A previous cose-corrtroi study of survivors of neoriy iethai suicide attempts indicates that about 24% of this group acted impulsively on their suicidal thoughts 0 less than 5 minutes passed between their initial thought ofsuicicle and their nearly lethal suicide attempt 76% of attempt survivors did not meet this definition of impulsivity with respect to their suicide attempt. Is a trigger usually identified, even if that trigger may seem trivial to us? Also, is there data on the effectiveness of resiliency training in preventing suicide? Triggering events can be difficult to identify. We found that 29% of suicide decedents had experienced a crisis {intimate partner problem, health problem, legal problem}, in the past or upcoming two weeks. These crises were seen as contributing to their suicide. That said, it is important to acknowledge that contributing crises can differ across people depending on individual reactions but also family, friend, employer, and community supports. Programs like the Good Behavior Game [page 32}, and Youth Aware of Mental Health program {p32}, which are referenced in our technical package and are designed to build coping and problem-solving skills, have shown positive impacts on suicide ideation andy?or behavior, however, a key point in our technical package and the conclusion we mean to draw in our MMWR is a comprehensive public health approach to suicide is important. ldeaily suicide prevention activities will be incorporated at the individual, relationship, community, and societal levels to have a real impact. The CDC Foundation is currently helping to raise money for us to test this concept in Colorado which consistently has one of the highest rates of suicide in the country. The US Air Force Suicide Prevention Program is the best example of a comprehensive approach that worked (while it was being fully implementedl?they saw reductions in suicide rates of 33% and reductions in related outcomes as well. Why does this study find such a low rate of mental health conditions compared to autopsy studies? autopsy studies that utilize in-depth interviewing of surviving friendsj'family and often include record reviews typically show that a larger proportion of suicide decedents have a mental health diagnosis or a substance use disorder. However, variations in the methodology of autopsy studies and the current study may impact the prevalence of mental health conditions identified. It is likely that some people without known mental health conditions in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. measures problematic substance use separately from mental health conditions and this report provides an estimate of problematic substance use among those with and without mental health conditions. The high prevalence of diverse contributing circumstances among those with and without known mental health conditions suggests the importance of addressing the broad range of factors that contribute to suicide. Why did you only look at suicide circumstances in 2? states? a. In 2015, the National Violent Death Reporting System collected data from 27 states. The data collected from these states were used for the analysis. More current data is not yet available. 17 b. In 2016, collected data from 40 states, DC. and Puerto Rico however data are not yet available. c. The FY 2018 omnibus appropriation bill provided funding and Congressional direction to expand the program to all SCI states and the District of Columbia. CDC is actively working toward that goal. 38. What are some of the limitations to this study? There are three limitations to the study: First, in the state-level analysis, rankings for four states MA, RI, UT) might have been impacted by large proportions of injury deaths of undetermined intent (potentially biasing reported suicide rates downward), or decreased percentages of such deaths over time [potentially biasing estimated rate trends upward]. Second, is not yet nationally representative; the 2? states included in this study represent 49.6% of the U.S. population Third, abstractors of data are limited to information contained in investigative reports. Therefore, the extent of informant knowledge can affect data completeness and accuracy. Studies including more in-depth interviews with next-of?kin often cite greater attributions to mental disorders, however many methodological variations across studies exist. It is likely that some people without known mental health conditions in the current study were experiencing mental health challenges that were unknown, and hence underreported by key informants. Nonetheless, the high prevalence of diverse contributing circumstances among those with and without known mental health conditions suggests the importance of addressing the broad range of factors that contribute to suicide. We know that suicides are underreported. It is possible that some suicides were coded as unintentional or deaths of undetermined intent. It is unclear how that could impact estimates of trends or conclusions about circumstances. The National Violent Death Reporting System 39.What is the National Violent Death Reporting System? The National Violent Death Reporting System is a data system that provides states and communities with a clearer understanding of violent deaths. data can be used to guide local decisions about efforts to prevent violence and track progress over time. is the only state~based surveillance {reporting} system that pools data on violent deaths from multiple sources into a usable, anonymous database. These sources include state and local medical examiner, coroner, law enforcement, toxicology, and vital statistics records. Pooling these data can provide CDC with a detailed, comprehensive picture of how and why violent deaths occur. includes over 600 unique data elements that provide valuable context about violent deaths such as 0 Relationship problems; mental health conditions and treatment; toxicology results; and life stressors I Including recent problems with a job, finances, or physical health problems. 18 0 Extensive information about the incidents, such as weapons used, characteristics of suspects, and locations where they occurred are included. Such data are far more comprehensive than what is available elsewhere. can help identify populations particularly affected by fatal violence. The system not only provides details on specific manner of violent death, but also identifies common factors that span multiple types of violence. - The FAQ page has more details: 40. How does using the National Violent Death Reporting System help to make the statistics more complete? Although limited to the 27 states participating in during the time period of the study, data from provide the only detailed information available on the circumstances surrounding these deaths, therefore taking the findings beyond reporting numbers and rates and providing unique information on the context in which people die from suicide. 41. Is the National Violent Death Reporting System expanding to 50 states? We are happy to announce that beginning in FY18, we are able to make funding available to all 50 states for the implementation of the Currently, 40 states, Washington, DC and Puerto Rico are funded by Expanding to 50 states allows us to meet one of the national goals set forth for Healthy People 2020 Warning signs of suicide and what to do it you know someone at risk. 42.A lot of the problems mentioned as contributing to suicide in this study seem very common, how can someone tell who?s at risk? Many people think that suicide is an inexplicable act, when, in reality, many known risk factors exist. These include: I History of previous suicide attempts - Family history of suicide . History of child maltreatment 0 History of depression or other mental illness 0 Alcohol or drug abuse - Feelings of hopelessness or isolation - Impulsive or aggressive tendencies - Stressful life event or loss 0 Easy access to lethal methods - Exposure to the suicidal behavior of others I Isolation, lack of social connectedness 19 Researchers agree that suicidal behavior results from an interaction of factors and is rarely due to a single cause. 43. Is suicide genetic? Research suggests that suicide can run in families. A famous example is the multiple deaths by suicide in the family of American novelist Ernest Hemingway. Both genetics {nature} and environment [nurture] can impact suicide risk; however, there are many strategies to prevent suicide. Suicide is never inevitable. A new field of study called epigenetics looks at the interaction of nurture and nature to help us understand risk of suicide. 44. What are the warning signs for suicide? The warning signs for suicide are: Expressing hopelessness Increased anger or rage Extreme mood swings Sleeping too little or too much Making plans for suicide Talking and/or posting about suicide Feeling unbearable pain Increased anxiety Securing lethal means Increased substance use Feeling like a burden Isolation 45.What should someone do if they believe someone may be suicidal? Ask the question, "Are you thinking about suicide?? Asking the question won?t make someone suicidal, and instead, may relieve or reduce the feeling. Ifthe person says yes, keep them safe. Find out if they have a suicide plan. Remove any lethal means in the environment, if possible, and do not leave the person alone. Be there and show concern. Don't act surprised or dismiss their feelings. Take the person seriously, and do not assume they are joking. Help them connect to resources, for example, by calling the National Suicide Prevention Lifeline {8255)} or by connecting the person to someone in the community who can help, e.g. emergency department, counselor, pastor. Follow up - After the person is safe, follow up in the days ahead with a phone call, ask them how they are doing. See if there is anything else that you can do. You can learn more about these steps to help by going to 46.Where can people go for help? NO matter what problems people deal with, we want to help them find a reason to keep living. By calling 1-800-273-TALK (8255] people will be connected to a skilled, trained counselor at a crisis center in their area, anytime 2M7. There are many success stories and stories of hope where people in need have reached out to others or family or friends have intervened to get people help. They got the support they needed and were able to get through a crisis and go on to live productive and fulfilling lives. 20 Suicide among Youth 47.Today?s Quick Stat shows rates of suicide and homicide going up among youth. How does this align with rates found in the The Vital Signs report did not examine suicide rate increases by age group or homicide at all, but we know that suicide is a problem across the lifespan. In fact, suicide rates increase with age up to age 54. Nationally, we have seen that suicide rates are increasing across all age groups younger than age 75. For example, middle aged adults have the largest number of suicides and have seen particularly high increases in rates. Suicide prevention strategies are needed across the lifespan. States and communities can adopt prevention strategies based on the best available evidence such as those found in the technical package to prioritize populations with the greatest burden based on both rates and numbers of suicide. 10-24 25-44 45-64 1999 (rate per 100,000} 2.04 13.5? 13.22 15.80 2016 rate 9.21 16.91 19.22 16.66 Percentage increase 31 25 45 5 1999 suicide counts 4143 11572 29?? 5439 2016 suicide counts 6159 14396 16196 8204 total counts 1999-2016 86118 221469 232108 109915 48. A report came out recently about suicidal thoughts and behavior in youth in Utah. Between these results and other recent findings, should we be focused primarily on youth suicide prevention? Suicide at any age is troubling and a cause for concern. Today?s Vital Signs did not look at suicide rate increases by age group; however, in order to bring rates down, we must apply effective suicide prevention strategies to those population groups at greatest risk and with the greatest burden (based on rates and numbers of suicide}. 21 Note: The Utah study results show similar suicide attempt rates to the National YRBS and while the percentage of peopie with ideation is greater than the national percentage, in Utah, rates of suicide ideation were defined by any serious thoughts of suicide in the past 12 months or any suicide planning. National rates do not combine these questions, which may explain the difference in state and national prevalence. Utah study National YRBS Suicide ideation 2096* Suicide attempts 8.2% 8.6% *The Utah study included students in grades 6, 8,10, and 12 whereas National YRBS is for students in 9- 1:2?1 grades. Also, the Utah study combined two questions [any serious thoughts of suicide or suicide plans). The National YRBS estimate shown in for thoughts of suicide only. 49. Is the Netflix series, 13 Reasons Why, making youth suicide rates increase? While we have seen youth suicide rates increase over the past several years, it is dif?cult to attribute the increases to any one factor. However, we do know that suicide contagion is a real phenomenon, and that when vulnerable youth are exposed to suicidal thoughts or behaviors, their risk for suicide can increase. The media, including the entertainment industry, can help prevent the risk of suicide contagion by safely reporting on suicide and referring to recommendations available at In response to season one of 13RW and in preparation for Season 2, SAVE {Suicide Awareness Voices of Education) convened a group of experts in suicide prevention, mental and physical health, and education to develop tools to help encourage positive responses to the 13 Reasons Why series. I The group developed a toolkit providing practical guidance and reliable resources for parents, educators, clinicians, youth and media related to the content of the series {suicide, school violence, sexual assault, bullying, substance abuse, etc}. The toolkit can help encourage conversations, identify those at risk and prevent unexpected tragedies. SD. Recently a study came out about high levels of loneliness among youth. Is that why youth suicide rates are going up? Loneliness or feeling a lack of connectedness to others is a risk factor for suicide among people of all ages. However, for any given individual, suicide is typically not caused by any one thing. Today?s Vital Signs reports on the multiple contributing factors to suicide including relationship problems, substance misuse, and health, joby?financial, and criminal legal problems. To help communities make use of the best available evidence for suicide prevention, CDC released a suicide prevention technical package. Many of the strategies in the technical package are likely to help people feel connected and less lonely. This is an important part of a comprehensive suicide prevention strategy. 22 51. Recently a study came out about increasing rates of depression, especially among youth. Is that why suicide rates are going up? On a population level, increases in depression can impact suicide rates, especially untreated depression, however, for any given individual, suicide is typically not caused by one thing. It is unclear how much these trends in depression are influencing the increases in suicide rates. Today?s Vital Signs reports on the multiple contributing factors to suicide including relationship problems, substance misuse, and health, job/financial, and criminal legal problems. A comprehensive approach to suicide prevention must address mental health conditions like depression as well as these other factors. Suicide among Veterans 52. Do you have any information on suicide among Veterans and Military service members? While we did not describe Veteran suicides in this study, here are some key epidemiologic findings from other reports published by the Departments of Veterans Affairs and Defense, as well as the CDC . CDC and its partners are currently doing more research to understand the extent to which the general rise in suicide rates can be attributed to the rise in suicide rates among Veterans. Veterans: 0 Veterans accounted for 18 percent of adult suicides but constituted only 8.5 percent of the U.S. adult population (ages I An average of 20 Veterans died by suicide each day; roughly 14 of these are not using VHA services. I The overall burden of Veteran suicide is mostly among Veterans of middle to older adult ages. - An estimated 55% of Veteran suicides occurred among Veterans ages 50 years an older I Rates dramatically increased from 12f100,000 in 2005 to in 2014 among young Veterans aged 13-24 years who were using VHA services and were in Operations Enduring Freedom, Iraqi Freedom, or New dawn I Suicides among young Veterans aged 18-35 years are highly concentrated in a small proportion of counties. . Within 17 states, an estimated 33% of suicides among Veterans aged 18-35 years occurred in just 3% of U.S. counties and 69% occurred in 13% of U.S. counties. Many of these high burden counties do not have easy access to VHA facilities. I Accounting for age and sex, risk for suicide was 21 percent higher among Veterans versus civilians. in Accounting for age, risk for suicide was 2.4 times higher among female Veterans versus female civilians Active duty: 23 0 Suicide rates have doubled from 12.5 per 100,000 in 2005 to 30 deaths per 100,000 in 2012. Steady declines in recent years have been observed (although this could be because more service members were recently discharged and therefore their suicides would be reflected in the Veteran population} I Since 2001-2014, 51% of suicide decedents were Army service members; 13% were Air Force service members; 12% were Navy service members; 14% were Marines . Key epidemiological findings include: 94% were male 72% were of white race 87% were of non-Hispanic ethnicity 33% were under the age of 35 years 88% were in the enlisted ranks of 22% only had a high school graduate level of education (or less) 52% were married 68% of suicides were the result of firearm injuries 54% had a history of deployment 53. Do you think the rate increases in suicide across the U.S. is the result of increases in Veteran suicides? For this study, we were unable to explore the reasons why we observed these state increases. Therefore, we are unable to determine the extent to which the broad increase in suicide rates across the states is the result of increases in the Veteran suicide rate. This question needs further exploration. 54. is CDC engaged in preventing suicides among Military service members and Veterans? CDC has partnered with the Departments of Veterans Affairs and Defense on numerous innovative suicide prevention projects to help address and prevent suicide among active duty service members and Veterans. - The innovations span across public health service. Such efforts are focused to: 0 Improve surveillance of suicide Increase understanding of the antecedents of suicide and potential factors that might protect against risk of suicide Improve early identification of suicide risk and rapid response to those in need of services, and evaluate key population?level suicide prevention policies and strategies being implemented across states and at military installations. Cipioids and SuiCIde 55. How are suicide, opioid misuse, and Adverse Childhood Experiences related? 24 We know that adults who experienced Adverse Childhood Experiences, or ACEs, are at risk for both Suicide and substance misuse. Additionally, it is important to note that children whose parents are dealing with substance use disorder or have overdosed are experiencing ACEs, as are children whose parents attempt or die from suicide. So addressing trauma and preventing ACEs can be important to prevention of suicide and opioid misuse as well. 56.Why are opioid overdoses increasing? Drug overdoses killed 63,632 Americans in 2016. Opioids?prescription and illicit?are the main driver of drug overdose deaths. Nearly two?thirds of these deaths involved a prescription or illicit opioid. Overdose deaths increased in all categories of drugs examined for men and women, people ages 15 and older, all races and ethnicities, and across all levels of urbanization. The rise in opioid overdose deaths can be outlined in three distinct waves: 0 The first wave began with increased prescribing of opioids in the 1990s with overdose deaths involving prescription opioids {natural and opioids and methadone} increasing since at least 1999. a The second wave began in 2010, with rapid increases in overdose deaths involving heroin. i The third wave began in 2013, with significant increases in overdose deaths involving opioids particularly those involving illicitly-manufactured fentanyl The IMF market continues to change, and IMF can be found in combination with heroin, counterfeit pills, and cocaine. I Recent CDC data {Seth P, Scholl L, Rudd RA, Bacon S. Overdose Deaths Involving Opioids, Cocaine, and United States, 2015?2016. MMWR Morb Mortal Wkly Rep. ePub: 29 March 2018.) confirms that increases in drug overdose deaths are being driven by continued sharp increases in deaths involving opioids other than methadone, such as illicitly manufactured fentanyl 57. Does prescribing opioids to patients with chronic health conditions increase suicide ?sk? Research has shown that chronic health conditions, including painful conditions such as arthritis, migraines, and fibromyalgia, are associated with increased suicide risk. Further, patients receiving opioid therapy for chronic pain are at elevated risk for mental health conditions and suicide attempts. This may reflect an increased likelihood of prescribing opioids by providers to patients with risk factors for suicide, including mental health conditions, chronic pain, and opioid use disorder. Increased opioid availability can also offer greater access to lethal means for suicide. 58.Can the increase in suicides among certain populations be attributed to opioid use, or to chronic pain? A recent study showed that chronic health conditions are associated with increased suicide risk, particularly when multiple chronic conditions are present {Ahmedani et al., 2017}. Dpioids can be prescribed for chronic conditions, and patients receiving opioid therapy are at elevated risk of attempting suicide. However, suicide risk might be able to be reduced by improving pain management consistent with prescribing guidelines. For example, in a study of veterans on long-term opioid therapy, approximately 1-294: of patients attempted suicide within 6 months of receiving a prescription. The VA facility engaged in an effort to increase compliance with prescribing guidelines by making more consistent use of drug screening, providing follow-up within 4 weeks for patients initiating new opioid prescriptions, and avoiding co-prescribing of sedatives with opioids. The study found that by providing follow-up as recommended in the guideline, the risk of suicide could be reduced by 5 times {Im at al., 2015]. In a second study, researchers found that compliance with the VAfDepartment of Defense 25 guideline improved patient safety for VA opioid?prescribed patients (Brennan et al 2016). For example, urine drug screening increased significantly, and this was associated with lower risk of suicide among patients. 59. Has the Guideline for Prescribing Opioids caused people suffering in pain to contemplate or die by suicide? Chronic pain can result in considerable suffering. Having a chronic pain condition, compared to no physical pain, is associated with a higher likelihood of suicide, suicidal ideation and suicide attempts, and in many cases this association persists even after controlling for co-morbid mental health andfor substance use disorders. This is the finding of a recent meta-analysis of 30 studies that examined the association of physical pain with a range of suicide related outcomes among people with and without pain conditions. {Ref: Calati, R., Artero, 5., Courtet, P., St Lopez?Castroman, J. {2016). Framing the impact of physical pain on suicide attempts. A reply to Stubbs. Res, 72, 102403. 0 Among patients taking opioids, a recent study suggests that the most important factor that predicts transition from suicidal ideation to suicidal attempt is the belief that pain can?t be successfully managed hopelessness about pain management], rather than factors such as condition or pain severity. I A recent study of US veterans prescribed opioid medications for chronic pain management revealed that a very small percent attempted suicide {less than and that having a mood disorder increased the risk for suicide attempt. Importa ntly, use of guideline?recom mended practices, including use of urine drug testing, greater?follow?up, and lower co?prescription of sedatives was associated with a lower risk of suicide attempts. Additional research would tell us more about the associations among chronic pain, opioid use, and suicide, and inform prevention efforts. The available evidence highlights the importance of urine drug testing and avoiding co-prescribing of benzodiazepines, whenever possible, and providers remaining alert to signs of anxiety and depression, using validated instruments to assess for mental health conditions, resevaluating patients with depression or mental health conditions more frequently than every 3 months, considering use of tricyclic or SNRI antidepressants for analgesic as well as antidepressant effects, and considering behavioral health specialist consultation for any patient with a history of suicide attempt or mental health disorder, as recommended in the CDC Guideline. 60.Why doesn?t CDC think chronic pain is important? Why is the prescription drug overdose epidemic the focus? Chronic pain is a public health concern in the United States. Patients with chronic pain deserve safe and effective pain management. - Opioids can help manage some types of pain but also have serious risks of addiction and overdose. While evidence supports short?term effectiveness of opioids, there is insufficient evidence that opioids control chronic pain effectively over the long term, and there is evidence that other treatments can be effective with less harm. 26 I Primary care providers are concerned about opioid pain medication misuse, are worried about patient addiction, and want more training in prescribing opioids. CDC's role is to tackle the biggest health problems causing death and disability for Americans, putting science and advanced technology into action to prevent disease and promote healthy and safe behaviors, communities and environment. CDC recently played a leading role in getting public health goals pertaining to chronic pain included in Healthy People 2020, and facilitated the inclusion of questions about chronic pain in the 2016?17 National Health interview Survey. CDC scientific experts also provided review and input regarding the overall National Pain Strategy led by HHS. The NPS outlines a coordinated plan for reducing the burden of chronic pain on the American public. It includes key recommendations in areas including population research, prevention and care, disparities, service delivery and payment, professional education and training, and public education and training. The strategy calls for: I ?Developing methods and metrics to monitor and improve the prevention and management of pain. I Supporting the development of a system of patient-centered integrated pain management practices based on a model of care that enables providers and patients to access the full spectrum of pain treatment options. I Taking steps to reduce barriers to pain care and improve the quality of pain care for vulnerable, stigmatized and underserved populations. I Increasing public awareness of pain, increasing patient knowledge oftreatment options and risks, and helping to develop a better informed health care workforce with regard to pain management." Drug overdose one of the few problems getting worse in US affecting all ages, races, communities. The opioid overdose crisis is being fueled by both prescription opioids and illicit drugs, like heroin and illicitIy-ma nufactured fentanyl. CDC plays an important role in understanding and addressing the causes of the opioid overdose epidemic. Opioids (including prescription opioids, heroin, and fentanyl} killed more than 42,000 people in 2015, more than any year on record. 0 40% of all opioid overdose deaths involve a prescription opioid. The best ways to prevent opioid overdose deaths are to improve opioid prescribing, reduce exposure to opioids, prevent misuse, and treat opioid use disorder. Managing chronic pain is important to the health and well-being of all Americans, and preventing, assessing, and treating chronic pain can be a challenge. Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse opioids, develop opioid use disorder, or overdose from these drugs. The CDC guideline provides recommendations to help determine when to initiate and continue opioid prescribing for pain outside of active cancer treatment, palliative care, and care to ensure patients have access to safe and effective chronic pain treatment. CDC aims to save lives and prevent prescription opioid overdoses by equipping providers with the knowledge, tools, and guidance they need. Adverse Childhood Experiences and SuiCIde 27 61.What are ACEs Adverse Childhood Experiences is the term given to describe types of abuse, neglect, and other household challenges that occur to individuals under the age of 18. The landmark Kaiser ACE Study examined the relationships between these experiences during childhood and reduced health and well- being later in life. The term encompass 10 experiences listed in the original ACE questionnaire. A. Abuse C. Household challenges 1. Emotional abuse 6. Substance abuse [of household 2. Physical abuse member) 3. Sexual abuse 7. Mental illness (of household B. Neglect member) 4. Emotional neglect 8. Mother treated violently 5. Physical neglect 9. Parental separation or divorce 10. Incarcerated household member 62.What is an ACE score? The ACE score, a total sum of the different categories of ACEs reported by people, is used to assess cumulative childhood stress. The score ranges from 0 {unexposed} to 10 (exposed to all categories). Study findings repeatedly reveal a graded dose-response relationship between ACES and negative health and well-being outcomes across the life course. 63.What is CDC doing to prevent Safe, stable, nurturing environments for all children play a large role in preventing ACEs by creating a context and atmosphere that allows families to share quality time together, to discuss and resolve conflicts, and to provide emotional support to one another. technical package for preventing the different forms of violence impacting children and families can help states and communities prioritize prevention activities based on the best available evidence. These strategies range from a focus on individuals, families, and relationships, to broader community and societal change. For example, the child abuse and neglect technical package includes changing social norms to support parents and positive parenting, enhancing parenting skills to promote health child development, Strengthening economic supports for families, and providing quality care and education early in life, and intervening to lessen harms and prevent future risk. 64. How are ACES and suicide related? Research suggests that the greater the number of ACEs, the greater the risk of suicide attempts. ACEs have been associated with increased risk for a variety of outcomes that could contribute to stress and 28 risk for suicide, including unhealthy coping; physical, mental health, and behavioral health disorders; and diminished life opportunities such as reduced education, employment, and income. Suicide Prevention 65. Did the study provide recommendations for prevention? Comprehensive suicide prevention activities both upstream (before suicide risk begins) and (after people have been identified as at-risk, or have attempted suicide} are needed to address the full range of factors contributing to suicide. II For example, among people with mental health conditions, the study identified a need for additional safety supports, including broader implementation of affordable and effective treatment modalities such as doctor-patient collaborative care models and proven cognitive-behavioral therapies. Additionally, greater access to providers in underserved areas is needed, as is expansion of healthcare systems that integrate physical and behavioral health with a priority on suicide prevention and patient safety, especially through care transitions. Ir In addition to strategies addressing mental health conditions, the study identified the need for attention to the broader range of circumstances contributing to suicide, including relationship, substance use, physical health,job, financial, and legal problems. Taken, together a comprehensive approach to suicide includes the following strategies: Identifying and supporting people at risk of suicide. 0 Teaching coping and problem-solving skills to help people manage challenges with relationships, jobs, health, or other concerns. 0 Promote safe and supportive environments, including safely storing medications and firearms to reduce access among people at risk. Connecting people to others in their community so they don?t feel alone. Connecting people at risk to effective and coordinated mental and physical healthcare. Expanding options for temporary assistance for those struggling to make ends meet. Preventing future risk of suicide among those who have lost a loved one to suicide 0000 Effective approaches to prevent the many suicide risk factors are available. States and communities can use data from and resources such as Preventing Suicide: a Technicai Package of Paiicies, Programs, and Practices, available at: to better understand their suicide problem, prioritize evidence~based comprehensive suicide prevention, and save lives. 66.What can be done to prevent suicide? Suicide is preventabie. CDC released a technical package of policies, programs, and practices to prevent suicide to help communities focus on a core set of strategies that have the best available evidence and greatest prevention potential. The technical package includes examples of programs that local implementers might tailor to fit the needs of their community. The technical package includes 7 strategies designed to work together to achieve the greatest impact possible. 29 67. i. Strengthen economic supports ii. Strengthen access and delivery of suicide care Create protective environments iv. Promote connectedness v. Teach coping and problem?solving skills vi. Identify and support people at risk vii. Lessen harms and prevent future risk For example, an evidenced based suicide prevention program called Sources of Strength was developed with rural and tribal communities in North Dakota to promote connectedness between youth and caring adults. The program works to understand and respond to underlying causes of suicidal behavior and promote protective factors against suicidal behavior before the causes result in adverse outcomes. Other innovative prevention strategies, such as telebehavioral health (telephone, video and web-based technologies}, are a promising option to increase access to health ca re and mental health care in rural communities. However, rural communities often have limited access to the internet suggesting a need to increase broadband access and to identify other ways to deliver promising prevention supports. Everyone can play a role in suicide prevention. I Physicians have an important role to play in recognizing and appropriately treating mental health conditions. - Other professionals who work with vulnerable populations parole officers, teachers, etc.) play an important role in identifying and referring at?risk individuals. - Employers can play a role too. 0 Employee assistance programs can work to reduce stigma about seeking help and improving access to care. There are also recommendations for the media regarding how to report on suicide to raise awareness without increasing the risk of additional suicides among vulnerable populations. We know that risk can increase when the media provides details about the methods used, dramaticigraphic headlines, or glamorize a death (see reportingonsuicideorg). What is a technical package? A technical package is a collection of strategies that represent the best available evidence to prevent or reduce public health problems like violence. They can help improve the health and well~ being of communities. suicide prevention technical package is intended as a resource to guide decision-making in communities and states. - CDC expert scientists reviewed the literature and summarized the best?available evidence in the technical package. The package has been reviewed by granteesifunded partners, federal partners, and other audiences. - The technical package highlights seven strategies to prevent suicide. I This technical package describes programs, practices, and policies along with the evidence of their impact on suicide or risk and protective factors for suicide. I The strategies are presented in order from those with the greatest potential to produce broad public health impact on suicide followed by those with potential to impact subsets of the population persons who have already made a suicide attempt]. 30 68. If suicide rates are increasing, does that mean the evidenced-based strategies that have been identified are not working? The evidence tells us that there are strategies that work. - These strategies and approaches do not work if they aren?t properly implemented or expanded to reach larger audiences. I There are many reasons why effective programs are not implemented and expanded, but a lack of funding for suicide prevention has been identified as a contributing factor. The most effective strategies are comprehensive and use a public health approach as opposed to focusing exclusively on mental health conditions, to impact a broader audience. There is also the issue of stigma around suicide and mental health care, which discourages people at risk for self-harm from seeking help. Suicide is preventable, but we need sufficient investment and a comprehensive public health approach. 69.Where can people go to get more information about suicide prevention? Visit the CDC Injury Center website at 70. What partnerships or sectors should be involved in suicide prevention? I Public health agencies can play an important role in preventing suicide. They can provide leadership and bring critical resources to address the problem. However, the strategies and approaches outlined in technical package cannot be accomplished by the public health sector alone and require a collective effort across sectors. 0 Other sectors vital to prevention efforts include: 2 Education Government (local, state, and federal} Social services Health services c; Business Labor Justice Housing Media Community organizations le.g., foundations orfaith-based and other organizations) 0 Each sector has an important role: 0 Local and state public health agencies and organizations can work to convene partners, lead efforts, track progress, and help evaluate efforts. 0 Education and the public health sector are vital to supporting the development, evaluation, and adoption of effective programs that promote connectedness or that teach coping and problem-solving skills. 0 Business, workplaces, housing, and local and state government entities are in a position to help implement policies and programs that directly address some of the underlying risks and environments that increase the risk for suicide. 0 The healthcare, public health, justice, and social service sectors can work together to identify and support people at-risk of suicide and their families. 0 Across all strategies community organizations and other non-governmental organizations are vital to prevention. 31 71. Is it necessary to monitor and evaluate prevention efforts? I It is important to have data to monitor the extent of the problem so you can see if your prevention efforts are producing the desired impact. I There are existing data sources for you to consider such as National Vital Statistics System the National Violent Death Reporting System the National Electronic Injury Surveillance System-All Injury Program the Youth Risk Behavior Surveillance System and the National Survey on Drug Use and Health (NSDUH). If gaps in the data exist, you may want to look for data collected at the local level. provides some local data. You may also want to consider data from state and local Child Death Review teams and Suicide Death Review Teams {where available). I The data you collect can be used to identify and address gaps in surveillance systems as well as plan programs and evaluate the impact of your efforts. Talking about suicide 8t suicide contagion 72.Will talking about suicide give people the idea to do it? Could we do more harm than good? Talking about suicide does not cause suicide to occur. I In fact, it can be an excellent prevention tool. Talking breaks the secrecy that surrounds suicidal behavior and lets people know that help is available. I By not talking about suicide, we increase the isolation and despair of individuals thinking about it and perpetuate the stigma associated with suicidal ideation and behavior. 73.What is meant by "suicide contagion" or "copy-cat" suicide? These words describe a process by which exposure to suicide or suicidal behavior of one or more persons influences similar behavior by vulnerable individuals. Research has shown that graphic, sensationalized or romanticized descriptions of suicide deaths in the news media can contribute to suicide contagion. 74. Do media reports regarding suicide increase the number of copy-cat suicides? What suggestions does CDC have for news media covering suicide issues in their community? CDC research suggests that stories about suicide can help inform readers and viewers about the likely causes of suicide, its warning signs, trends in suicide rates, and recent treatment advances. They can also highlight opportunities to prevent suicide. Media stories about individual deaths by suicide may be newsworthy, but they also have the potential to do harm. lmplementation of recommendations for media coverage of suicide has been shown to decrease suicide rates. For more information about these recommendations and tips for covering suicide visit Reporting on Suicide: Recommendations for the Media: 75.What suicide story angles should reporters consider? I Trends in suicide rates accompanied by prevention strategies I Recent advances in prevention strategies I individual stories of how prevention was lifeusaving 32 What 76 77. Stories of people who overcame desperate circumstances without attempting suicide about suicide Warning signs of suicide I Actions that individuals or families can take to prevent suicide by others I Actions that communities can take to support connections among people that help to reduce risk role do the economy and social media play in increasing suicide rates? .What role does the economy play in increasing suicide rates? The role of the great recession in the late 2000?s and subsequent financial challenges and concerns about economic instability could have contributed to increases in suicide risk. Past research on the association between business cycles and U.S. suicide indicate that the overall suicide rate rises and falls in connection with the economy, with increases during economic recessions. We know that suicides increase in times of economic turmoil, and financial stress experienced by parents may trickle down resulting in vulnerable youth. ls social media use to blame for increasing suicide rates? More research is needed on the impact of social media use on suicide rates. However, changes in social media content or use patterns could potentially be contributing to risk. Social media can exacerbate bullying, romanticize suicide, and provide harmful content on suicide methods. Alternatively, social media can be used to enhance connections between people, correct about suicide, and facilitate access to help. Research is needed to determine how to reduce risk and enhance the protective factors associated with social media. Select Recent CDC Research CDC has released several publications recently. 0 CDC just released a study on the timing of suicides. - The study examined 122 thousand suicides from the National Violent Death Reporting System in 18 US. States from 2003 through 2014. I Results: Suicides significantly increased (p 0.05] I from March to peak in September before falling, the first week of the month I early in the week I in the morning, mainly peaking during the afternoon, although suicides in adolescents peaked in the evening and in those 65 years and older peaked in the morning. I differences were observed by sex, age, and race/ethnicity. I Results from research on suicide timing can potentially help inform planning for prevention activities before periods of relatively high suicide. To help communities make use of the best available evidence for suicide prevention, CDC released a suicide prevention technical package. The technical package describes the importance of a comprehensive approach, which includes Identifying and supporting people at increased suicide risk and upstream approaches that reduce a range of known risk factors. 33 Tian, N., Zack, M., Fowler, K. A, 8: Hesdorffer, D. C. (2018). The Timing of Suicide in 18 United State States from 2003-2014. Archives of5uicide Research, (just-accepted}, 1-21. In mid-May, the National Center for Health Statistics released a study describing county-level trends in U.S. suicide rates from 2005-2015. I This study, published in the American Journal of Preventive Medicine, documents that county-level suicide rates increased by more than 10% from 2005 to 2015 in 99% of counties in the U.S. I 87% of counties showed an increase of greater than 20% I States and communities can use these data in combination with the results from the present study to obtain more granular level detail about suicide rates within their states and to help focus prevention efforts. 0 Late last year, we released a JAMA article analyzing the number of youth visiting emergency rooms with nonfatal, self-inflicted injuries. I We found that self-inflicted injuries are one of the strongest risk factors for suicide. Our research found that emergency room visits for self?inflicted injuries among young females increased significantly in recent years (2001?2015i?particularly among girls 10? 14. I And since the risk leads to a potentially fatal outcome, monitoring trends in Self?inflicted injuries is critical to preventing suicide in young people. - Mercado MC, Holland K, Leemis RW, Stone DM, Wang J. Trends in Emergency Department Visits for Nonfatal Self-inflicted Injuries Among Youth Aged 10 to 24 Years in the United States, 2001-2015. In February of this year, CDC released a Morbidity and Mortality Weekly Report (MMWR) summarizing 2014 data from the 18 states participating in the National Violent Death Reporting System at that time. I Violent deaths due to self-inflicted injury or interpersonal violence disproportionately affected people aged 45?64 men, and American Indian/Alaska Natives. I There were several primary precipitating factors for both homicides and suicides that stood out including: intimate partner problems, interpersonal conflicts, mental health and substance abuse conditions, and recent crises I is currently in 40 states, the District of Columbia, and Puerto Rico, with goals to expand nationally. I Developing and expanding is crucial to public health efforts at the federal, state, and local levels, in order to identify information like precipitating factors and also to target prevention efforts. I Fowler KA, Jack SP, Lyons BH, Betz CJ, Petrosky E. Surveillance for Violent Deaths National Violent Death Reporting System, 18 States, 2014. MMWR Surveill Surnm 2018;67lNo. As part of our commitment to suicide prevention in vulnerable populations, in March of this year, CDC released another MMWR, specifically on suicides among American lndiaanlaska Natives. I it showed that the rates of suicide among American lndiaanlaska Natives have been increasing since 2003. 34 II Analysis of the data from 18 states, showed that people who died by suicide were younger and were more likely to live in a non-metropolitan area than non-Hispanic whites who died by suicide. I The data show a clear need for culturally relevant intervention strategies for this population. Leavitt RA, Ertl A, Sheets K, Petrosky E, Ivey?Stephenson A, Fowler KA. Suicides Among American lndiaaniaska Natives National Violent Death Reporting System, 18 States, Morb Mortal Wkly Rep Partner Activities 1. What is the Nationai Action Alliance for Suicide Prevention? The National Action Alliance, also referred to as the "Action Alliance" is a public?private partnership that works to advance the National Strategy for Suicide Prevention and make suicide prevention a national priority. 2. What is the Nationai Strategy for Suicide Prevention? This is a report created by the US. Surgeon General and the Action Alliance. It emphasizes the role everyone can play in protecting their friends, family, and colleagues from suicide. it has been revised to include a decade of research and other advancements in order to provide guidance for several sectors like schools, businesses, and health systems. 3. What is Project 2025 Project 2025 is a collaborative initiative developed by American Foundation of Suicide Prevention (AFSP). The goal of Project 2025 is to reduce the annual suicide rate 20 percent by year 2025. AFSP has determined a series of actions and critical areas to help reach the goal, which includes approaches that reach across all demographic and sociological groups. 4. What is Zero Suicide? This a key concept of the 2012 National Strategy for Suicide Prevention, a priority of the National Action Alliance for Suicide Prevention, and is supported by the Substance Abuse and Mental Health Services Administration It requires that health and behavioral health care systems commit to making suicide prevention a core priority and implement processes and strategies that prevent suicide and improve the care of patients at risk for suicide. Additional Resources Recommendations for Media about Safe Reporting on Suicide, reportingonsuicdeorg if you or someone you know is thinking about suicide or needs support, help is always available. Call the National Suicide Prevention Lifeline at [8255) or visit Preventing Suicide: A Technical Package of Policy, Programs, and Practices: National Strategy for Suicide Prevention, suicide-prevention-D Suicide Prevention Resource Center, 35 Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Weekly/Vol. 67 i No. 22 June 8, 2018 Vital Signs: Trends in State Suicide Rates United States, 1999?201 6 and Circumstances Contributing to Suicide 27 States, 2015 Deborah M. Stone. 5:th 'l?homas R. Simon l?hDi; Katherine A. Fowler, l?th; Scott R. Kegler, Pth; Keniing Yuan, Kristin M. Holland, Asha Z. hey-Stephenson, I?th; Alex E. Crosby, Abstract Introduction: Suicide rates in the United States have risen nearly 30% since 1999., and mental health conditions are one of several factors contributing to suicide. Examining stateelevel trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. Methods: Trends in age-adjusted suicide rates among persons aged :10 years, by state and sex, across six consecutive 3-year periods (1999?2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data From the National Violent Death Reporting System, covering 27 states in 20! 5, were used to examine contributing circumstances among decedents with and without known mental health conditions. Results: During 1999?20 16, suicide rates moreased signi?cantly in 44 states, with 25 states experiencing mcreases Rates increased significantly among males and females in 34 and 43 states, rmpectively. Fifty-four percent ofdecedents in 27 states in 201 5 did not have a known mental health condition. Among decedents with available information, several circumstances were signi?cantly more likely among those without known mental health conditions than INSIDE among those with mental health conditions, including 625 Invasive Methicillin-Resistant Staphylococcus oureus relationship problemsi'loss (45.1% versus life Infections Among Persons Who Inject Drugs Six Sites, 2005?201 6 629 Tobacco Product Use Among Middle and High School Students United States, 2011?2017 634 Update: Influenza Activity in the United States During stressors (50.5% versus and recent! impending crises (32.9% versus but these circumstances were common across groups. Conclusions: Suicide rates increased significantly the 201??18 Season and Composition ofthe 2018?19 across most states during 1999?2016. Various Influenza Vaccine circumstances contributed to suicides among persons 643 Update: ACIP Recommendations for the Use of With and without known mental health conditions. Quadrivalent Live Attenuated Influenza Vaccine Implications for Public Health Practice: States United Sis??95: 2018?19 Influenza 59350" can use a comprehensivg evidence?based public 646 Notes from the Hemorrhagic health approach to prevent suicide risk before it Fever Outbreak?Central Uganda, August?September occurs, identify and support persons at risk, prevent 201? reattempts, and help friends and family members in 6?48 QuickStats the aftermath of a suicide. Continuing Education examination available at infolitmliiweekly. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report Introduction in 2016. nearly 45,000 suicides population [age-adjusted? occurred in the United States among persons aged :10 years From 1999 to 2015. suicide rates increased among both sexes, ail racial/ ethnic groups, and all urbanization levels (2.3). Suicide rates have also increased among persons in all age groups <75 years, with adults aged 45?64 having the largest absolute rate increase (from 13.2 per 100,000 persons [1999] to 19.2 per 100,000 [2016]) and the greatesr number ofsuicides (232,108) during the same period (1.3). Suicide is the tenth leading cause ofdeath and is one ofjust three leading causes that are increasing in addition, rates ofemergency department visits for nonfatal self-harm, a main risk factor for suicide, increased 42% from 2001 to 2016 (1). Together, suicides and self-harm injuries cost the nation approximately $730 billion per year in direct medical and work loss costs if}. The National Strategy for Suicide Prevention calls for a public health approach to suicide prevention with efforts span? ning multiple levels (individual, famiiyfrelationship, community, and societal]. Such a comprehensive approach underscores that suicide is rarely caused by any single factor. but rather, is deter? mined by multiple factors. Despite this call to action, suicide prevention largely focuses on identifying and tefEtring suicidal persons to mental health treatment and preventing reattempts (6). in addition to mental health conditions and prior suicide attempts, other contributing circumstances include social and economic problems, access to lethal means (eg, substances, firearms) among persons at risk, and poor coping and problem- solving skills Expanded awareness of these additional circum- stances contributing to suicide risk and action to address them can be] reach the national goal, established by the National Action Alliance of Suicide Prevention and the American Foundation for Suicide Prevention, of reducing the annual suicide rate 20% by 2025 To assist states in achieving this goal, CDC analyzed state?specific trends in suicide rates and assessed the multiple contributing factors to suicide; this report presents options for strategies to include in comprehensive suicide prevention efi'orts that are based on the best available evidence. Methods Suicide rates were analyzed for persons aged :10 years because determining suicidal intent in younger children can be difficult (8). Ageaspecific suicide counts were tabulated based on National Vital Statistics System coded death certificate records (International Class?imrion ofDireiases, Fitme- Revision, underlying?cause?ofdeath codes ?37.0. Age? specific population estimates were obtained from U.S. Census Bureau/National Center for Health Statistics bridged?race population data releases. National and staterlevel suicide rate estimates were calculated for six consecutive 3?year aggregate periods spanning i999? 2016 (1999?2001; 2002?2004; 2005?2007; 2003?2010; 2011?2013; and 2014-2016). Rate estimates were age- adjusted to the U.S. 2000 standard population and expressed The of publications is published by the Center for Surveillance. Epidemiology, and Laboratory Services. Centers For Disease Control and Prevention US. Department DE Health and Human Services, Atlanta, GA 30329-4027. Suggc?ed citation: [nudist tomes; first three. then ct .1L. if more than steel [Report title]. MMWR Morb Mortal Wkly Rep 2018;67:linc1usive page numbers]. Centers for Disease Control and Prevention Robert R. Redfield, MD, Dir-retal- Annc Schucllat. MD. Principe! Depend Dirmor Leslie Dauphin. Acting Arterial? Diremar?r .S'rz?mcr Joanne Conn. MD. 542M, Dir-emu [wire 43am.- Quality Chesiey L. Richards, MD. MPH. Deputy Public Health Erin-tri?e 5mm: Michael F. ladetnaico. MD. MPH. Din-am: Center?rr Epidemiology mm'LdiEremmq Service: MMWR Editorial and Produetion Staff [Weaklyl Charlotte K. Kent. MPH. Acting Edimn'n Chief: Executive Editor- Jacqueline Gladier. MD. Editor Mary Dotr, MD. MPH, (Julius Editor Temsa F. Rutledge. Managing fairer Douglas W. Weathuwax. Lead Tat?nimi? Wtr??f?ar Glenn Damon. Soumya Dunworth, Teresa M. Hood. MS. manual Writer-a?oat: Martha F. Boyd. Lew} Visual Specialise Maureen A. Lei-ally. Julie C. Mnrtinroe. SmphenR. Spriggs. Tong Yang. Vitae! In?rmetfm Sammie: 'Quang M. Dean. MBA. H. King. Terraye M. Starr, Mona Yang, In?ramim spa-area MMWR Editorial Boon! Timothy F. Jones. MD. Matthew L. Buuitoo. MD. MPH Virginia A. Cains. MD Katherine Daniel. PM) Jonathan E. Fielding, IulD. MPH, NIBA David Fleming. MD eta MMWR Jun88,2018 r' Vol.6? No.22 William E. Helper-in. MD. DIPH. MPH King K. Holmes. MD. Robin Ikrda. MD. MPH Rim-.1 F. Khabbaz. MD Meadows. MSN. RN Jewel Mullen. MD. MPH. MFA Patricia Quinlislt. MD. MPH Patrick L. Remington. MD. MPH Carlos R'oig. M5. MA Wait-.1.? L. Roper. MD. MPH William Seha?iter. MD US Department of Health and Human ServicesiCemers for Disease Control and Prevention Morbidity and Mortality Weekly Report per 100,000 persons per?year. Age-adjusted suicide rate trends were modeled using the same 3-year data aggregates, employ- ing weighted least-squares regression with inverse-variance weighting. Modeled rate trends are reported in terms oF average annual percentage changes. Characteristics oF persons aged 1:10 years who died by suicide, with and without known mental health conditions, and the circumstances surrounding the suicides were compared in the 27 states? with complete data participating in CDC's National Violent Death Reporting System in 2015. defines mental health conditions as disorders and listed in the Diagnostic and Statistical Manual Disorders, Farr; Edition (9), with the exception oF problematic alcohol use and other subsranee use that are captured separately in VDRS aggregates data From three primary data sources: death certi?cates, coroneri'medical examiner reports (including toxi? cologyl, and law en Forcement reports. A range oF circumstances (relationship problems, life stressors, and recent or impending crises)I have been identi?ed as potential risk Factors For suicide in Circumstances captured are those identi?ed as con? tributing to suicide in coronerfmeclical examiner or law en Force? ment reports, which re?ect inForntation provided by Family and Friends at the time oF death. Decedents could have experienced multiple circumstances. Decedents with and without known mental health conditions were compared using chi-square tests. Logistic regression analyses were used to estimate adjusted odds ratios (aORsl with 95% confidence intervals (Cls), controlling For sex, age group, and tacoll ethnicity. Results The most recent overall suicide rates (representing 2014? 2016} varied FourFold, From 6.9 (District oF Columbia]I to 29.2 (Montana) per [00,000 persons per year (Supplementary Table; Across the study period, rates increased in all states except Nevada (where the rate was consistently high throughout the study period}, with absolute increases ranging From 0.8 per 100,000 (Delaware) to (Wyoming). Percentage increases in rates ranged From 5.9% (Delaware) to 57.6% (North Dakota), with increases >50% observed in 25 states (Supplementary Table; 53?8 5) (Figure). Modeled suicide rate trends indicated significant increases in 44 states, among males (34 states) and Females (4.3 states), as well as For the United States overall (Supplementary Table: Nationally, the model? estimated average annual percentage change For the overall Alaska. Arizona. Colorado, Connecticut. Georgia, Hawaii, Kansas, Kentucky, Maine. Maryland. Massachusetts. Michigan. Minnesota. New Hampshire. Newjetsey, New Mexico. 1hit-.w York. North Camlina, Ohio, Oklahoma, Oregon, Rhode Island. South Carolina, Utah, Vermont, Virginia. and Wisconsin. US Department of Health and Human Servicesr?Centers for Disease Control and Prevention FIGURE. Percent change in annual suicide rate,* by state United States, from 1999-2001 to 2014-2016 I I Increase: increase: 19%?30% Increase: 5%?18% Decrease: 1.0% Per 100,000 population, age-adjusted to the 2000 U5. standard population. suicide rate was an increase By sex, estimated national rate trends Further indicated significant average annual per? centage change increases For males and Females (Supplementary Table; Suicide decedents without known mental health conditions (1 1,039: 54.0%} were compared with those with known mental health conditions 40.0%) For 27" states. Whereas dece? dents were predominantly male (Table 1) and non: Hispanic white those without known mental health conditions, relative to those with mental health conditions, were more likely to be male (83.6% versus 68.8%; odds ratio 2.3, 95% CI 2.2+25} and belong to a taciali?ethnic minority (OR range 1.2-2.0l. Suicide decedents without known mental health conditions also had significantly higher odds onerpetrating homicide Followed by suicide 2.9, 95% CI Among decedents aged 218 years, 20.1% oFthose without known mental health conditions and 15.3% oF those with mental health conditions had previously served in US. military or were serving at the time oF death. Whereas firearms were the most common method Suicide overall decedents without known mental health conditions were more likely to die by Firearm and less likely to die by (26.99/43) or poisoning (l than were those with known mental health conditions 31.3%, and 19.8%, respectively). These difFerences remained signi?cant in the adjusted models. 'l'oxicology testing was less likely to be perFormed For dece- dents without known mental health conditions. Among those with toxicology results, decedents without known mental health MMWR June 8,2008 Vol.6? No.22 E119 TABLE 1. Selected demographic and descriptive characteristics of suicides among persons aged 210 years with and without known mental Morbidity and Mortality Weekly Report health conditions National Violent Death Reporting System, 21' states,* 2015 Known mental No known mental Total health condition1 health condition 20,446] in 9.407] [n 1 1,1139} Chi-square 0R5 Adjusted on'" Characteristic 00.1%] [110.1%] 010.1%] p-vaiue {95% Cl] [95% Sex Male 15.202 {76.81 6.459 (58.81 9,233 (83.61 {0.01 2.3 NA Female 4,244 {23.2] 2.933 (31.2] 1,306 (16.4] <0.01 0.4 NA Age group [yrsW? 1044 2,304 1,211 (12.9] 1,593 (14.4] <0.01 1.1 (1.1-v1.2] NA. 25?44 5.4563115] 3,036 (32.3] 3,420 (31.0] <0.05 03103?10] NA 45?64 {31.11 3.320 (?10.61 3.898 (35.3] {0.01 0.13 NA 265 3,463 {17.0} 1,340 (14.2] 2,128 (19.3] (0.01 NA RacefEthnicity White, non?Hispanic 12,102 (83.6] 8,165 (86.8] 8,93? (81.0] (0.01 0.5 NA Black, non-Hispanic 1,225 411 81213.4] <0.01 1.7 NA American Indianfnlaska Native, 37811.3] 112 26612.41 40.01 2011.54.61 NA non-Hispanic Asian, non-Hispanic 525 235 341 {0.05 1.2(1.141.5] NA Hispanic 1,096 463 533 <0.05 NA Other 00 21 45 (0.05 1.3 NA Extended demographics Ever served in militantll 3,429 {113] 1,354 (15.31 2.025 (20.1] <0.01 1.4 1.1 Homeless 24011.21 10411.1] 136 {1.31 NS 1.1 1.2 {0.51?1.51 Incident type Single suicide 20,063 (98.2] 9,313 (99.1] 10,?45 {9714] {0.01 0.3 0.4 Homicide followed by suicide 319 6410.7] 25512.31 error 3.5 2392-381 Multiple suicides 64 25 3901.4] NS 1.3 (0.32.21 1.6 Method Firearm 9,909 {43.51 3,321 {40.5} 6,088 {55.31 (0.01 1.3 {tr-1.9} 1.511.543) 5,907 (23.9] 2,940 {31.31 2,96? [26.9] <0.01 013018?09] 0.8 [0.1503] Poisoning 3,003 (14.2] 1,351 (19.3] 1,142 (10.4] {0.01 0.5 0.5 Substance class causing Other ovar?the?counter] 1,021 {34.0] 05:61:35.8] 355 (31.1] {0.01 0.8 0.9 Upioids 944 {31.4] 608 330 (29.4] NS 0.9 0.9 Antidepressants 300 {26.61 1544 {34.61 1515 {1 3.?1 (0.01 0.3 0.3 Benzodiazepines 624 (20.3] 458 (25.1] 156 [13.1] 4:001 0.5 0.5 219 19511105] 24 <0.01 0.2 0.2 (ill?0.3] Other 1.595013] 130 (8.31 815 {0.05 0.9(034101 0.21 {0.13?1.01 See table footnotes on next page. conditions Were less likely to tesr positive for any substance overall 0.8, 950/0 Ci including opioids 0.90, 95% CI 0.814199). but were more likely to test positive For alcohol 1.2, 95%, CI information on circumstances surrounding suicide were available For all decedents with mental health conditions (9,407) and approximately 35% oF those without known mental health conditions (9,357) in 27 states (Table Persons without known mental health conditions were less likely to have any problematic substance use 0.7, 95% CI 0.7?0.8] than Were persons with known mental health conditions. Whereas two thirds of decedents with known mental health conditions had a history of mental health or subStance use treatment just over half were in treatment at the time of (leads. Decedents without known mental health conditions had a signi?cantly higher likelihood ofany relationship problem/loss 520 MMWR June8,2018 Vol.6? No.22 than did those with known mental health conditions (39.00.10), specifically intimate partner problems (30.2% ver? sus {17.5% versus and perpetrating interpersonal violence in the past month versus Decedents without known mental health condir tions were also more likely than were those with known mental health conditions to have experienced any life stressors (50.5% versus 412%} such as recent criminal legal problems (10.7% versus or evictionr'loss ofhome versus and were more likely to have had a recent or impending (within the preceding or upcoming 2 weeks. respectively] crisis (a current or acute event thought to contribute to the suicide) (32.9% ver- sus 20.0%] . All of these differences remained significant in the adjusted models. Physical health problems and jobffinancial problems were commonly contributing stressors among both persons without mental health conditions (23.2% and 15.0%, respectively} and those with mental health conditions (21.4% US Department of Health and Human Servicestente-rs for Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 1. {Continued} Selected demographic and descriptive characteristics ofsuicides among persons aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,* 2015 Known mental No known mental Total health condition'r health condition 20,446] {n 9,413?) {n 11,039} Chi-square 0115 Adjusted oFt?1 Characteristic 110.1%} No. 11%} No. i?itrl p-value {95% Cl} {95% Cl} Toxicology results Any toxicology testing 1 3,317 {65.1} 6,658 {20.3} 5,659 {50.3} (0.01 0.6 0.7 {0.15-0.20 Positive for 21 substance? 9,913 {24.4} 5,192 {18.0} 4,221 {20.9} ?0.01 0.3 Substance detected*? Alcohol Tested 10,950 {53.6} 5,409 {57.5} 5,541 {50.2} (0.01 0.8 Positive 4,442 {40.6} 2,115 {39.1} 2.32? {42.0} c001 1.1 1.2 Upioids Tested 8,554 {41.5} 4,253 {45.3} 4,296 {38.9} ?10.01 0.8 0.8 Positiva 2,279 {20.6} 1,2 38 {29.1} 1,041 {24.2} <0.01 0.8 0.9 Benzodiazepines Tested 3.124 {39.2} 4,226 {44.9} 3,398 {35.3} {0.01 0.7 Positive 2,464 {30.3} 1,639 {38.3} 325 {21.2} c0111 0.4 0.5 Cocaine Tested 2,973 {39.0} 3,866 {41.1} 4,112 {312} <0.01 0.9 0.9 Positive 499 210 233 (0.05 1.2 {1 1.2 AmphetaminES Tested 11,61 5 {312} 3,696 {39.3} 3,919 {35.5} ?:001 0.9 0.9 Positive 730 326 {10.2} 300 NS 0.9 1.0 {0.8?1 Marijuana Tested 6,569 {32.1} 3,127 {33.2} 3,442 {31.2} (0.01 0.9 0.9 Positive 1,471 {22.4} 3'10 {22.70 2'61 {22.1} NS 1.0 0.9 Antidepressants Tested 5,425 {25.5} 3,103 {33.0} 2.322 {21.0} {0.01 05 0.6 Positive 2,21 4 {40.3} 1,735 {55.9} 429 {20.6} (0.01 0.2 0.2 Abbreviations: CI con?dence interval; NA not adjusted: N5 not signi?cant; OH odds ratio. Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah. Vermont, Vi rginia, and Wisconsin. 1 Decedent had been identi?ed as having a current diagnosis of mental health condition in coronerrmedical examiner or law enforcement reports. 5 DR reflects the risk among those without known mental health condition relative to those with known mental health condition. 1? Logistic regression was used to estimate adjusted 01-1 with 95% after controlling for sex, age group. and racefethnicity. Known mental health condition was used as the reference group. ?i Decedents We're aged 210 years, as per standard in the suicide prevention literature. ii Denominator is decedents aged 213 years with reported military service status. Denominator is decedents who died by poisoning, including overdose. 11'? Denominatoris decedents with any toxicology testing. Denominator for each positive group is the number tested for the substanca in that group. and 16.8%, respectively}. Similarly, among all persons with recent crises. intimate partner problems were the most com- mon types and did not by group. Decedents withour known mental health conditions had signi?cantly lower odds of recent release From any institu? tion laOR 0.5, 95% C1 Among those recently released, decedents without known mental health conditions were significantly more likely than decedents with mental health conditions to have been released from a correctional Facility (25.7% versus hospital {433% versus or other facility, such as an alcohollsubstance use treatment facility {24.2% versus Among decedents with known mental health conditions who were recently released from an institution1 46.7% were released from facilities. Decedents without known mental health conditions were significantly less likely to have a history of suicidal ideation US Department of Health and Human Services/Centers for Disease Control and Prevention {25.00.41} or prior suicide attempts compared with those with known mental health conditions {40.8% and 29.4%, respectively). Suicide intent was disclosed by 22.4% and 24.5% ofpersons without and with known mental health conditions, respectively. Conclusions and Comments During 1999?2016. suicide rates increased signi?cantly in 44 states, and 25 states experienced increases :309/0. Rates increased signi?cantly among males in .34 states, and females in 43 states. Additional research into the specific causes of. these trends is needed. Data from the 27 states participating in provide important insight into cir- CLIrnstances surrounding suicide and can help States identify prevention priorities. MMWR I June 8,2018 Vol.6? r? No.22 i321 TABLE 2. Circumstances preceding suicide among decedents aged 21]] years with and without known mental health conditions National Morbidity and Weekly Report Violent Death Reporting System, 27 states,* 2015 Known No known mental health mental health Chi? Total conditior?' condition square 005 Adjusted Characteristic No. No. 110.1%] p-value (95% Cl] (95% Cl] Suicide with known circumstances 13.7641913] 9,407 (100] 9.35? (84.0] ?10.01 NM. NM Mental health Any current diagnosed mental health condition? ??11 1076 0?52] NM WA NM WA Anxiety disorder ?11 1,529 (16.3] NM. NM (WA NIP. Bipolar disorder ?11 1,431 (15.2] NM NM MIA NM Schizophrenia ~11 509 NM NM NIP. NM PTSD 424 MM we no. NM _11 225 {2.41 mm NM NM NM Not speci?ed 16010.1] N14. WA WA NRA Current depressed mood?? 2,033 (37.5] 3,962 (42.1] 102682.91 (0.01 0.1" 0.2 Problematic substance use Any 5,319 (23.3] 2,976 (31.5] 2,343 (25.0] {0.01 0.7 (or-0.3] Alcohol 3.268 (12.4] 1,862 (19.0] 1,406 (15.0] (0.01 0.2 0.2 Other 3,084 (16.4] 1,268 (113.8] 1,316 (14.1] {0.01 0.2 0.7 Treatment Current mental healthr?substance use treatment 5,141 5,02? (54.0] 64 <00] 0.01 (0.01?0.01] 0.01 (0.01?0.01] Ever treated for mental disorder 6,712 (35.3] 6,323 (67.2] 394 <00] 0.02 (0.02?0.02) 0.02 (0.02?0.03] Relationship problemsfloss Any relationship problemfloss 2.9430114] 12261396] 4,222 (45.1] {0.01 Intimate partner problem 5,098 (22.2] 22201241] 232880.21 <0.01 1.4 1.4 (1.3?1 Perpetrator ofinterpersonal violence in past month 414 131 283 :00] 2.2 2.0 lir'ictim of interpersonal violence in past month 84 53 31 <0.05 0.6 (04?09] 0.8 (0.5-4 Family relationship problem 1,671 323 293 NS 03013?10} 1.0 (0.9?1 Either relationship problem (nonintimatei 403 202 201 NS 1 0 (0.3-1.21 1.1 Argument or conilictlnot speci?ed] 2.914(155] 1.2281156] 1,636 <00] 13(12?15] 1.4 Death of a loved one {any} 1,497 326 {0.01 0.3 0.9 (08?09] Nonsuicide death 1,181 547 534 (53] <00] 0 8 09013?10] Suicide of family or friend 31912.0] 211'123] 162 (0.01 1' (06-03} 0.8 Other life stressors Anylife stressor 9,1?1 (48.9] 44420112] 4,129 (50.5] <00] 1.1 1.1 Recent criminal legal problem 1,530 586 1.002 <00] 1.0 (Lo-2.0] 1.7 (15-10] Other legal problem 248 328 320 NS 1.0 (0.8?1 1.0 Physical health problem 2,012 (21.4] 2,16? (23.2] (0.01 1.1 1.0 lobeinancial problem? 2,941 (16.2] 1,530 (16.13] 1,411 (15.6} (0.05 0 9 (0.13?1.01 0.59 Eviction or loss of home 222(18] 31? 405 {0.01 1 3 1.4 School problem*? 162 (19.9] 20(118] 921121.19] N5 1 3 (0.9?1.81 1.3 Recent release from an institutioni"1 1,412 (16] 941 [10.2] (0.01 05 0.5 (04?05] JailfPrisonfDetention facility 203 (14.4] 82 121 (25.2] ?c001 3.6 [2.24.9] 4.5 HoSpital 513ll (36.6] 311 (33.0] 206 (43.7] (0.01 1 1.3 hospitaliinstitution 46933.2] 439146.21 30 <00] 01 0.1 Other [includes alcohDIISU treatment facilities} 2231153] 109 (11.6] 114 {24.2} 40.01 2 4 (I .8?33} 2.5 (1 3-3.3] See table footnotes on next page. Suicidologists regularly state that suicide is not caused by a single factor however, suicide prevention is often ori? ented toward mental health conditions alone with regard to identification of suicidal persons, treatment of mental health conditions. and prevention titre-attempts. This study Found that approximately half of suicide. dcceclents in did not have a known mental health condition. indicating that additional Focus on nonmental health Factors Further upstream could provide important information For a public health approach (.10). Those without a known mental health condition suffered more From relationship problems and 622 MMWR June8,2018 Vol.6? No.22 other life stressors such as criminalr'legal matters. evicrionr?loss of home, and recent or impending criSes. Similarly, persons with mental health conditions also often experienced other circumstances such as relationship problems and johi'tinancial or physical health problems that contributed to their suicide. These findings point to the need to both prevent the circumstances associated with the onset of mental health conditions and support persons with known mental health conditions to decrease their risk for poor outcomes Two thirds ot'suicide decedents with mental health conditions had :1 history oi?treaonent for mental health or substance use disorders. US Department of Health and Human Servicestenters (or Disease Control and Prevention Morbidity and Mortality Weekly Report TABLE 2. {Continued} Circumstances preceding suicide among decedents aged 210 years with and without known mental health conditions National Violent Death Reporting System, 2? states,ii 2015 Known No known mental health mental health Chi- Total condition+ condition square Adjusted 0R1 Characteristic No. No. No. p?value (95% Cl} [95% Cl} Crisis within past or upcoming 2 5,525 {29.41 2,444 {25.0} 3,081 {32.9} (0.01 1 4 1.411.345) Intimate partner problem 1.96.1356] 354134.51] 1,1141362} N5 1 1 1.1 Physical health problem 739 {13.41 315 {12.9) 424113.81 NS 1 1 [0.94.3] 1.0 Criminal legal problem 621 {11.2} 203 {8.31 41811345} (Bill 1.6 Family relationship problem 431] (18] 218111} {0.05 0.910.714.? Job problem 354 191 153 40.01 3? 0.7 {(15?03) Suicide eVentr?history Left a note 53581345] 3,1821333] 3,256 (35.1} NS 1.1 1.2 Disclosed suicide intent 4,405 (23.5] 2.0991214) corn 0.9 0.9 History of ideation 5.990 {31.9) 3,833 [40.8] 2,152 (23.0} I14 0.4 History of attempts 3,?32 {19.9} 2,?70 (29.41 962 {10.3) <0.01 [1.3 {0.3v0,3} 0.3 Abbreviations: ADDEADHD attention de?cit disorderrattention de?cit hyperactivity disorder; CI con?dence interval; WA not applicable; NS not signi?cant; OR odds ratio; PTSD posttraumatic stress disorder; St] substance use. Alaska. Arizona. Colorado, Connecticut, Georgia, Hawaii. Kansas, Kentucky, Maine, Maryland. Massachusetts. Michigan. Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Flhocle Island, South Carolina, Utah, Vermont. Virginia, and Wisconsin. 1 Decedent had been identified as having a current diagnosis of mental health condition in coronerfmedical examiner or Iainr enforcement reports. i UR re?ects the risk among those without known mental health condition relative to those with known mental health condition. Logistic regression was used to estimate adjusted OH with 95% after controlling for sex. age group. and racer?ethnicity. Known mental health condition was the reference group. Includes decedents with one or more diagnosed current mental health conditions, which are not mutually exclusive. Therefore, sums of percentages for the diagnosed conditions exceed 100%. Denominator includes the number of decedents with one or more current diagnosed mental health conditions. 1'1 The speci?c type of mental health condition was calculated only among those with one or more known diagnosed mental health conditions. 55 Not a diagnosis. 11?? Denominator is decedents aged 218 years. Denominator is decedents aged 10?1 3 years. 111 Denominator ofinstitution subgroup is decedents with recent release from an institution- Recent release from an institution is de?ned as having occurred within the past month. Denominator of crisis subgroUp is decedents with any crisis within past or Upcoming 2 Weeks. Crises depicted here represent the most commonly occurring categories. with approximately half in treatment when they died. This find- ing suggests the [seed for additional safety supports, including broader implementation of affordable and effective treatment modalities, such as doctorrpaticnt collaborative care models and proven therapies. in addition, increased access to behavioral health providers in areas is needed, as is expansion of health care systems that integrate physical and behavioral health, with a priority on suicide preven- tion and patient safety, especially through care transitions Comprehensive sratcwidc suicide prevention activities are needed to address the full range offacturs contributing to suicide. Prevention strategies include strengthening economic supports housing stabilization policies, household financial support): teaching coping and problem?solving slcills to manage everyday stressors and prevent future relationship problems, especially early in life; promoting social to increase a sense of belonging and access to informational, tangible, emotional, and social support; and identifying and horror supporting persons at risk (cg, military veterans, persons with physical} mental health conditions) (12). Other Strategies include creating protective environments (cg, reducing access to lethal means among persons at rislc for suicide, creating organizational and US Department of Health and Human Servicesr?Centers for Disease Control and Prevention workplace policies to promote casing transitions into and our of work for persons with mental health conditions and other life challenges), strengthening access to and delivery of care, supporting family and friends alter a suicide. and cncourag ing the media to follow safe reporting recommendations (12). Some States, such as Colorado, are planning to implement such :1 comprehensive approach to suicide prevention The ?ndings in this report arc- to at least three limita- tions. First, in state-level analysis, rankings for four States (Maryland, Massachusetts, Rhodc island, and Utah) might have been affected by large proportions of injury deaths of undetermined [potentially biasing reported suicide rates downward) or decreased percentages of such deaths over time {potentially biasing estimated ratc trends upward). Second, is not yet nationally representative; the 27 states included represent 49.6% ofthc population tmll. Finally, ahsrractors of data are limited to informa- tion contained in investigative reports. the extent of informant knowledge can data completeness and accuracy. Studies that include more in tcrvicws with nextaof-ltin often identify greater to mental health disorders MMWH June 8.2018 Vol.6? i No.22 511 Morbidity and Mortality Weekly Report Summary What is already known about this topic? In 2016. nearly 45,00!) pecans died by suicide in the United States. Mental health conditions are one ofseveralcontrihutorsto suicide. What is added by this report? During 999?201 a, suicide rates increased in nearly every state,- lncluding 80%. increases in 25 Staten 2015 data From 27 states indicate 54% of suicide decodents Were'not known tin-have mental health conditions. Relatitmship. substance use health..andjeb or ?nancial problems?a re among the other circumstances contributing to suicide. What are the implications for public health practice? A comprehensive approach using proven prevention strategies, such as th use in PreventingSulcide: A Itchnical Package of Policy Programsand Practices, can help reach the national goal of reducing the annual suicide rate 20% by 2025. however. many methodological variations across studies exist it is likely that some persons without known mental health conditions in the current study were experiencing men? tal health challenges that were unknown, undiagnosed, or not reported by key informants. Nonetheless, the high preval of diverse contributing circumstances among those with and with out known mental health conditions suggests the importance of addressing the broad range offsetors that contribure to suicide. Suicide is a growing public health problem. Effective approaches to prevent the many suicide risk factors are avail- able. States and communities can use data from and resources such as Suicide: A Echrricel Package off-bitty, Hogmms, and Practices [12) to better under- stand suicide in their populations. prioritize evidence?based comprehensive suicide prevention, and save lives. Acknowledgments Robert Anderson. oily H'cdegaard. Margaret Warner. Division of Vital Statistics. National Center For Health Statistics. CDC. Con?ict of Interest No conflicts of interest were reported. IDivision of? 1Violence Prevention. National Center for injury Prevention and Control. CDC: 2Division of Analysis. Research. and Practice integration. National Center for lniury Prevention and Control, CDC. Corresponding author: Deborah M. Stone. Listonc?f?icdcgov. 624 MMWR June-8.2018 r' Vol.6? No.22 -I 9. ii]. References .CDC. Web?based lniury Statistics Query and Reporting System Atlanta, US Department of Health and Human Services, CDC. National Center for Injury Prevention and Control: 2?18. . [trey?Stephenson AZ, {:Irosby nE, Jack SPD. T, Sedacca Suicide trends among and within urbanization levels by sex. racelerhnicity. age group. and mechanism ofdeath?Unitcd States. 2001~2015. MMWR Surveill Surnm 2017;66lNo. 5548). i1ttps:lldoi. orgll U. Sal .Currin SC, Warner M. H. increase in suicide in the United States, 1999?3114. NCHS darn hricl?no. 24 l, Hyattsville, MD: US Department of Health and Human Services. CDC. National Center for Health Statistics; 2016. db241.pdf . Kochnneic K. Murphy 5. Xu Arias E. Mortality in the United States, 2016. NCHS data brief-no. 295. Hyartwille, MD: US Department of Health and Human Services. (DC. National Center For Health Statistics; 2017. . Orlicc of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National strategy For suicide prevention: goals and objectives For action. 1'ilif'sisl?iington. DC: US Department of Health and Human Services, (Ji?cc of the Surgeon General; 21]] 2. full-reportpdi . Zalsman C, Hawton K, D, ct Suicide prevention strategies revisited: 10?year review. Lancet K, O?Brien A. Leading suicide prevention cFForts unite to address rising national suicide rate. Washington. DC: American Foundation for Suicide Prevention; .Crepcau-Hobson F. The autopsy and determination of child suicides: a survey of medical examiners. Arch Suicide Res 2illD:l?i:l4?34. 33l I 10905-47901 American Association. Diagnostic and statistical manual oi: mcnial disorders DC: American Association: 2013. Cainc ED. Reed J, Hindman J, Quinlan K. Comprehensive, integrated approaches to suicide prevention: practical guidance. Prev 2017. Epub December .World Health Organization. Risks to mental health: an ovcrvicw oi vulnerabilities and risk factors. Geneva. Switzerland: World Health Organization: 2012. risks_ to_mental_hc3l .Stonc DM, Holland KM, Bartholow EN. Crosby All, Davis SP. Wilkins N. Preventing suicide: :1 technical package oipolicy. programs, and practice. Atlanta. US of Health and Human Services. 2017. suicidctechnicalpackagc.pdf . Milnerr?i. Sveticic J. De Leo D. Suicide in the absence disorder? A review of autopsy studies across countries. int] Soc 2015:59z?45?54. 1rtps:lldoi.orgfl {1.1 . Poulior Dc lco D. Critical issues in autopsy snidics. Suicide Lili: 'l'hrcar Belt-av US Department of Health and Human Serviceleenters for Disease Control and Prevention From: Stone, Deborah Sent: 15 Mar 2018 18:22:53 +0000 To: Khalil, George M. Cc: Merrick, Melissa T. Joseph Caitlyn Subject: RE: Mental Health Work Group Announcements Attachments: MHWG Suicide Technical Package_Final.pdf Here you go, thanks! Deb From: Khalil, George M. Sent: Thursday, March IS, 2018 2:0] PM To: Stone, Deborah (CDCIONDIEHWCIPC) Cc: Merrick, Melissa T. Holbrook, Joseph Lutfy, Caitlyn Subject: RE: Mental Health Work Group Announcements Deb, Great job today! When you have a moment, can you email me the updated PowerPoint"? Thanks! George From: Stone, Deborah (CDCJONDIEHJNCIPC) Sent: Wednesday, March 14, 2018 10:5? AM To: Khalil, George M. Cc: Merrick, Melissa T. (CDCIONDIEHJNCIPC) Holbrook, Joseph Lutfy, Caitlyn ; Lutfy, Caitlyn. (CDC KOPHPRIDEO) Subject: RE: New VS release date ?June Hi Tom 8: Bob I think this is looking great ?just wanted to share a couple of things, both minor, that popped out at me: I noticed in the pie charts that we use a decimal for the percentages, which we don?t do for the infographic that will show circumstances. Not sure if VS prefers one or the other, just noticed that they are different. In the infographic that will show circumstances, I noticed that we list ?Housing problems Technically, in this variable is more narrow than general housing problems. It is specific to eviction/loss of home. it doesn?t capture many other types of housing problems, like inability to pay rent, housing instability, and problems with the housing environment, and would therefore probably underestimate the of people having some type of housing problem in general. If there?s still time, perhaps we could edit to something like ?Loss of housing?? Thanks, Katie From: Simon, Thomas Sent: Monday, April 23, 2018 6:23 PM To: Stone, Deborah Fowler, Katherine A. Kegler, Scott R. Yuan, Keming Holland, Kristin lyey- Stephenson, Asha Z. Crosby, Alexander Black, Erin Bruce, Ballman, Marie R. Kurnit, Molly Regina Richmond-Crum, Malia Subject: RE: New VS release date ?June 7? Hi everyone, We want to share the latest version of the VS fact sheet with you. We received a lot of specific edits last week and the fact sheet subgroup has been working to address them. It is stronger with each iteration. We need to send this back to the VS office by COB on Wednesday so if you have any suggestions or concerns that are important to consider please send them by cob tomorrow. Thankyoul ?Tom From: Stone, Deborah Sent: Monday, April 16, 2018 10:10 PM To: Simon, Thomas Fowler, Katherine A. (CDCIONDIEHINCIPC) Kegler, Scott R. ssnk?chcgow; Yuan, Keming (CDCXONDIEHINCIPC) Holland, Kristin ; lyey- Stephenson, Asha Z. Crosby, Alexander (CDCIONDIEHINCIPC) (aecl cdc. Black, Erin Bruce, (CDCIOPHPRIOD) x6 cdc. Ballman, Marie R. Kurnit, Molly Regina Richmond-Crum, Malia <"ry8 cdc. ov) Subject: New V5 release date ?June Please see Rich?s email below. The date of our US release is now June 7th with no early release of the issue. Thanks, Deb From: Schieber, Richard A. Sent: Monday, April 16, 2018 6:35 PM To: Schuchat, Anne MD Daniel, Katherine Lyon Dauphin, Leslie Cc: Sorrells, Marjorie J. Downie, Diane (Dee Dee) Stone, Deborah Simon, Thomas Sokler, Peaker, Brandy Dmisore, Shannon L. Harben, Kathy Bonds, Michelle E. Roberts, Ursula (CTR) Kent, Charlotte Kate (migEQ?ggx ladema rco, Michael Schieber, Richard A. Smith, Rhonda K. (ab 0 cdc. ov>; Smith, Patti Guest, Megan Subject: Change in June VS release date go Thurs June 7 Folks, We?re now set up have the Tues June 5 Suicide Prevention VS release and telebriefing moved to Thurs June 7 at Noon instead. There will not be an early release of this issue as we usually do. This should better accomodate Dr. Schuchat?s travel schedule. Thank you. Rich Rich Schieber, MD MPH CAPT, USPHS Director, CDC Vital Signs Program R854 cdc. DU 404 697 9666 From: Simon, Thomas Sent: 23 Apr 2018 18:22:47 -0400 To: Stone, Deborah Katherine A. Scott R. Keming Kristin Asha Z. Alexander Erin Marie R. Molly Regina Malia Subject: RE: New VS release date ?June 7? Attachments: Suicide VS FS V2_4.9.2018_4pm after VS input to V5 group.docx Hi everyone, We want to share the latest version of the VS fact sheet with you. We received a lot of specific edits last week and the fact sheet subgroup has been working to address them. It is stronger with each iteration. We need to send this back to the VS office by C08 on Wednesday so if you have any suggestions or concerns that are important to consider please send them by cob tomorrow. Thankyoul -Tom From: Stone, Deborah Sent: Monday, April 16, 2018 10:10 PM To: Simon, Thomas Fowler, Katherine A. Kegler, Scott R. Yuan, Keming Holland, Kristin lyey-Stephenson, Asha Z. Crosby, Alexander Black, Erin Bruce, Bellman, Marie R. Kurnit, Molly Regina RichmondCrum, Malia (CDCJONDIEHINCIPC) Subject: New VS release date ?thJune Please see Rich's email below. The date of our US release is now June 7th asue. Thanka Deb From: Schieber, Richard A. Sent: Monday, April 16, 2018 6:35 PM To: Schuchat, Anne MD Daniel, Katherine Lyon Dauphin, Leslie (CDCIODIOADLSS) Cc: Sorrells, Marjorie J. Downie, Diane (Dee Dee) Stone, Deborah Simon, Thomas Sokler, Pea ker, Brandy Dmisore, Shannon L. Harben, Kathy Bonds, Michelle E. Roberts, Ursula (CTR) Kent, Charlotte Kate ladema rco, Michael Schieber, Richard A. Smith, Rhonda K. (lb 0 cdc. 0y}; Smith, Patti Guest, Megan Date: April 17, 2018 at 11:40:11 AM EDT To: Kegler, Scott R. Cc: Simon, Thomas ct 59 cdc. oy> Subject: RE: New VS release date MJune Thanks, Scott. Tom, have you by chance communicated with I don?t want to email if you already have. Deb From: Kegler, Scott R. (CDCIDNDIEHINCIPQ Sent: Tuesday, April 17, 2018 10:47 AM To:5tone, Deborah cdc. 0y:- Cc: Simon, Thomas Subject: RE: New US release date ?June I'm sure you've already thought of it, but if not, better get NCHS to move the release date for their data brief, as well. From: Stone, Deborah Sent: Monday, April 16, 2018 10:10 PM To: Simon, Thomas Fowler, Katherine A. Kegler, Scott R. Yuan, Keming (CDCIONDIEHXNCIPC) Holland, Kristin ; Smith, Patti Guest, Megan Subject: RE: Question Works for me. From: Simon, Thomas Sent: Monday, June 4, 2018 3:32 PM To: Richmond-Crum, Malia McDavid Harrison, Kathleen Frazier, Leroy Jr. Jack, Shane P. Davis Cc: Blair, Janet Stone, Deborah Black, Erin Subject: RE: Question Thanks for that clarification. I would suggest a shorter response then and just say: CDC expects the remaining states to join this year. We anticipate releasing estimates in Fall of 2021. From: Simon, Thomas Sent: Monday, June 4, 2018 3:08 PM To: Richmond-Crum, Malia McDavid Harrison, Kathleen Frazier, Leroy Jr. Jack, Shane P. Davis do4 cdc. ova Cc: Blair, Janet Stone, Deborah (zafB cdc. ova; Black, Erin Subject: RE: Question Hi everyone, There are some important nuances to consider here. ljust spoke with Shane to confirm. This part of the response is problematic for a couple of reasons: Data from all 50 states, DC and Puerto Fiico will be available in Summer 2020 [18 months after data collection begins] - It is possible that not all states will come in for funding and it is likely that not all states will collect state?wide data - Also they have 16 months from the end of funding to close Out the cases so the data won?t be available until Fall of 2021. What if we respond with expects the remaining states tojoin in Fall of 2018. These states will begin data collection in 2019. We anticipate releasing estimates in Fall of 2021." ?Tom From: Richmond~Crum, Malia Sent: Monday, June 4, 2018 1:47 PM To: McDavid Harrison, Kathleen Frazier, Leroy Jr. cdc. ov> Cc: Blair, Janet Simon, Thomas Stone, Deborah Black, Erin Subject: FW: Question Kathleen and Leroy Sending this to you as Janet is out of the office. In prep for the suicide vital Signs release on Thursday, Dr. Schuchat is asking when we will be able to report on for all 50 states. We haven?t cleared and answer for this (that I'm aware of but have been working on it). Could you review highlighted text below and see if you agree with this response? Malia From: Richmond-Crum, Malia Sent: Monday, June 4, 2018 1:43 PM To: Simon, Thomas Stone, Deborah Blair, Janet Subject: RE: Question We have not been asked about this publically yet so we haven?t cleared a response. My understanding is the following: CDC expects the remaining 10 states to join by Fall 2013. These states will begin data collection in January 2019. Data from all 50 states, DC and Puerto Rico will be available in Summer 2020 [18 months after data collection begins} From: Simon, Thomas Sent: Monday, June 4, 2013 1:29 PM To: Stone, Deborah Blair, Janet Richmond-Crum, Malia c'ry8 cdc. oy> Subject: RE: Question Hi Malia, Do we have a go to response approved already for this? From: Stone, Deborah Sent: Monday, June 4, 2018 1:25 PM To: Simon, Thomas Blair, Janet <2ud5@cdc.goy> Subject: Question Importance: High Dr. Schuchat?s office is asking when we will be able to report on for 50 states? This is for the telebrief. Thank you. Deb Deb Stone, MSW, MPH Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Suicide, Youth ?y?iolei'ice Si Elder Maltreatment Team 220.488.3942 dstone3@cdc.goy Injury Center Preventing Injuries and Violence Through Science and Action From: Brown, Pam Sent: 1 Jun 2018 14:48:34 -0400 To: Knuth, Alida (CDCIONDIEHINCIPC) Cc: Stone, Deborah Subject: RE: Pics from the Suicide Technical Package Hi Alida, Images from the Suicide TP that I?d like to provide to CDCF are: - P.3-pensive man couple - P.28?students talking 0 P.34-woman listening - P.44- hands overlapping Please let me know if you have any questionsfconcerns. Thank you very much!! Pam From: Knuth, Alida Sent: Thursday, May 24, 2018 7:39 AM To: Brown, Pam Subject: RE: Pics from the Suicide Technical Package Pam, was out of the office yesterday. Yes, just send me the page numbers of the images you?d like to provide CDCF. I will be happy to download them for you. Thankg Alida From: Brown, Pam Sent: Wednesday, May 23, 2018 10:19 AM To: Knuth, Alida 5 cdc. ov> Subject: RE: Pics from the Suicide Technical Package Hi Alida, Sorry to bug you; just checking back with you about these images. After looking at the Suicide TP, there are several images that I would like to provide to CDCF, if possible. Would it be helpful for me to list them for you? Thank; Pam From: Brown, Pam Sent: Tuesday, May 22, 2018 5:2? PM To: Knuth, Alida Cc: Ballman, Marie R. Stone, Deborah czaf9@cdc.goy> Subject: RE: Pics from the Suicide Technical Package Hi Pam, Our licensing agreement for stock photography has some pretty tight limitations on image sharing. Could you check with CDCF to see which stock photography service they are using for images? If they are using the same one, I can just provide the image numbers for the stock photos we used in the TP and they can download them under their license with no worries about rights infringement. If not, maybe you could select specific images you?d like them to use and I can download them again for this specific purpose. Thanka Alida From: Brown, Pam Sent: Tuesday, May 22, 2018 12:52 PM To: Ballman, Marie R. (CDCIONDIEHINCIPC) Subject: Pics from the Suicide Technical Package Hi Marie, Sorry to bother you with this, but I wasn?t sure who on your team would be my best contact for this: Can we send files of some of the pictures used in the Suicide Technical Package to the The Foundation has created a two?page brief for one of our suicide prevention projects and it looks good except for the stock photos they used. We think some of the pics used in the TP would be a much better suited to our effort (and more consistent with ourframing for the work} and i'd like to send a few to CDCF for them to insert into their document. The brief will be used by CDCF {and us) for our outreach to potential funders for the project. Thanks! Pam From: Brown, Pam Sent: 22 May 2018 17:10:02 -0400 To: Stone, Deborah Subject: RE: Pics from the Suicide Technical Package OK, will do; thanks! Pam From: Stone, Deborah Sent: Tuesday, May 22, 2018 5:02 PM To: Brown, Pam (CDCIDNDIEHINCIPC) Subject: RE: Pics from the Suicide Technical Package Hi Pam, I?m happy to defer to you. Just don?t choose the picture of the older gentleman that?s on the front of the technical package. I really dislike that picture! Deb From: Brown, Pam Sent: Tuesday, May 22, 2018 3:55 PM To: Stone, Deborah <2an cdc. ov> Subject: RE: Pics from the Suicide Technical Package Hi Deb, CDCF doesn't have a stock photography service [per Alida?s question). However, Alida has offered to download specific images from the technical package for are some really nice ones in there. Do you have some favorites? Pam From: Knuth, Alida Sent: Tuesday, May 22, 2018 2:25 PM To: Brown, Pam 3 cdc. Cc: Ballman, Marie R. Stone, Deborah (CDCKONDIEHINCIPC) (zafgg?cdcgoyzv Subject: RE: Pics from the Suicide Technical Package Hi Pam, Our licensing agreement for stock photography has some pretty tight limitations on image sharing. Could you check with CDCF to see which stock photography service they are using for images? If they are using the same one, I can just provide the image numbers for the stock photos we used in the TP and they can download them under their license with no worries about rights infringement. if not, maybe y0u could select specific images you?d like them to use and I can download them again for this specific purpose. Thanks Alida From: Brown, Pam Sent: Tuesday, May 22, 2018 12:52 PM To: Ballman, Marie R. Cc: Stone, Deborah <2an cdc. ova- Subject: Pics from the Suicide Technical Package Hi Marie, Sorry to bother you with this, but i wasn?t sure who on your team would be my best contact for this: Can we send files of some of the pictures used in the Suicide Technical Package to the The Foundation has created a two?page brief for one of our suicide prevention projects and it looks good except for the stock photos they used. We think some of the pics used in the TP would be a much better suited to our effort {and more consistent with ourfra ming for the work} and l?d like to send a few to CDCF for them to insert into their document. The brief will be used by CDCF (and us) for our outreach to potential funders for the project. Thanks! Pam From: Stone, Deborah Sent: 2? Feb 2018 16:01:29 +0000 To: Daniel, Valerie M. Cc: Bartholow, Brad Erin Subject: RE: Please Review Dr. Schuchat's TPs for Appropriate Documentation of Partners Attachments: 2012-10-31-CNC One Pager.pdf, ds.docx Ok, here you go. Sorry for the delay. See comments in the document and the revised language. Are you taking out VS results. See Tom's entail. Ithinlr he suggested that Partners in CNCjalso included in the attached one pacer on the bac? National Partners: I Centers for Disease Control and Prevention?s Injury Control Research Center [or Suicide Prevention - Centers for Disease Control and Prevention's National Center for Injury Prevention and Control I- National Action Alliance for Suicide Prevention 0 Substance Abuse and Mental Health Services Administration?s (SAMHSAJI Suicide Prevention Resource Center 0 American Foundation for Suicide Prevention Local Partners: I Colorado Department ofPublic Health and Environment Colorado?s Suicide Prevention Commission I Rocky Mountain Mental Illness Research, Education and Clinical Center at the Denver Veterans Administration Medical Centers for Disease Control and Prevention 0 Governor?s Office 0 Colorado Behavioral 'Healthcare Council tColorado School of Public Health I University of Colorado Depression Center ?Also, if anyone asks re the Vital Signs?Mental Health Problem is de?ned by as currently having a mental health problem {includes those disorders and listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition with the exception of alcohol and other substance dependence (as these are captured in separate variables). From: Daniel, Valerie M. Sent: Tuesday, February 27, 2018 10:25 AM To: Stone, Deborah (CDCIONDIEHXNCIPQ Cc: Bartholow, Brad Black, Erin Subject: RE: Please Review Dr. Schuchat's TPs for Appropriate Documentation of Partners Deb, Please copy Erin Black when you send your edits. Thanks, Valerie From: Stone, Deborah Sent: Tuesday, February 27, 2018 9:18 AM To: Daniel, Valerie M. Logan, Joseph Cc: Bartholow, Brad Subject: RE: Please Review Dr. Schuchat's TPs for Appropriate Documentation of Partners Sure. I can review at 10. Deb From: Daniel, Valerie M. Sent: Tuesday, February 2018 8:53 AM To: Stone, Deborah (CDCXONDIEHXNCIPQ Logan, Joseph (1.) (?e??gdcgovrw Cc: Bartholow, Brad Subject: Please Review Dr. Schuchat's TPs for Appropriate Documentation of Partners Deb and 1., Can you take another look at the talking points for Dr. Schuchat? I had Shakiyla Smith in DARPI review the Colorado Collaborative TPs as asked by Tom, but Jim wants to make sure we aren't leaving out any partners that should be acknowledged in this work. J. let me know if you have any edits to the TPs, drafted these based on the info that Brad shared. I also left in his comments where Dr. Schuchat is providing information that this group knows better than anyone, so we just want to make sure she understands that and can couch it appropriately. Thanks, Valerie Valerie Daniel, MPH, CHES Acting Health Communication Lead Division of malaria; Prevention National Center for Injury Pl'E?VE?l'ttlUl'l and Control Centers for Disease Control and Prevention 4WD Buford Highway ME. 30341 77El?I333-5296-l [(1135ch am i eww-sdsew?uulv and Fridays The goal of the CNC is to create a comprehensive suicide prevention model to redUCe suicide statewide by 20% by 2024. Through careful evaluation, the CNC also aims to become a model for other states. The tasks include: 4- Assessment: 0 Identify counties experiencing the highest numbers and rates of suicide and, in those counties, work to plan prevention efforts. This will involve learning more about the characteristics of people dying by, attempting or contemplating suicide including demographic information age, race, marital status), the method used in suicide deaths and attempts, and information about the circumstances surrounding suicide deaths. This information is available through Colorado's Department of Public Health and the Environment, and can be found bv clickino here. 0 Work with those counties experiencing the highest numbers and rates of suicide to identify existing prevention initiatives. available resources, existing gaps, and interest in supporting new and enhanced efforts. 0 Inventory existing data and identify gaps in what we know about the problem to help identify the best solutions. I Capacity Building: 0 Engage partners from diverse systems and settings public health, social services, workplaces) that serve individuals and communities at risk, with initial focus on engaging leaders from counties experiencing the highest numbers and rates ofsuicide. 0 Work with newly-engaged partners to identify how they can contribute to and benefit from the efforts. 0 Strengthen public awareness and professional education to build suicide prevention capacity. a Planning: Build on and enhance prevention efforts within health care and commUnity-based settings using a range of evidence-based policies, programs and practices to prevent risk before it occurs and to identify and support people at risk. Facilitate and strengthen coordinated and comprehensive suicide prevention action plans across communities, systems and settings. I Implementation: Implement coordinated action plans to ensure cost-effective and sustainable change. I Evaluation; Svstematicallv evaluate progress and outcomes in order to support continual improvement, demonstrate success, and allow Colorado to serve as a model for other states. A 0 Department of Public Health a Envnonmcm Background and History Colorado's suicide rate, 20.30 per 100,000 in 2016?, is among the highest in the nation.2 Solutions to complex public health problems, like suicide, are often most successful when government, businesses, health services, nonprofit organizations, and individual citizens coordinate their efforts. This way, partners can channel their resources to the same goals, avoid dupiicating efforts, and enhance each other's work to produce lasting change. The Colorado-National Collaborative (CNC) is a partnership of scientists and public health professionals working with health and social service agencies, nonprofit organizations, government agencies, businesses, academic organizations, and Colorado residents to identify, promote and implement successful state- and community- based strategies for suicide prevention in Colorado. Current CNC partners include: National Partners: . Centers for Disease Control and Prevention?s Injury Control Research Center for Suicide Prevention . Centers for Disease Control and Prevention's National Center for Injury Prevention and Control 0 National Action Alliance for Suicide Prevention . Substance Abuse and Mental Health Services Local Parti?iers: S) Administration?s (SAMHSA) Suicide Prevention Resource Center . American Foundation for Suicide Prevention Vital Statistics Program. Colorado Department of Public Health and Environment 2 Centers for Disease Control and Prevention, National Center for Health Statistics, CDC WISDARS Online Database Colorado Department of Public Health and Environment (CDPHE) Colorado?s Suicide Prevention Commission Rocky Mountain Mental Illness Research, Education and Clinical Center at the Denver Veterans Administration Medical Center Governor?s Office Colorado Behavioral Healthcare Council Colorado School of Public Health University of Colorado Depression Center For more information contact Jarrod Hindman, MS, Deputy Chief of Violence and injury Prevention in the Mental Health Promotion Branch of Colorado?s Department of Public Heaith and the Environment, at iarrothind?mangstatexo. us. information on Colorado's Suicide Prevention Efforts and resources can be found by ciicking here. one-RA grepavhgm 01% EXCDM Talking Points for Dr. Schuchat DVP Signs on Suicide (coming out June Eackgtound on the Problen'] Goals of the l.iital Signs I such evidence Nearly 45,000 lives are lost every year in the U.S. to suicide. More than half of these occur among adults in the prime of their lives ages 35 64 Between 1999 and 2016, suicide rates [age-adjusted} in the U.S. increased by nearlyr 30% while most other leading causes of death declined. SUlClde and attempts cost more than $69 billion annually in direct medical and work loss costs Decades of research have shown that suicide is preventable. First MMWR report with state speci?c trends on suicide rates Compares suicides in which there was evidence of mental health problems with those without Raise awareness of the increasing suicide rates across states over time Increase demand for suicide prevention in states Raise awareness that suicide is a public health problem lnotjust a mental health problem), . among both people with or without mental health problems, multiple factors contribute to suicide 0 Highlight the best available evidence for suicide prevention as described In the technical package Preventing Suicide: A Technical Package of Policy, Proqroms, and Practices [released February 27, 201?} Suicide TP Downloads by Month 380 295 are month. Downloads February Elli?December 201?: 3050 Hard copies distributed April 201?-December 2017: 9155 The spike In October and November is likely due to the promotion following suicide prevention 85 Websztes have cited the technical package. These include local health departments - . professional development organizations, advocacy groups, and other federal agencres including the Dill, DUE. HRSA, and SAMHSA background Info on Limited Overlap Between Mental and Comment [Mall]: Of course, this audience knows this very well. I would make sure that Dr. Schuchat understands that and can say something like ?As you ,all Well r? Comment Again, this is something this audience knows very well and Dr. Schuchat wants to avoid talking down to them about these things. She should just be alerted so she can couch it appropriately EXCDM Talking Points for Dr. Schuchat (- Comment Note: C0 DPHE and the started the effort so i always try to acknowledge that so it doesn't seem like Mental health is an important risk factor for suicide, however suicide is typically not caused by i ,i this was DVP or idea. i I any single factor--therefore even if mental illness is present it is likely not the only risk factor/cause Many people with mental health problems don?t get or delay getting mental health treatment Among suicides in people older than 10, more than half did not have a known mental health Also, the state goal is a reduction of 20% probIEm {2015 uvoes data]. i A large proportion had some combination of relationship problems health problems by 2024 and the nationa1 goal '5 20% 5 reduction by 2025. Feel free to just keep i one or the other. I know it?s confusing. i 0 job or financial problems, or a recent crisis Among those who did have a known mental health problem About one?third never received mental health/substance abuse treatment More than half had any life stressors or crises {some combination of relationship, job, Re Partners. EDC is a collaborator with Univ of Rochester on the but not i sure you need to say that as they are also part of the CNC. Other people who are partners on the CNC: Action Alliance, 5AMHSA, and AFSP. 0 Cl C: financial, health and other problems) - Comprehensive prevention as laid out in the technical package is needed. Second--Attaching one-pager if this is helpful {you can see all partners on the I ll 5 II Colorado Collaborative for a Comprehensive Approach to Suicide Prevention I Eihe is collaborating with the Colorado Department of Public Health and Environment-in eoilaberationavith the CDC-funded Injury Control Research Center ttholorado kbackl. National Collaborative (CNC), and th_eCo orado Suicide Prevention Commission are?eeilabeeating . ?i on the first state-wide, large-scale, population-based initiative serving-asamedel?f-ar?ether C?mmem Head to Change . . - In the room Will be many key states?to reduce surcrde rates 20% by 20254 In CD and to serve as a model for other states to i collaborators not mentioned here {Ogii?fhi??itl?n' 5" including the Action Alliance itself: the Education Development Center and the American Suicide Foundation. Have you The project will pilot test the implementation and evaluation of a comprehensive, integrated gotten input on this wording from Deb I approach to suicide prevention guided, in part, by the of 1ii'iolence Prevention?s Preventing Suicide: A Technical Package of Policy, Programs, and Practices and from the Nat?o lACtion Alliancef Suicide eventi n's (NAASP) Tronsformin Communities Ke Stone? lwould check With her to make na 0 1 sure Dr. Schuchat avoids alienating any Elements for the implementation of Corrmrehensrve Community?Based Surcrde Prevention. im portant partners. Working with CDCF to seek external funding Why Colorado? Colorado consistently ranks among the states with the highest suicide rates in the nation (rate: 19.5 per 100,000 in 2015), almost 50% greater than the U5. rate of 13.3 per 100,000. Colorado has sizable populations at increased risk of suicide, including veterans, American Indian/Alaska Natives and rural communities. . Colorado demonstrates readiness as evidenced by a strong state suicide prevention infrastructure, a history of political will, and a proven track record of valuing and implementing public health approaches to prevention. Specifically, the State has: A funded Office ofSuicide Prevention iegislated in 2000} CI Suicide Prevention Commission {legislated in 2014] 0 Colorado National Collaborative (est. 2015) A strong platform of existing suicide prevention activity 0 A commitment to ?connecting the dots?fshared risk and protective factors New opportunities for understanding and tracking suicide EXEDM Talking Points for Dr. Schuchat Linking ?pugs with Departments of Defense and Veterans Affairs data on suicidal Ir 1. I This project will link pertinent data on active duty Military and Veteran suicide decedents across i, National Violent Death Reporting System the Department of Defense Suicide Event Reports, and the Veteran Health Administrative databases. II Provide more information on suicides among active duty Military personnel and Veterans as well as partition study populations in the civilians, active duty, VHA Veterans, non- VHA Vetera ns]. - Help agencies monitor common and unique precipitating factors of suicide captured in by groupfpopulation and inform comprehensive community-based efforts to help address specific population needs. All linkages will use a tie?identi?ed matching technique. No personal identifying information will be used. Social media interventiari .r . The purpose ofthis project is to implement, test, and refine a Web?based peer-to?peer a therapeutic support platform for U5. I?t-iroilitary Veterans aimed at preventing suicide and related problems. I This system called TalkVet, has the potential to bridge the gap between the many social media sites that are widely used by Veterans Facebook, Snapchat, etc.) and the growing number of clinical interventions that are available to Veterans, but currently under-utilized. 0 With the explicit consent of users, we will test the novel features of the TalkVet platform in three ways: 1] Use an artificial intelligence {All guided system to help identify participating Veterans most in need of help based on their posts and other user activity; 2] Connect Veterans in need of help with other Veterans participating in TalkVet who can support them: and 3] Conduct outreach with experimentally refined methods for Veterans in need of a higher level of care to encourage them to obtain such care in the form of links and hand-offs provided by the TalkVet system [this phase of the work will include the use of Veteran moderators with training in crisis counseling who will work with our team}. I This project includes partners from Harvard University, West Virginia University and has been approved by CDOF. Ir" Comment Again, don?t want to ,_the wording here. Lwording of this":I 1 alienate key partners in the room by not ?rst acknowledging them, the VA especially, they coachair the Action Alliance. Please check withJ Logan about JL lLJii]: Partners include Department of Veterans Affairs, Department of Defense Suicide Prevention Office, and the Health Center of Excellence} Defense ,Heaith Agency Comment Talkvet is not so much about social media data as it is a social media intervention. Again need to acknowledge partners in this and has anyone talked toJ Logan about the Comment Partner POE if needed: Drs. Matt Mock and Ron Kessler [Harvard University) Dr. Rob Bossarte (West Virginia kUniversityj From: Stone, Deborah Sent: 3 May 2018 13:20:54 +0000 To: Kingery, Helen H. Subject: RE: pre-brief super appreciate that! Deb From: Kingery, Helen H. Sent: Thursday, May 3, 2018 2:39 AM To: Stone, Deborah Subject: RE: pre-brief You?re welcome?I am really rooting for you all! Your work and topic are so needed in our country at this time. I?m one of greatest fans! From: Stone, Deborah Sent: Wednesday, May 2, 2018 7:48 PM To: Kingery, Helen H. Subject: RE: pre-brief Thank you so much, Helen! This is so helpful. I really appreciate your time and support!! Deb From: Kingery, Helen H. Sent: Tuesday, May 1, 2018 10:28 AM To: Stone, Deborah <2an cdc. ov> Subject: RE: pre-brief Hi Deb! It is not a bother at all, I?m glad to offer what I can! The pre-brief {is Dr. Schuchat the spokesperson, or is it Dr. Redfield?l, is where there are lots of questions, mainly of the SMEs. Dr. Schuchat uses this time to clarify any points in the MMWR and VS materials that either don?t make as much sense to her, or that might be missing the mark for media. She basically asks a lot of questions to get her mind wrapped around how to handle all types of questions, to be able to hear your division?s voice and priorities, and convey that accurately in her own voice. She also makes excellent recommendations for reframing, if necessary. Take her advice and edits as seriously as possible, and if you cannot, please always develop justification statements! I would recommend going in person, since you are the primary SME along with any other involved SMEs. It?s good to get to know Dr. uchat and also to interact with the things that she would like to highlight. I would also recommend the main Comm folks (and maybe policy, depending, and definitely Courtney Lenard] go in person to be able to hear all the conversation that goes on in the room [there may be recommended edits and shifts in messaging right on the spot, and it would be helpful to catch/interact with them all while they?re happening). We have typically met in the Director OD suite, so there is a big conference table and some chairs. I think they recommend no more than 2 program folks come in person, but people are welcome to call in. I personally like to reserve a room in Chamblee 106 so that remote program folks can call in together, but that?s just my preference, not a requirement at all. So yeah, this discussion can help you developiincorporate any final edits/tweaks in messaging to telebriefing script and etc. the more you can resolve after this meeting, the smoother the week before the release will be! Thank you!! Helen Helen Kingery, MPH Health Communication Specialist CDC I NCIPC I DUIP oo Phone: T70488OTBS Email: HKingeryl?icocgoy From: Stone, Deborah Sent: Tuesday, May 1, 2018 7:39 AM To: Kingery, Helen H. (WI 8 cdc. ova Subject: ore-brief Hi Helen, I hate to bother you again but I assume you went to the pre-brief, correct? Can you give me a little bit of lowdown on what happens??! Ours is next Tuesday! Thanks! Deb Deb Stone, MSW, MPH Centers for Disease Control and Prevention National Center for Injury Prevention and Control Division of Violence Prevention Suicide, Youth Violence Elder Maltreatment Team 7?0.488. 3942 CDC's Injury Center Preventing Injuries and Violence Through Science and Action From: Richmond-Crum, Malia (CDCIONDIEHINCIPC) Sent: 22 Mar 2018 16:46:40 -0400 To: Black, Erin Deborah Cc: Simon, Thomas James Corinne Subject: RE: Pre-clearance Draft of Suicide Vital Signs MMWR Attachments: Suicide Vital Signs MMWR Text 3.19.18 v3 (pre-cleara MRC.docx Thanks for the opportunity to review and for all your hard work on this MMWR. It?s really exciting to see the final draft! I think this is going to be very important info for states. I had some minor comments for your consideration that I added to Erin and Cory?s feedback {attached}. No feedback on the tables and figures. Thought the map of the US that showed the percent change in states was nicely done and easy to understand. Malia From: Black, Erin Sent: Thursday, March 22, 2018 3:25 PM To: Stone, Deborah Cc: Simon, Thomas Mercy, James Ferdon, Corinne Richmond-Crum, Malia Subject: RE: Pre-clearance Draft of Suicide Vital Signs MMWR FABULOUS job Deb! This was very exciting and compelling to read! Congratulations on this huge milestone! I agree with Jim?s comment about emphasizing more the increase in female vs. male rates. I also provided some mostly editorial questions/comments and suggested edits in track changes summarized below: 0 Sometimes it is referred to as a ?contributing circumstance? and sometimes its referred to as a ?contributing factor?. I wonder if its best to be consistent so as not to confuse the reader that the two are different. From a plain language perspective, I prefer contributing factors? Also, sometimes it is referred to a just ?contributing factor? while other times it is referred to as ?contributing risk factor?. Also, sometime it is referred to as ?contributing? and sometimes as ?associated?. Should we be consistent? - ?Suicide is the 10th leading cause of death and is among the only leading causes to be increasing.? Can we be more specific? is it the only or is it only one of 2 leg.) leading causes increasing ?among the only? is vague? - Is it better to say the current ?social ecology? (which I think many think of social, environmental and economic) versus I think what is used most often the ?social ecological model? (individual, family/relationship, community, and societal]. 0 ?can help reach the nation?s goal of reducing suicide rates 20% by 2025? is it really the ?nation?s goal? versus the goal set by the American Foundation for Suicide Prevention. - ?Across the entire study period, rates increased in all but one state (Nevada].? Per our discussion in our last VS group meeting, should we add a note that despite NV not increasing, they still have a significantly high rate of suicide? 0 Sometimes criminal-legal is hyphenated and sometimes it?s not. I ?Nearly half of suicide decedents in had a known I would add the actual percentage in parenthesis I People with known MHP also experienced other life stressors such as job and/or financial, relationship, and/or physical health problems. Should this be ?and?, ?or? or ?andfor?? ?It is likely that some people without known MHP in the current study were experiencing mental health challenges at the time of death that were either not known or reported by informants.? Do you mean reported by informants? From: Ferdon, Corinne Sent: Thursday, March 22, 2018 2:25 PM To: Mercy, James Stone, Deborah Black, Erin Richmond-Crum, Malia Cc: Simon, Thomas Subject: RE: Pre?clearance Draft of Suicide Vital Signs MMWR Deb, Congratulations to you and the entire vital signs writing team to getting to this point! It is an enormous achievement. I really like the direction the analyses have gone in. I know there is a considerable amount of work ahead, but you have a solid platform to build on. I offer in the attachments some suggestions. Track changes are not easily done in the excel file sol highlight words in red to draw your attention to things to consider. In the text, I think there are a few numbers to double check, a few data points and clarifications to be added in, and the references to the tablesffigure adjusted. I do like the balance that is currently in there on the versus aDRs. Mental health problems as a driver of suicide jumped out to me as one of the main messages since the text kept coming back to it. I think there are some subtle reorganization or broader phrasing that could be used in some places to modify this if the communication goal is different; I offer some ideas in comment boxes. I recognize that I am suggesting adding some clarifying text in some places and word count is always an issue, so I did try to identify some places to potentially cut. Please review this as suggestions and ta ke/leave what feels right. FYI, in a meeting I was in with the MMWR editors yesterday they said they prefer little to no use of acronyms. So, in a few places suggest taking a couple out but I did leave in the MHP one since that is necessary for word count. Cory From: Mercy, James (CDCIONDIEHINCIPC) Sent: Thursday, March 22, 2018 12:34 PM To: Stone, Deborah Ferdon, Corinne Black, Erin Richmond-Crum, Malia (CDCIONDEEHINCIPCJ Cc: Simon, Thomas Subject: RE: Pre-clearance Draft of Suicide Vital Signs MMWR Hi Deb, This is outstanding. Thank you and everyone else for this really nice and clear statement about suicide and its prevention. I have just a few general com ments/suggestions: 1. One finding that you don?t make much of, but I think is important, is that suicide rates across states are increasing faster for females relative to males. Overall, of course, this is a problem still dominated by males, but that appears to be changing. And that?s not surprising in terms of societal changes around gender roles and norms. I realize you can?t highlight everything, but that is very interesting and may signal a longer term trend that's worth noting. 2. You may have to cutback the word number some and if you do I think you can get away without the second sentence in the results that focusses on absolute changes in rates. People understand the meaning of 96 changes much easier, so no biggie, but that could be dropped if needed. 3. In regards to the first sentence in the last paragraph, I wondering if the last clause could be changed to but is only one of If we say one of ?many? then the argument is that we can't focus on everything so we should focus on the most important risk factor. I'm not wedded to this, but clearly we are emphasizing the need to focus on factors beyond mental illness [but not excluding mental illness) and I think this sentence could be made a little stronger in support of that, especially because it ties things up at the end. Thanks that is all I had. Thanks so much and can?t wait until this comes out. Jim From: Stone, Deborah Sent: Thursday, March 22, 2018 8:14 AM To: Ferdon, Corinne Mercy, James (CDCIONDIEHJNCIPCJ ; Black, Erin Richmond-Crum, Malia cdc. ov> Cc: Simon, Thomas ?it 59 cdc. ov> Subject: Pre-clearance Draft of Suicide Vital Signs MMWR Importance: High Hi Jim, Cory, Erin, and Malia, Just a friendly reminder to please send your feedback on the MMWR by COB today. Your time and insights are greatly appreciated! Deb Hi Everyone, Please find attached a draft of our suicide Vital Signs MMWR for pre?clearance. Thank you for previously agreeing to review it with a quick turnaround of COB 3,!22. We are still working out one outstanding issue?whether to report percentages and/or aORs pertaining to results. Right now we opt for percentages however we may also include and Cl?s. Please send your edits in tracked changes. if you have any questions, please let me know. We look forward to your feedback! And thanks to the whole team for a whole lot of time, thought, and expertise dedicated to this draft! Thanks again! Deb Deb Stone, MSW, MPH Centers for Disease Control and Prevention National Center for Injury Prevention and Control Dzvision of Violence Prevention Youth Violence 8t Elder Maltreatment Team 3942 dstone3 cdceov CDC's Injury Center Preventing Injuries and Violence Through Science and Action LinRev 3.19.18 v3 Short title: Vital Signs: increasing Trends in State Suicide Rates and ontributing Circumstances Deborah M. Stone, Thomas R. Simon Katherine A. Fowler, PhD;l Scott R. Kegler, Keming Yuan, Comment Sometimes it is referred to as a rcontrilziuting circumstance? and sometimes its referred lvlS;1 Kristin M. Holland, Asha Z. Ivey-Stephenson, Alex E. Crosby, lle1 Structured abstract {2552529150 words?this word count is not included in the 1800 max for the remainder) Comment Can a couple 9f words be added here to reflect a date Since rates Background: Over all ssuicide rates have been rising in the United States 199L?Examining state? level trends have been rising. seeword count suicide and its multiple contributing circumstances can inform comprehensive git-d- prevention lannin Comment Style consideration. Since focus on suicide and states is clear, Methods: Trends in age?adjusted suicide rates. byEstatci and sex, among people aged 210 years. were assessed these words Ml?e i? sentence usmg data from the National Vital Statistics System Changes In rates were examined across so: consecutive ?arr?W?s . . omment transition rom I to three year periods from 1999 2016 :9 National Violent Death Reporting System I ?cpven?gg? reading covers states to states, was used to examine Ina-precipitating circumstances among suicide decedents With and without known methods to the first line in the results Enental health problems ?t Comment Unclear ifthis was Results: rates inereases?anrgased ai. from 1999- supposed to be a reference or can come 2015 iI"i .14 states. In 25 states, rates increased by 30% or more. Male suicide rates increased signi?cantly In 34 out states, I_444le#Femaie rates increased significantly in 43 states?eople with and without known MHP ?hrc a I ommen I U5 5? ES lOI'i an had both differing and similar circumstances precipitating suicide. Several circumstance, such as any 7i? may not be feasible, but would suggest relationship problemsfloss [39.6 and 45.1%, any life stressorsfloss [49.7 and 54.2%, 5 and recent ?t?Hn not using MHP through the document. crises {26.0 and 32.9%, 5 respectively, were more likely among those without known l'leP. but were I a common across groups. Comment Ithink this is a Significant finding should we say more Conclusions: Suicide rates rose significantly across most states from 1999?2016. Varied circumstances beyond about it the fact that it is increasing more lv'lHP alone contributed to suicides among people with and without known MHP. Nomadic-n? 3? Comment I think edits are needed Implications for Public Health Practice: States can use a comprehensive public health approach based on the here for a few reasons. I am finding the best available evidence to prevent suicide risks before they occur, identify and support people already at risk, statements that there are differences and prevent- reattempts, and help after a suicide occurs. 5 Comment Please double check. INTRODUCTION ,3 [am getting 15.9 from WISCLARS BACKGROUND AND PURPOSE words] i? i Comment Can we be more ,e specific is it the only or is it one of only in 2016, nearly 45,000 suicides occurred in the United States among people all] years old r' 3: leading causes increasing- ?among the 15 Suicide is the 10th leading cause of death and isEamong the onlyleading causes to be increasing Cummt??t Please double Additionally, rates of Emergency Department visits for nonfatal self-harm injury, a key risk factor for suicide, wonder if ??15 might. h'fwe been increased more thank??between 2001 and 2015 Together, suicides and self-harm injuries cost the nation It, for all ages and mt ?mum to am years" 3, more than $59 billion in direct medical and work loss costs ,"[C0mment IJRVSI: Suggest identifying this as a US Surgeon General report. 1, lihs Nation? mm, .5 beta, ,0 mg, prevention With efforts spanning across multiple levels e. ., individual, family/relationship, community, and It,? ecology [which i think many think of societal}, of theEocial ecolog?." Such an approach underscores that s_uici_de Is rarel_y caused by any single factor If social, environmental and economic} alone, but rather, is multi- determined. Despite the NSSP guidance, suicide prevention efforts largely focus on identifying and treating individuals with mental health problems lOther asseeiateel?conttibutingrisle factors include social and economic problems, access to lethal means leg, substances, firearms, bridges] among people at risk, poor coping and problem?solving skills. and prior suicide attempts, Expanded Ftev 3.19.18 v3 40 awareness of the additional circumstances that contribute to suicide risk apart from MHP. can help reach the 4' E?atiunts 42 state-specific trends in suicide rates, assesses the multiple contributing and 43 provides recommendations for multirlevel comprehensive suicide prevention. 44 METHODS @260 words} 45 Suicide rates were analyzed for those aged 10 years and older [because of variability in attributions of suicidal as intent, younger children are excluded] Age?specific suicide counts were tabulated based on National Vital 4? Statistics System coded death certificate records [international Classification of Diseases 10'? Revision 48 underlying-cause-of death codes Age-specific population estimates were obtained from 49 US. Census Bureaquational Center for Health Statistics bridged?race population data releases. 50 5 National and statEvlevel suicide rate estimates were calculated for six consecutive three-year aggregate periods 52 from 1999-2015. Rate estimates were age?adjusted to the U.S. year 2000 standard population and expressed per 53 100,000 persons per year. Age?adjusted suicide rate trends were modeled using the same three?year data 54 aggregates, employing weighted least squares regression with inverse?variance weighting. Modeled rate trends 55 are reported in terms of average annual percentage changes 50 I 5? beta from 2015 from the 2? states with complete data participating in shaggy; National iiv'iolent Death 58 Reporting System ages 10 and older, were used to compare the characteristics among suicide I 59 decedents with and without known current menial health-nodule ms 60 disorders and listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 6 5} except alcohol and other substance use disorders [captured aggregates data from three primary data sources: death certi?cates, coronerfmedical examiner reports [including toxicology], and law 63 enforcement reports. Decedents with and without known MHP were compared using Chi-square tests; logistic 64 regression was used to estimate adjusted odds ratios with 95% confidence intervals controlling for age 65 group, sex, and racelethnicity. as RESULTS (5121591 words] 6? The most recent overall suicide rates (representing 2014-2016] ranged from 6.9 (District of Columbia] to 29.2 (58 {Montana} per 100,000 persons per year, a four-fold difference liable ill-?Acres thesetire . increased in all but one state {luevaddlt Hith??i?i?l?i109319-535. +3.1 [Wyoming] pr" 70 per 100,000. Percentage increases in rates ranged from +59% [Delaware] to 67.6% {North Dakota}, with TI percentage increases of at least 30% observed in 25 states. 1?2 7?3 Modeled suicide rate trends indicated significant increases for 44 states, as well as for the U.S. overall {Table T4 By sex, modeled rate trends indicated significant increases in 34 states for males and in 43 states for females. 75 Nationally, the model-estimated AAPC for the overall suicide rate was By sex, the national MPO was 7's +11% for males and +16% for females. T8 Suicide decedents with and without [N=11,039l known MHP were i9 were predominately male and non-Hispanic white. .sSuicide decedents without known MHP relative to inns-r: 80 ti". known I'viI-ii- were more likely to be male [83.5% vs. p5.01,l. and racialf'ethnic minorities (odds ratio 81 range: Cl range also had 33 firearm suicide 1.6, 95% CI and of positive toxicology results for alcohol 1.2, 95% CI ad served or were 34 1-1" 13}- [19.12.954.51 Hill]. 511.959.9103}; 59.9392351353qu 85 serving sewed-in the us. military. '82 significantly greater odds of perpetrating homicide-suicide {adjusted odds ratio 2.gclearer. Tracked is an idea. i LA. f. exception is described. DEM-5 does have I if two ?Table 1? in attachments state I r: still have a signi?cantly high rate of I words so you may not be able to do this .1 Commant Is It really the 'nation?s goal? - versus the goal set by the American Foundation for Suicide ,Prevention. 1 Comment Sentence has a lot of different points. it may be easier to read if it were two sentences. Suggestion: Data from the National Violent Death Reporting System were used to compare characteristics among suicide decedents with and without known current mental health programs. Complete data from 2? states participating in in 2015 were used ,for this analyses. Comment lam confUSed by how i the alcohol and substance use disorder an alcohol use disorder diagnosis and a Lsuhstance use disorder dx. 1 Comment Some labeling of the tables and how reflected in the text need some modi?cation. There are current trends: select demographics}. The two d..l a hlilh?f d. r? Comment IBEU: Per our discussion in our last VS group meeting, should we add I a note that despite NV not increases, they Lsuicidei' x? Comment Please double check. ,Table reflects +0.3 Comment Suggest revising in ,3 order to allow in the next sentence the .i comparison group to be clear and the I order the should be considered Comment Wonder if need to be i clear here this is limited to 18+. Tracked might be a simple approach to consider. have seen MMWR want to present 96?s Comment IJRVEI: I realize this adds 4? but the "ever? in the original sentence at. In. Jk E'l'll I was block to me as a i read. Not sure ifthe additional language WW If]? [08 ?m9 Illi Ill ?2 113 ?4 H5 Ilf) 117 its i 9 l20 22 [23 IE4 IRS [20 Hey 3.19.18 y3 Although firearms were used most often in both groups, decedents with known MHP died by poisoning more than those without known MHP {19.8% vs. 10.4%: 5 most frequently by over-the-counterfotherwise f: unclassified Eirugs opioids antidepressants or benzodiazepines (25.1% . All suicide decedents with known MHP lN=9,407} and approximately 35% without had precipitating circumstances 2 on People with known MHF were more likely to have any substance abuse problems [31.6% vs. 25%, 5 While two-thirds of those with known MHP had a history of MH or substance abuse treatment just over half were in current treatment at the time of their deaths. Decedents without known MHP, versus those with known MHP had a greater likelihood of any relationship problemfloss {45,199. aadvs 39.5%, 5 specifically intimate partner problems [30.2% 24.1%, 5 andys 13.6%, pg and recently perpetrating interpersonal violence [3.0225 as.dy_s_ f, They were also more likely to have experienced other life stressors, such as bosses {197?s ass Elites ?01! estates431951902919. assesses. iiases?iessj be: assesses" likely to have had a crisis within the preceding or upcoming two weeks {32.9% antly_s_. 26.0%, Among Both grows, the most common crises were intimate partner and physical health problems. i? ?1 Comment I think the comparison group 96?s are needed. For instance, drugs (35.8% vs. I think the presentation of the 93's would be easier here and later on in the results if the p's came out and the text could simply reflect ?significant differences? or some variation of indicating in the groups ,were different. JL Comment Sometimes criminal? legal is hyphenated and sometimes it?s Ln DL .2 Comment IFCU: The all reported in this sentence appear to be only for the groUp with MHPs. Based on the sentence wording, the 96 for both groups need to Decedents without known MHP had signi?cantly lower odds of recent release from any institution, but among those who were recently released, those without a known MHP were more likely to be released from a correctional facility {25.7% vs. p501) or hospital (43.7% vs. 33.0%, p501} than those with a known Mi-lP. Among decedents with known MHP recently released from an institution 42.8% were released from facilities. Suicide decedents without known MHP were more likely than tl?io?se Without known lyii ii? to leave a suicide note i35-1i'i it?d? were more likely to have a history of suicidal ideation [40.3% vs. 23.0%, 5 .01] and attempts (29.4% vs. 10.3%, p5 .Dli? i I .rcm? N?HF-ri-r? wo-H-?iDO-lwn .-.-- Conclusions and Comments [655(215 wordsi From 1999-2015, ?14 states saw significant suicide rate increases. Half of the states experienced increases of 30% or more. Rates increased significantly in 34 states among males and 43 states among females. More research into the causes of these trends is necessary MHP. This group was challenged by comorbid substance abuse problems and histories of suicidal ideation and attempts While two-thirds of people with known MHP had a history of MH andfor ?a substance abuse treatment and over half Were in treatment at the time of their deaths, additional support eeald m_ay_he p address the needs of this vulnerable population. This includes broader implementation of affordable and evidence-based treatments, such as doctor?patient collaborative care models and cognitive-behavioral therapy. Additionally, greater access to behavioral health providers, especially in underserved areas is important, as is healthcare systems changethat supports suicide prevention and patient safety through care transitions While mental health problems are a significant contributor to suicide, 54% of suicide decedents in this study did not have a known MHP. This group suffered more relationship problems and life stressors such as criminal?legal matters, evictionlloss of home, and recent or impending crises. This is noteworthy in light of findings that suggest manyi suicides and attempts occur with minimal deliberation time, particularly among people without mental health disorders and who faced impending life crises 3 r{illuminant Please double check ,be reported. JL. number. Table reflects 33.3% Comment My two cents: I think we should do more to raise attention to the fact that almost a quarter of both groups disclosed suicide intent. This is a true prevention opportunity sol think this is a common risk to highlight. Knowing space constraints, I think this is more important to highlight than the presence of a suicide note which often doesn't inform prevention. I suggest adding into Lresults and into discussion. Comment lfeel typically don?t do a lot of repeat of the specific data findings in the discussion. I think the numbers could come out here. i think it would be helpful to put this into a larger context, indicating whether this is l__consistent with other research. I also .Jk Comment lwould add the Lpercentage in parenthesis [28 I29 I30 l3l 132 I33 l34 I35 36 137 I38 I39 I40 I4I I42 I44 I45 I46 14? I48 I49 I50 I5I I52 I53 I54 I55 l56 I58 159 I60 I6l I62 I63 I64 I65 166 167r I68 169 Rev 3.19.18 v3 Heople with known MHP also Experienced other life stressors such asjob andfor financialL-pseblemss; conditions associated with mental health problems in the first place and the need to support people with known MHP to decrease theirEIulnerability}o poor social, health, and economic outcomes 2? These results underscore the importance of comprehensive In! beyond a focus on maturing} health treatment alone. Prevention strategies may include: strengthening It economic supports housing stabilization policies, household ?nancial teaching coping and ?y problem-solving skills, especially early in life to manage everyday stressors and prevent future relationship problems; and promoting social connectedness to increase a sense of belongingness and access to informational, tangibie, emotional, and social sopport,eeneeded. Other strategies indicated lay these result:- include creating protective environments leg, reducing access to lethal means among people at risk, creating organizational and workplace policies to promote help-seeking and positive social norms}, supporting family and friends after a suicide?has?taieen?piaee, and assuring safe reporting by the media in order to prevent suicide contagion [ll?Some states, such as Colorado, are planning and implementing a comprehensive we?w?e approach to The steelyfindings have at least three limitations. in the state-level analysis, rankings for four states (MD, MA, RI, might have been impacted by large proportions of injury deaths of undetermined intent, For by decreased percentages of such deaths over timt-i which likely include some unrecognized suicides. Second, is not yet nationally representative, and incl udedes 2? states that represent hair?itiBE?iI?ui of the U5. population. Third, abstractors of data are limited to data included in invEstigative reports. For exampie. and MHmor'Ital Ill'?l? information are rial. records?eat g?from key informants leg, family, friends} via coronerfmedical examiner reports and can impacts sheared completeness and accuracy, of tfieanformation reported, and Some studies including in?depth interviews with family members It is likely that some people without known l'leP in the current study were experiencing mental health challenges at the time of death that were either not known or i?eported by menial nee-oi a dcii'essing-i-he-Fa-nge ~0i-ceni-r-i bet-ing- Suicide is a growing public health problem. [Nkntal illness is an important risk factor for suicide, and is one of many requiring preventive action. Data from and resources such as Preventing Suicide: a Technicai Package of Policies, Programs, and Practices [11] can help states and communities better understand their a suicide problem and prioritize comprehensive suicide prevention. Acknowledgments The authors acknowledge Robert Anderson, Holly Hedegaard, and Margaret Warner from the Division of Vital Statistics, National Center for Health Statistics, CDC, for their statistical consultation. Con?ict of Interest No conflicts of interest were reported. Corresponding author: Deborah M. Stone, i30-488-3942 Author Affiliations: Comment suggest pulling this out into a separate paragraph. If contained in the above, it seems to undercut the main point that many suicides don't have MPH. A new paragraph might need a lead?in sentence or maybe start with the current last sentence to frame points about common ,risks. Comment Should this he 'and?, L?or? or ?andfor?? JL. Comment Suggest using "risk of" rather than "vulnerabifity to?, as vulnerability sometimes can have negative connotations aligned with ,weakness. i- Comment IFCU: I think it is fine that the TP strategies are presented in different areas of the discussion. i don?t easily see "identify and support people at-risk?. I think that can go in the proposed paragraph immediately above when talking about common risk factors. In adding that, suggest adding so me examples of approaches leg, crisis Lintervention, gatekeeper training). Comment [17ka I am not easily following this point. Can this be stated more simply such as by variations of undetermined injury deaths, which To help wfword count, offer a couple of suggestions in next few sentences to streamline. Certainly takej'leave what you tlike and check for accuracy. ., Comment Do you mean ?reported by informants? JL Comment To me, this sentence puts the spotlight pack on mental illness and makes it likely it will be the take home message of media reporting. If that isn?t the goal of this V5, suggest framing broadly. ideas: Effective approaches are Lavailobie to prevent or ameliorate many 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 Rev 3.19.18 v3 1Division of Violence Prevention, National Center for Injury Prevention and Control, 2Division of Analysis, Research, and Practice Integration, National Center for Injury Prevention and Control, CDC References: 1. 10. 11. 12. 13. 14. 15. Centers for Disease Control and Prevention, Web-based injury Statistics Query and Reporting System Atianto, GA: Nationai Center for injury Prevention and Controi. Retrieved March 15, 2018. 2016. Ivey-Stephenson, A.Z., et al., Suicide Trends Among and Within Urbanization Leveis by Sex, Race/Ethnicity, Age Group, and Mechanism of Death - United States, 2001-2015. MMWR Surveill Summ, 2017. 66118): p. 1-15. Kegler, S.R., OM. Stone, and KM. Holland, Trends in suicide by ievei of urbanization?United States, 1999?2015. MMWR. Morbidity and mortality weekly report, 2017. 65(10): p. 270. Kochanek, K., et al., Mortaiity in the United States, 2015. NCHS Data Brief, no 293. National Center for Health Statistics, 2017. Office of the Surgeon General and National Action Alliance for Suicide Prevention, 2012 Nationai strategy for suicide prevention: goais and objectives for action: a report of the US Surgeon Genera.f and of the Nationai Action for Suicide Prevention. 2012. Rosenman, 5.1., Preventing suicide: what work and what not. The Medical Journal of Australia, 1998. 169(2): 100?102. Torguson, K. and A. O'Brien, Leading Suicide Prevention Efforts Unite to Address Rising Nationai Suicide Rate. 2017: Washington, D.C. Crepeau-Hobson, F., The Autopsy and Determination of Chiid Suicides: A Survey of Medicai Examiners. Archives of Suicide Research, 2010. 14(1): p. 2434. American Association, Diagnostic and statistical manuai ofmentai disorders 2013: American Pub. Li, 2., et al., Attributobie risk of and socio?economic factors for suicide from individuoi?ievei, popuiation-based studies: A systematic review. Social Science Medicine, 2011. 72(4): p. 608616. Stone, D.M., et al., Preventing suicide: A technicai package ofpoiicies, programs, and practice. 2017. Simon, T.R., et a1, Characteristics of impuisive suicide attempts and attempters. Suicide and Life- Threatening Behavior, 2002. 32(51): 49-59. World Health Organization, Risks to mentai heaith: An overview of and risk factors. Geneva: WHO, 2012. Caine, E.D., et al., Comprehensive, integrated approaches to suicide prevention: practicai guidance. Injury prevention, 2017: p. injuryprev?2017?042366. Hawton, K., et al., The autopsy approach to studying suicide: or review of methodoiogicai issues. Affect Disord, 1993. 50(23): p. 269-76. Tables and Figures (attachments) Table 1 and Figure 1.doc Tables 2 and 3.pdf Word Count: 1826/ 1800 From: Black, Erin Sent: 22 Mar 2018 15:25:15 To: Stone, Deborah Cc: Simon, Thomas James Corinne Malia Subject: RE: Pre-clearance Draft of Suicide Vital Signs MMWR Attachments: Copy of Tables (23) Suicide Vital Signs (pre- clearance)_CF xlsx, MMWR Table 1 and Figure Suicide Vital Signs MMWR Text 3.19.18 v3 FABULOUS job Deb! This was very exciting and compelling to read! Congratulations on this huge milestone! I agree with Jim?s comment about emphasizing more the increase in female vs. male rates. I also provided some mostly editorial questionsfcomments and suggested edits in track changes summarized below: I Sometimes it is referred to as a ?contributing circumstance? and sometimes its referred to as a ?contributing factor?. I wonder if its best to be consistent so as not to confuse the reader that the two are different. From a plain language perspective, I prefer contributing factors? Also, sometimes it is referred to a just ?contributing factor? while other times it is referred to as ?contributing risk factor?. Also, sometime it is referred to as ?contributing? and sometimes as ?associated?. Should we be consistent? - ?Suicide is the 10?? leading cause of death and is among the only leading causes to be increasing.? Can we be more specific: is it the only or is it only one of 2 leading causes increasing - ?among the only? is vague? - Is it better to say the currEnt ?social ecology? (which I think many think of social, environmental and economic) versus I think what is used most often the ?social ecological model? (individual, family/relationship, community, and societal). - ?can help reach the nation?s goal of reducing suicide rates 20% by 2025? - is it really the ?nation?s goal? versus the goal set by the American Foundation for Suicide Prevention. - ?Across the entire study period, rates increased in all but one state (Nevada).? Per our discussion in our last VS group meeting, should we add a note that despite NV not increasing, they still have a significantly high rate of suicide? - Sometimes criminal-legal is hyphenated and sometimes it?s not. I ?Nearly half of suicide decedents in had a known I would add the actual percentage in parenthesis (X96). 0 People with known MHP also experienced other life stressors such as job and/or financial, relationship, andfor physical health problems. Should this be ?and?, ?or? or ?andfor?? 0 ?It is likely that some people without knovvn MHP in the current study were experiencing mental health challenges at the time of death that were either not known or reported by informants.? Do you mean reported by informants? From: Ferdon, Corinne Sent: Thursday, March 22, 2018 2:25 PM To: Mercy, James Stone, Deborah Black, Erin Richmond?Crum, Malia Cc: Simon, Thomas Subject: RE: Pre-clearance Draft of Suicide Vital Signs MMWR Deb, Congratulations to you and the entire vital signs writing team to getting to this point! It is an enormous achievement. I really like the direction the analyses have gone in. I know there is a considerable amount of work ahead, but you have a solid platform to build on. I offer in the attachments some suggestions. Track changes are not easily done in the excel file sol highlight words in red to draw your attention to things to consider. In the text, I think there are a few numbers to double check, a few data points and clarifications to be added in, and the references to the tables/figure adjusted. I do like the balance that is currently in there on the versus aORs. Mental health problems as a driver of suicide jumped out to me as one of the main messages since the text kept coming back to it. I think there are some subtle reorganization or broader phrasing that could be used in some places to modify this if the communication goal is different; i offer some ideas in comment boxes. I recognize that I am suggesting adding some clarifying text in some places and word count is always an issue, so I did try to identify some places to potentially cut. Please review this as suggestions and ta ke/leave what feels right. FYI, in a meeting I was in with the MMWR editors yesterday they said they prefer little to no use of acronyms. So, in a few places I suggest taking a couple out but I did leave in the MHP one since that is necessary for word count. Cory From: Mercy, James Sent: Thursday, March 22, 2018 12:34 PM To: Stone, Deborah <2an cdc. ovb; Ferdon, Corinne Black, Erin Richmond-Crum, Malia <"rv8 Cdc. 0v:- Cc: Simon, Thomas Subject: RE: Pre~clearance Draft of Suicide Vital Signs MMWR Hi Deb, This is outstanding. Thank you and everyone else for this really nice and clear statement about suicide and its prevention. I have just a few general com 1. One finding that you don?t make much of, but I think is important, is that suicide rates across states are increasing faster for females relative to males. Overall, of course, this is a problem still dominated by males, but that appears to be changing. And that's not surprising in terms of societal changes around gender roles and norms. I realize you can?t highlight everything, but that is very interesting and may signal a longer term trend that?s worth noting. 2. You may have to cut back the word number some and if you do I think you can get away without the second sentence in the results that focusses on absolute changes in rates. People understand the meaning of 96 changes much easier, so no biggie, but that could be dropped if needed. 3. In regards to the first sentence in the last paragraph, I wondering if the last clause could be changed to but is only one of If we say one of "many? then the argument is that we can?t focus on everything so we should focus on the most important risk factor. I?m not wedded to this, but clearly we are emphasizing the need to focus on factors beyond mental illness [but not excluding mental illness) and I think this sentence could be made a little stronger in support of that, especially because it ties things up at the end. Thanks that is all I had. Thanks so much and can?t wait until this comes out. Jim From: Stone, Deborah Sent: Thursday, March 22, 2018 8:14 AM To: Ferdon, Corinne Mercy, James Black, Erin Richmond-Crum, Malia Cc: Simon, Thomas Subject: Pre-clearance Draft of Suicide Vital Signs MMWR Importance: High Hi Jim, Cory, Erin, and Malia, Just a friendly reminder to please send yourfeedback on the MMWR by COB today. Yourtime and insights are greatly appreciated! Deb Hi Everyone, Please find attached a draft of our suicide Vital Signs MMWR for pre-clearance. Thank you for previously agreeing to review it with a quick turnaround of COB 3/22. We are still working out one outstanding issue?whether to report percentages andfor aORs pertaining to results. Right now we opt for percentages however we may also include and Cl's. Please send your edits in tracked changes. if you have any questions, please let me know. We look forward to your feedback! And thanks to the whole team for a whole lot of time, thought, and expertise dedicated to this draft! Thanks again! Deb Deb Stone, MSW, MPH Centers for Disease Control and Prevention National Center :r_11 Injury and Corn-ml Division of Vioienre Dreveniinn Soicide. "i?oulh Violence t1. Eider Maltreatmem Team ND 394?; Injury Center Preventing Injuries and Violence Through Science and Action 'I'lHIIJihc?l . ?ram Hml?i Whit 2015 thud-HI: TDH Humid-Ila ?lr DH wwm' [mm Mun-1m spun {9:95:11 {mun Ilium-Io?! mum Mala aromas} mam a.2za[aa.a HELL Janus: Fumlla 3.: 2.93mi: 1.3105; [1:01 0.4 .1415 1024 2.3m[111 Lzulum 1.593qu p Cc: Simon, Thomas Subject: RE: Clams It seems the following might be alluded to in a previous version of the {1&A's i found in email. But it might be worth ensuring this question or similar is in the 0&As. Do we know if suicide is trulv MORE than a mental health issue or is it more that it?s a problem of UNDIAGNDSED and therefore untreated mental health conditions? (Mentioned that men might be less likely to seek help, receive diagnosis, etc.) And would this change or shift a prevention approach? This question came from Katherine Lvon Daniel. Please let me know if you are adding or if you feel it is already addressed. Thanks Marie From: Stone, Deborah Sent: Wednesday. May 23, 2018 3:54 PM To: Holland, Kristin Simon, Thomas (t 59 cdc. ova- Cc: Ballman, Marie R. Cc: Omisore, Shannon L. Schieber, Richard A. Peaker, Brandy Sokler, <2520@cdc.goy> Subject: RE: (1A document Thanks Deb, for your kind words! I?ve answered below. Feel free to let us know if you have any other questions. From: Stone, Deborah Sent: Friday, June 1, 2018 2:45 PM To: Sokler, Simon, Thomas Holland, Kristin Bruce, Cc: Dmisore, Shannon L. (?yw?oyr?; Schieber, Richard A. Peaker, Brandy Subject: RE: CIA document Hi Lynn, Thank you very much for this run down (and for everything else while I'm at it?! A few questions: 0 Should I be at Roybal on Wed pm? You can do any interviews on Weds from your office. Thurs is when you will want come to Roybal. The pre-brief and telebriefing are held on the 12lh floor, conference room 12116. It is a smaller room in the middle of the floor. a Is NPHIC to get the material on Thursday at 9 as well? Yes, NMB will send out to NPHIC. I Also we have the CAN number for printing but sounds like we need a formal authorization. When do you need this by? Yes, we?d like to have all {including formal authorization of funds from your M0) by COB Monday, if possible. Thanks, Deb From: Sokler, Sent: Friday, June 1, 2018 2:32 PM To: Simon, Thomas Stone, Deborah Holland, Kristin Bruce, Cc: Omisore, Shannon L. Sokler, Schieber, Richard A. Peaker, Brandy Subject: RE: CIA document Just got ASPA final clearance on materials with no further changes. We?ll make your last changes to F5 and will now be final on the Fact Sheet and Press Release. (no more changes}. Next week: MON-WEDS I Finalize all other materials. I Send Fact Sheet to printer. Must deliver copies to CDCW by COB on Weds. Still need your quantity, CAN it and MD written authorization]. ATL copies will deliver by Thurs afternoon or Friday to mail rooms. I Translate Spanish press release, and social media I Build VS website, program reviews, finalize website I Send final materials to everyone (Weds around 2 pm), to DD, senior leaders, VS distributors. I Media advisory out Tues, again Weds, with final materials on Thurs. I Pre?embargoed media interviews with national media Dr. Schuchat does on Weds afternoon and Thurs am. THURS 9 AM I Critical Contacts email sent by Dr. Schuchat with materials I materials distribution ASTHO, NAACHO, CSTE, APHL, includes SHOs I Program partner distribution with materials, including state and local violence prevention coordinators I CDC Hill Alert with materials and hard copy Fact Sheets to policy makers I Media advisory and materials distribution ?to CDC media list and on wire I Medical media and collaborators materials distribution I Media Telebriefing 12-12:45 pm? I Materials are LIVE on web 1 pm. Materials are off embargo. I Other media interviews Deb Stone 1 as requested I Facebook and Twitter posts out over two weeks, other social media. I CDC Gov-D announcement goes out I HHS promotes VS on their social media handles Hope this helps. And you?ve done at great job of ?rounding everything up? for your first rodeo. I will miss being here with you for the launch, but know there will be a lot of attention to this. From: Simon, Thomas (CDCIONDIEHXNCIPC) Sent: Friday, June 1, 2018 2:10 PM To: Sokler, Stone, Deborah Omisore, Shannon L. Holland, Kristin (CDCXONDIEHXNCIPC) Bruce, Cc: Omisore, Shannon L. Subject: RE: (1A document I did not know it is going back to ASPA. When will they provide comments? Can you all provide a sense of the schedule for next week? This our first VS rodeo and we aren?t sure what to expect. Thank you, Tom From: Sokler, Sent: Friday, June 1, 2018 2:02 PM To: Stone, Deborah Dmisore, Shannon L. Simon, Thomas Holland, Kristin Bruce, <5 x6 cdc. ova- Cc: Sokler, <2520 cdc. ova; Omisore, Shannon L. Subject: QA document Hi Folks, I need to have the DA document now to send with other materials to Anne. She?s waiting on them. Please send as soon as you can. Thanks, From: Dmisore, Shannon L. Sent: Friday, June 1, 2018 12:15 PM To: Stone, Deborah Simon, Thomas (CDCIONDIEHINCIPQ Holland, Kristin Bruce, x6 cdc. ova- Cc: Sokler, <2520@cdc.gov> Subject: RE: June VS: Related Links, Deadlines Deb, Sorry for the confusion. I meant to say that the related links are due by Monday at Noon. Thanks, Shannon From: Stone, Deborah Sent: Friday, June 1, 2018 12:02 PM To: Omisore, Shannon L. Simon, Thomas Holland, Kristin Bruce, Cc: Sokler, (CDCIODIOADCHISIO cdc. ov> Subject: RE: June Related Links, Deadlines HiShannon, So the related links deadline is changed from June 4 at noon to today at noon (now)? Also, did you get our printing info emailed to you? Deb From: Omisore, Shannon L. Sent: Friday, June 1, 2018 11:59 AM To: Simon, Thomas Stone, Deborah (CDCXONDIEHXNCIPC) <2an cdc. ova; Holland, Kristin Bruce, x6 cdc. 0v:- Cc: Sokler, Subject: June VS: Related Links, Deadlines Hi all, As a friendly reminder, the related links are due. Please send the related links by Noon on Friday. Deadlines are listed below: Fact sheet and due by today, June 1 at 2 pm Approval email and information for printing, due by COB today, June 1 Related links, due by Monday, June 4 at Noon Thanks Shannon From: Dmisore, Shannon L. Sent: Thursday, May 24, 2018 10:02 AM To: Simon, Thomas (CDCIONDIEHINCIPCJ Stone, Deborah Holland, Kristin Bruce, (CDCXOPHPRIOD) x6 cdc. 0v:- Cc: Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet Hi Tom, Please plan to incorporate additional changes in the version of the FS that addresses comments. I need the related links by Wednesday, May 30. For samples of the related links, see previous V5 {for example: The MMWR and Medline Plus links are provided by VS staff. For the PR graphic, it will consist of the map, headline, legend, and source from the top of page 2. Adding the graphic at the bottom of page 2 to the PR graphic would make it look too busy. Thanks, Shannon From: Simon, Thomas Sent: Thursday, May 24, 2013 9:20 AM To: Omisore, Shannon L. Stone, Deborah Holland, Kristin Bruce, x6 cdc. ov> Cc: Peaker, Brandy Schieber, Richard A. Sokler, Subject: RE: fact sheet HiShannon, Thank you for the update. We have some edits to the FS as well. Should we plan to incorporate them in the version we send back to you that addresses HHSIASPA comments? When will you need that back from us? Please see responses to your points below. please check this out too. Thank you, -Tom From: Dmisore, Shannon L. Sent: Wednesday, May 23, 2018 11:10 AM To: Simon, Thomas Stone, Deborah Holland, Kristin ; Bruce, (CDCIOPHPRIOD) x6 cdc. ov> Cc: Peaker, Brandy Schieber, Richard A. Sokler, <2520 cdc. ov> Subject: RE: fact sheet Hi Tom and all, We will probably get feedback from HHSKASPA by COB on Friday, May 25. However, we can?t guarantee that we?ll receive the feedback by that date. Please see below. 1. What would you like to use for the PR graphic? For the PR graphic, we suggest that it include the top graphic on page 2 (Suicide rates and the middle graphic [Differences exist). We agree with using the map from page 2. If there is a second image it would be great to include the circumstance figure from the bottom of page 3. 2. For page 3 of the fact sheet, the following change will be made to the note for clear language: delete ?Suicide decedent?. Insert ?Persons who died by suicide?. This makes sense. 3. Please provide the related links for the June V5. The two categories for related links are Related Pages (internal CDC links) and Other Sites (external links). Please have the hyperlink embedded in the description (for example, MedlinePlus A Antibiotic Resistance} When do you need this by? Do have an example that you can share with us. How many of each do you include? is this something that you or someone from communications can draft for Deb and to review? Thanks, Shannon From: Simon, Thomas (CDCKONDIEHINCIPC) Sent: Wednesday, May 23, 2013 10:09 AM To: Omisore, Shannon L. Sokler, Stone, Deborah Holland, Kristin Castro Perdomo, Julio (CTR) Vital Signs Web (CDC) Cc: Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet HiShannon, Are we still anticipating feedback from ASPA and HHS by cob today? When will you need changes back from us? Thank you, Tom From: Omisore, Shannon L. Sent: Wednesday, May 23, 2018 7:46 AM To: Simon, Thomas (CDCIONDIEHXNCIPC) Sokler, Stone, Deborah (CDCIONDIEHKNCIPC) Holland, Kristin Castro Perdomo, Julio Vital Signs Web (CDC) McDaniel, Rebecca (CDCIODIOADC) (CTR) Lansclale, Ashley (oh28 cdc. oy> Cc: Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet Hi all, Attached is the June VS fact sheet. This includes the latest change (the word just was deleted}. Shannon From: Simon, Thomas Sent: Friday, May 18, 2018 4:12 PM To: Sokler, Omisore, Shannon L. Stone, Deborah Holland, Kristin cdc. 0y:- Cc: Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet HiLynn, 0k, thank you. Our Communication director suggested that we drop this to avoid sounding like we are minimizing mental health conditions. We were hoping to do that before it went to HHS and ASPA. Tom From: Solder, Sent: Friday, May 18, 2018 4:08 PM To: Simon, Thomas (CDCXONDIEHINCIPC) Omisore, Shannon L. Stone, Deborah Holland, Kristin Cc: Peaker, Brandy Schieber, Richard A. Sokler, Subject: RE: fact sheet HI Tom, Shannon has gone for today so I?ll respond. Unfortunately the graphics team has gone and the package is in prep to go to ASPA. We?re happy to make the change next week while we wait for comments to come back from HHS staffdiys and opdiys. There will be other changes to make in responding to their comments, so this isn?t the final of the fact sheet. Thanks, From: Simon, Thomas Sent: Friday, May 13, 2018 3:59 PM To: Omisore, Shannon L. Stone, Deborah Holland, Kristin Cc: Sokler, Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet HiShannon, Is it too late to remove the word ?just" from the subtitle at the top of page one? Thank you, Tom From: Omisore, Shannon L. Sent: Friday, May 13, 2018 2:21 PM To: Simon, Thomas Stone, Deborah (zafg cdc. ov>; Holland, Kristin Cc: Sokler, Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet Tom, I have discussed page 3 with and the graphic artist. The current Warning Signs graphic is a major improvement from what was there before. This version encourages the reader to read from left to right, which is ideal. It also can stand alone as a graphic to be tweeted out or posted in for example, a doctor?s office. 50, we suggest that it remain as is. An additional change for the fact sheet is for ?healthcare systems? to be changed to ?health care systems" for Vital Signs style requirements. Thanks, Shannon From: Simon, Thomas Sent: Friday, May 18, 2018 1:05 PM To: Omisore, Shannon L. Stone, Deborah Holland, Kristin Cc: Sokler, (CDCIDDIDADC) Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet Hi Tom, Attached is the updated June VS FS, which includes changes that I?ve indicated on stickies. Please send any additional changes by 1 pm today, Fridav, May 18, Thank; Shannon From: Simon, Thomas Sent: Thursday, May 17, 2018 5:43 PM To: Omisore, Shannon L. Stone, Deborah Holland, Kristin Subject: fact sheet Hi Shannon, ljust spoke with Deb and we want to make one additional change to the F5. The bubble at the bottom of page 2 should be "problematic substance use." We made the change to the Word doc {attached}. What is the next stEp with the Will we get to review it before it goes to Best, Tom From: Stone, Deborah Sent: 1 Jun 2018 18:44:48 +0000 To: Sokler, Thomas Kristin Cc: Omisore, Shannon L. Richard A. Brandy Subject: RE: QA document Hi Lynn, Thank you very much for this run down (and for everything else while I'm at A few questions: 0 Should I be at Roybal on Wed pm? It Is NPHIC to get the material on Thursday at 9 as well? 0 Also we have the CAN number for printing but sounds like we need a formal authorization. When do you need this by? Thanks, Deb From: Sokler, (CDCIODIDADC) Sent: Friday, June 1, 2018 2:32 PM To: Simon, Thomas Stone, Deborah Holland, Kristin Bruce, Cc: Omisore, Shannon L. Sokler, (CDCIODIDADC) Schieber, Richard A. Peaker, Brandy Subject: RE: QA document Just got ASPA final clearance on materials with no further changes. We?ll make your last changes to F5 and will now be final on the Fact Sheet and Press Release. [no more changes). Next week: MON-WEDS 0 Finalize all other materials. I Send Fact Sheet to printer. Must deliver copies to CDCW by COB on Weds. Still need your quantity, CAN ti and MD written authorization). ATL copies will deliver by Thurs afternoon or Friday to mail rooms. oTranslate Spanish press release, and social media 0 Build VS website, program reviews, finalize website Iv Send final materials to everyone (Weds around 2 pm), to DD, senior leaders, VS distributors. 0 Media advisory out Tues, again Weds, with final materials on Thurs. - Pre?embargoed media interviews with national media Dr. Schuchat does on Weds afternoon and Thurs am. THURS 9 AM a Critical Contacts email sent by Dr. Schuchat with materials - materials distribution ASTHO, NAACHO, CSTE, APHL, includes SHDs - Program partner distribution with materials, including state and local violence prevention coordinators In CDC Hill Alert with materials and hard copy Fact Sheets to policy makers I Media advisory and materials distribution to CDC media list and on wire I Medical media and collaborators materials distribution - Media Telebriefing 12-12:45 pm- I Materials are LIVE on web r? 1 pm. Materials are off embargo. - Other media interviews Deb Stone as requested a Facebook and Twitter posts out over two weeks, other social media. 0 CDC Gov-D announcement goes out - HHS promotes VS on their social media handles Hope this helps. And you?ve done at great job of ?rounding everything up? for your first rodeo. I will miss being here with you for the launch, but know there will be a lot of attention to this. From: Simon, Thomas Sent: Friday, June 1, 2018 2:10 PM To: Sokler, Stone, Deborah <2an cdc. oy>; Omisore, Shannon L. Holland, Kristin (CDCXONDIEHXNCIPC) Bruce, x6 cdc. ov> Cc: Omisore, Shannon L. (CDCIODIDADQ Subject: RE: QA document I did not know it is going back to ASPA. When will they provide comments? Can you all provide a sense ofthe schedule for next week? This our first VS rodeo and we aren?t sure what to expect. Thank you, Tom From: Solder, (CDCIODIOADC) Sent: Friday, June 1, 2018 2:02 PM To: Stone, Deborah <2an cdc. ovb; Omisore, Shannon L. Simon, Thomas ; Holland, Kristin (CDCIONDIEHINCIPC) Bruce, x6 cdc. ova- Cc: Sokler, Omisore, Shannon L. Subject: RE: CIA document Thanks. We are sending the materials to Anne now. The F5 will go as we have it currently. We?ll make Tom?s suggested changes once we have comments from ASPA as well. Thanks everyone! From: Stone, Deborah Sent: Friday, June 1, 2018 1:59 PM To: Sokler, (CDCIODXOADC) Omisore, Shannon L. Simon, Thomas Holland, Kristin Bruce, x6 cdc. ov> Subject: RE: QA document Hi Lynn, Here you go!i Thanks for your patience! Deb From: Sokler, Sent: Friday, June 1, 2018 1:56 PM To: Omisore, Shannon L. Stone, Deborah Simon, Thomas Holland, Kristin Bruce, x6 cdc. ova Subject: CIA document Hi Folks, I need to have the QA document now to send with other materials to Anne. She?s waiting on them. Please send as soon as you can. Thanks, From: Omisore, Shannon L. Sent: Friday, June 1, 2018 12:16 PM To: Stone, Deborah (CDCXONDIEHKNCIPQ Simon, Thomas Holland, Kristin Bruce, x6 cdc. 0y) Cc: Sokler, <2520@cdc.goy> Subject: RE: June VS: Related Links, Deadlines Deb, Sorry for the confusion. I meant to say that the related links are due by Monday at Noon. Thanks, Shannon From: Stone, Deborah Sent: Friday, June 1, 2018 12:02 PM To: Omisore, Shannon L. Simon, Thomas Holland, Kristin Bruce, x6 cdc. 0y) Cc: Sokler, cdc. oy> Subject: RE: June VS: Related Links, Deadlines HiShannon, So the related links deadline is changed from June 4 at noon to today at noon (now)? Also, did you get our printing info emailed to you? Deb From: Omisore, Shannon L. Sent: Friday, June 1, 2018 11:59 AM To: Simon, Thomas (CDCIONDIEHINCIPC) Stone, Deborah (zafg cdc. ova?; Holland, Kristin cdc. ova; Bruce, (CDCIOPHPRIOD) x6 cdc. 0y) Cc: Sokler, Subject: RE: fact sheet Hi Tom, Please plan to incorporate additional changes in the version of the FS that addresses comments. I need the related links by Wednesday, May 30. For samples of the related links, see previous VS [for example: The MMWR and Medline Plus links are provided by VS staff. For the PR graphic, it will consist of the map, headline, legend, and source from the top of page 2. Adding the graphic at the bottom of page 2 to the PR graphic would make it look too busy. Thanks, Shannon From: Simon, Thomas Sent: Thursday, May 24, 2018 9:20 AM To: Dmisore, Shannon L. Stone, Deborah Holland, Kristin Bruce, x6 cdc. ova Cc: Peaker, Brandy Schieber, Richard A. Sokler, (CDCIODIOADC) <2520 cdc. ova Subject: RE: fact sheet HiShannon, Thank you for the update. We have some edits to the FS as well. Should we plan to incorporate them in the version we send back to you that addresses comments? When will you need that back from us? Please see responses to your points below. please check this out too. Thank you, ?Tom From: Omisore, Shannon L. Sent: Wednesday, May 23, 2018 11:10 AM To: Simon, Thomas Stone, Deborah (CDCIONDIEHINCIPC) Holland, Kristin Bruce, (CDCIOPHPRIOD) x6 cdc. ova Cc: Peaker, Brandy Schieber, Richard A. Sokler, ?czszU cdc. ov> Subject: RE: fact sheet Hi Tom and all, We will probably get feedback from by COB on Friday, May 25. However, we can?t guarantee that we?ll receive the feedback by that date. Please see below. 1. What woold you like to use for the PR graphic? For the PR graphic, we suggest that it include the top graphic on page 2 (Suicide rates and the middle graphic (Differences exist). We agree with using the map from page 2. If there is a second image it would be great to include the circumstance figure from the bottom of page 3. 2. For page 3 of the fact sheet, the following change will be made to the note for clear language: delete ?Suicide decedent". Insert ?Persons who died by suicide?. This makes sense. 3. Please provide the related links for the June VS. The two categories for related links are Related Pages (internal CDC links) and Other Sites (external links]. Please have the hyperlink embedded in the description (for example, MedlinePlus Antibiotic Resistance) When do you need this by? Do have an example that you can share with us. How many of each do you include? is this something that you or someone from communications can draft for Deb and to review? Thanks, Shannon From: Simon, Thomas Sent: Wednesday, May 23, 2018 10:09 AM To: Omisore, Shannon L. Sokler, (CDCIODIOADC) Stone, Deborah Holland, Kristin Castro Perdomo, Julio cyi'7 cdc. ow; Vital Signs Web (CDC) McDaniel, Rebecca (CDCIODIOADC) {Id 8 cdc. oy>; Lansdale, Ashley Cc: Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet HiShannon. Are we still anticipating feedback from ASFA and HHS by cob today? When will you need changes back from us? Thank you, Tom From: Omisore, Shannon L. Sent: Wednesday, May 23, 2018 7:46 AM To: Simon, Thomas (CDCXONDIEHXNCIPC) Sokler, Stone, Deborah Holland, Kristin Castro Perdomo, Julio Vital Signs Web (CDC) McDaniel, Rebecca (CTR) Lansdale, Ashley (CDCXODIOADC) (CTR) Cc: Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet Hi Lynn, 0k, thank you. Our Communication director suggested that we drop this to avoid sounding like we are minimizing mental health conditions. We were hoping to do that before it went to HHS and ASPA. Tom From: Sokler, Sent: Friday, May 18, 2018 4:08 PM To: Simon, Thomas Dmisore, Shannon L. Stone, Deborah (CDCIONDIEHINCIPQ Holland, Kristin Cc: Peaker, Brandy Schieber, Richard A. Sokler, Subject: RE: fact sheet HI Tom, Shannon has gone for today so I?ll respond. Unfortunately the graphics team has gone and the package is in prep to go to ASPA. We?re happy to make the change next week while we wait for comments to come back from HHS staffdivs and opdivs. There will be other changes to make in responding to their comments, so this isn?t the final of the fact sheet. Thanks, From: Simon, Thomas Sent: Friday, May 18, 2013 3:59 PM To: Omisore, Shannon L. Stone, Deborah Holland, Kristin Cc: Sokler, Peaker, Brandy Subject: RE: fact sheet HiShannon, Is it too late to remove the word ?just" from the subtitle at the top of page one? Thank you, Tom From: Omisore, Shannon L. Sent: Friday, May 18, 2018 2:21 PM To: Simon, Thomas (CDCXONDIEHINCIPC) Stone, Deborah Holland, Kristin Cc: Sokler, Peaker, Brandy Schieber, Richard A. Subject: RE: fact sheet Tom, I have discussed page 3 with and the graphic artist. The current Warning Signs graphic is a major improvement from what was there before. This version encourages the reader to read from left to right, which is ideal. It also can stand alone as a graphic to be tweeted out or posted in for example, a doctor?s office. So, we suggest that it remain as is. An additional change for the fact sheet is for ?healthcare systems? to be changed to ?health care systems? for Vital Signs style requirements. Thanks, Shannon From: Simon, Thomas (CDCXONDIEHINCIPC) Sent: Friday, May 18, 2018 1:06 PM To: Omisore, Shannon L. Stone, Deborah Holland, Kristin Subject: RE: fact sheet HiShannon, Overall this looks very good. Given the time limit we skimmed it quickly and had a few suggestions. I just used stickies to indicate these in the pdf. Hopefully these can be made before this goes forward. In addition to these, we aren?t sure about the checkerboard for the warning signs. It seems to make the page busier. What do you all think? We?ll ask our communication folks to be looking at this too and might have suggestions next week. Thankyou! -Tom From: Omisore, Shannon L. Sent: Friday, May 18, 2013 11:25 AM To: Simon, Thomas Stone, Deborah Holland, Kristin Cc: Sokler, Peaker, Brandy Schieber, Richard A. (CDCIOPHSSICSELSIDPHID) Subject: FIE: fact sheet Hi Tom, Attached is the updated June VS FS, which includes changes that i'ye indicated on stickies. Please send any additional changes by 1 pm today, Friday, May 18. Thanks, Shannon From: Simon, Thomas Sent: Thursday, May 17, 2018 5:43 PM To: Dmisore, Shannon L. Subject: fact sheet Hi Shannon, ljust spoke with Deb and we want to make one additional change to the F5. The bubble at the bottom of page 2 should be "problematic substance use.? We made the change to the lMord doc (attached). What is the next step with the Will we get to review it before it goes to Best, Tom From: Stone, Deborah Sent: 1? Apr 2018 01:50:37 +0000 To: Black, Erin Robin Cc: Dorigo, Leslie Subject: RE: Question RE: AAS Conference Logistics Attachments: CNC One Pager_11Jan18 ds.pdf Hi Robin and Erin, I made some notes on the one pager attached. 0 In general, the Colorado national collaborative (CNC) is still very much in the planning phase. [per Erin?s email below, we are just in the beginning phase of Phase 1 (Strategic planning for collective community action, which will bring together state and county stakeholders to create a shared agenda). So far funds are extremely limited. I would say that yes, the project is reliant on an infusion of funds through CDCF or elsewhere. So farthe CNC has met with 3 of the selected counties and has gotten their buy in. Meetings with the other 3 will take place later in the year. IApart from a lack of funds, the CNC is grappling with how best to roll out {and then evaluate) comprehensive and integrated (health and community based interventions) prevention in 6 counties, using data to drive planning and considering the social ecological model, upstream and approaches, and a community driven process. I I think it would be strategic to mention the technical package (of course], transforming communities* (came out of the transforming communities task force of the action alliance}, possibly zero suicide if you can work it in since this is part and parcel of comprehensive and integrated prevention and is where a lot ofthe momentum in the field is right now and we should be supportive of it (while at the same time pushing for upstream primary prevention}. *The transforming communities was meant to be to communities what zero suicide is for healthcare systems. Might also want to hint about our vital signs without giving it away as I believe Dr. Schuchat did at the action alliance meeting. - Looking at trends in state suicide prevention rates over time {1999-2016) and assessing the multiple risk factors for suicide, including but not limited to mental health problems. I hope this is helpful and I hope it?s not too much. Deb From: Black, Erin Sent: Monday, April 16, 2018 4:10 PM To: lkeda, Robin Cc: Stone, Deborah Dorigo, Leslie Subject: FW: Question RE: AAS Conference Logistics Hi Robin - Below is some info that might be useful, I am copying Deb Stone, the POC for the CD project. She is out of the office today but I have copied her to add additional information. What are the specific activities that CO intends to pilot test and evaluate as part of this initiative? Realize this may still be in early stages of discussion/development, but if some decisions have already been made, am curious to know. The Colorado National Collaborative (CNC) was formed in 2015 by the Colorado Department of Public Health and Environment (CDPHE) and the Colorado Suicide Prevention Commission, in collaboration with the nded Injury Control Research Center for Suicide Prevention the National Action Alliance for Suicide Prevention (Action Alliance} and the American Foundation for Suicide Prevention (AFSP). A one page fact sheet about the (INC is attached. Deb can update you on where the CNC is in their implementation of the tasks described in the one pager. The Colorado National Collaborative hopes to: 0 Identify and prevent suicide in counties with the highest rates - Engage partners from counties facing high suicide rates I Facilitate and strengthen coordinated suicide prevention action plans 0 Implement coordinated prevention plans to ensure cost-effective and sustainable change I Evaluate progress and outcomes in order to support continual improvement This is a 5-year project with implementation in three phases. Currently they are in phase 1 of implementation: - Phase 1: Strategic planning for collective community action, which will bring together state and county stakeholders to create a shared agenda, timeline and milestones for moving forward, using the transforming communities (TC) process and the CDC technical package. This phase will also include the drafting of community grants that will be available to counties for implementing suicide prevention activities in Phase 2. Providing technical assistance to potential applicants will serve as a powerful tool for enhancing their understanding and skills to define and develop locally applicable, evidence-based activities. 0 Phase 2: Continued local roll-out of TC, uptake of the CDC technical package and awards of community grants in the 6 targeted counties. - Phase 3: Preparation of a field-informed dissemination package and plan for guiding efforts to achieve coordinated, comprehensive suicide prevention efforts in Colorado statewide and in other states and communities nationwide. Have some activities for this initiative already gotten underway, or are they dependent on receipt of funding? - Partnership engagement in Colorado and specifically in those counties that have the highest suicide rates has already begun. Some funding has already been secured by the CNC, however, the project will not reach the state goal to reduce suicide 20% by 2024, nor help the nation move toward its goal, to reduce the suicide rate 20% by 2025, without an infusion of national level support. From: ikeda, Robin Sent: Monday, April 16, 2018 10:10 AM To: Dorigo, Leslie Black, Erin swa' Subject: RE: Question RE: AAS Conference Logistics Thanks. Quick qua-stions: I What are the specific activities that CO intends to pilot test and evaluate as part of this initiative? Realize this may still be in early stages of discussion/development, but if some decisions have already been made, am curious to know. 0 Have some activities for this initiative already gotten underway, or are they dependent on receipt of funding? From: Dorigo, Leslie Sent: Monday, April 16, 2018 9:50 AM To: lkeda, Robin (Wm Black, Erin (CDCKONDIEHINCIPC) Subject: RE: Question RE: AAS Conference Logistics Totally fine! Erin might know that answer quickly. [Ifl remember correctly, that?s a cross-Division project with Erin, if there?s someone in DARPI I need to connect with, just let me know.) From: lkeda, Robin Sent: Monday, April 16, 2018 9:48 AM To: Dorigo, Leslie Cc: Black, Erin Subject: RE: Question RE: AAS Conference Logistics Thanks! I also have a couple questions about the work in CO who is the FCC for that? Sorry for multiple emails! From: Dorigo, Leslie (CDCIONDIEHINCIPQ Sent: Monday, April 16, 2018 9:46 AM To: lkeda, Robin Cc: Black, Erin Subject: RE: Question RE: AAS Conference Logistics Hi Robin, Logan in DVP is the lead for this project. I?m cc?ing in Erin in DVP to connect you and J. Thanks Leslie From: Ikeda, Robin Sent: Sunday, April 15, 2018 4:33 PM To: Dorigo, Leslie Subject: Question RE: AAS Conference Logistics Hi Leslie, Many thanks again for sending all this material. Is there someone I could chat with about the TalkVet initiative? It sounds quite innovativefinteresting, so I want to make sure I understand how it works and what is planned. Thank you. Robin From: Dorigo, Leslie Sent: Tuesday, March 13, 2018 1:33 PM To: lkeda, Robin (CDCIONDIEHIOD) Cc: Peeples, Amy B. Subject: RE: AAS Conference Logistics Thank you, thank you, thank you! From: Dorigo, Leslie Sent: Thursday, March 1, 2018 1:00 PM To: lkeda, Robin Peeples, Amy B. Subject: RE: AAS Conference Logistics Happy to help with prep! We'll get you something in advance of their deadline. From: lkeda, Robin Sent: Thursday, March 1, 2018 12:54 PM To: Peeples, Amy B. Dorigo, Leslie (CDCIONDIEHINCIPC)