Surgeon General Releases First Installment of a National Strategy for Suicide Prevention

Two years ago the Surgeon General's office determined that suicide is a public health problem and called for the development of a national strategy for suicide prevention. The first installment of this ongoing effort was unveiled in May 2001 by Surgeon General David Satcher. The National Strategy for Suicide Prevention: Goals and Objectives for Action specifies 11 goals and 68 associated objectives for reducing the loss and suffering that result from suicide and suicidal behaviors. The document represents the combined work of public and private groups that include suicide prevention advocates, clinicians, researchers, and survivors.

As noted in the document, suicide is the eighth leading cause of death in the United States. Every year more than 30,000 Americans take their own lives, and more than half a million attempt suicide. Men aged 25 to 65 account for more than half of all suicides, and men are four times more likely to die from suicide than women. Among adolescents and young adults, the incidence of suicide tripled between 1952 and 1995; more individuals in this age group die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease combined. The highest suicide rates for any age group occur among persons aged 65 years and older. In 1998, this group constituted 13 percent of the U.S. population but suffered 19 percent of all suicide deaths.

The national strategy recognizes that suicide is closely linked to mental illness and to substance abuse, and that the stigma associated with these disorders has contributed to the establishment of separate systems for physical and mental health care as well as inadequate funding for preventive mental health services and low insurance reimbursements for treatment. One goal of the strategy is to reduce this stigma, with the dual objectives of creating conditions that enable suicidal persons to receive appropriate mental health treatment and transforming public attitudes toward a view that mental and substance use disorders are real illnesses, equal to physical illnesses, that respond to specific treatments.

Another goal is to develop and promote effective clinical and professional practices that identify at-risk individuals and engage them in treatments that reduce the personal and situational factors associated with suicidal behaviors and promote protective factors that reduce the risk of acting out of despair and distress. Among the objectives associated with this goal are incorporating suicide risk screening into primary care; changing risk-assessment procedures and policies in hospital emergency departments, substance abuse treatment centers, and specialty mental health treatment centers; and ensuring that persons with mood disorders receive adequate treatment.

The National Strategy for Suicide Prevention is designed to be a catalyst for social change. It calls for collaboration across a broad spectrum of agencies, institutions, and organizations—from schools to health care associations to the federal government—in addressing the psychological, biological, and social factors involved in suicide and suicide prevention.

The National Association for the Mentally Ill and the American Psychiatric Association issued statements commending Dr. Satcher for his leadership in addressing suicide as a public health issue and in promoting a national prevention strategy. The National Strategy for Suicide Prevention: Goals and Objectives for Actionis available at www.mentalhealth.org/ suicideprevention or www.surgeon general.gov/library. A copy can be obtained by contacting the Knowledge Exchange Network of the Center for Mental Health Services at 800-789-2647.

HCFA Issues Rules on Restraints With Amendments to Ease Staffing Requirements

On May 22 the Health Care Financing Administration (HCFA) issued an "interim final" rule that establishes new standards for the use of restraints and seclusion by psychiatric residential treatment facilities that treat individuals under the age of 21 whose care is paid for by Medicaid. The rule contains amendments to address strenuous objections from a broad coalition of medical and hospital groups, including the American Psychiatric Association, warning that staffing requirements in the unamended rule would have resulted in the closure of residential treatment facilities that are critical to the care of at-risk youth.

The new rule amends regulations issued in January that would have required that restraint and seclusion be initiated only by an on-site physician's written order or by an off-site physician's spoken order to a registered nurse (see Psychiatric Services, February 2001, page 251). The medical groups objected that this requirement was based on the inpatient hospital model and ignored the fact that there is a shortage of psychiatrists in certain parts of the country and that many community-based residential treatment facilities cannot afford 24-hour staffing by registered nurses. An amendment allows "other licensed practitioner[s] permitted by the state and the facility" to order restraint and seclusion and to receive such orders.

Another contentious directive of the January regulations was the "one-hour rule," which required a physician to assess the patient within one hour after restraint or seclusion was initiated. The amended rule permits "other licensed practitioner[s] trained in the use of emergency safety interventions, and permitted by the state and the facility to assess the physical and psychological well-being of residents." The new rule also allows licensed staff other than registered nurses to contact the ordering physician if an episode of restraint extends beyond the time limit of the order.

In addition, the amended rule attempts to clarify which facilities are covered. The original language identified covered facilities as those that receive Medicaid funds to provide inpatient services to youths under the age of 21. The amended rule clarifies that the facilities covered are inpatient settings specified in the Social Security Act, not facilities that are licensed as hospitals. The rule does not apply to providers that receive Medicaid compensation on a service-by-service basis and that do not receive Medicaid payment for patients' room and board. Acknowledging that the amendments may create confusion, HCFA has directed facilities that are not sure whether they must comply with the rule to contact the state Medicaid agency for more information.

Since January, APA and a coalition of other groups, including the American Medical Association, the American Academy of Child and Adolescent Psychiatry, the American Hospital Association, the National Association of Psychiatric Health Systems, and the National Association of Psychiatric Treatment Centers for Children, have urged withdrawal of the proposed rule, asking Secretary of Health and Human Services Tommy Thompson to meet with all concerned parties. Of special concern to these groups is the proliferation of overlapping, duplicative, and differing standards across settings. The National Alliance for the Mentally Ill has strongly supported the rule, calling for a single national standard on the use of restraints, particularly one that covers residential treatment centers for children.

The amendments to the HCFA regulations bring them more closely in line with requirements of the Children's Health Act of 2000 (CHA), However, the requirements are stricter than those in the CHA, which covers facilities that receive any federal support. Later this year the Department of Health and Human Services will issue another regulation to comply with the CHA, which has raised concerns that residential treatment facilities that are spared by the current HCFA amendments may face stricter requirements in the near future.

Despite objections, HCFA chose not to delay implementation of the rules beyond May 22. However, the agency will consider public comments on the amendments until July 23. The text of the HCFA regulations is available at www.access.gpo.gov/ su_docs/fedreg/frcont01.html. Click on Tuesday, May 22.

NMHA Survey Reveals Barriers to Diagnosis and Treatment

The second annual America's Mental Health Survey, carried out by the National Mental Health Association, has found that three commonly held views appear to prevent the diagnosis and treatment of millions of Americans who have clinical depression or generalized anxiety disorder.

The survey found that only 18 percent of all adult Americans who appear to have met lifetime diagnostic criteria for these disorders have ever received a diagnosis or treatment for either condition. More than 19 million Americans are affected by depression and another four million by generalized anxiety disorder, according to the National Institute of Mental Health.

The survey findings suggest that the following beliefs account for this gap.

• Symptoms are not associated with a disorder. Ninety-three percent of the survey respondents who met diagnostic criteria told investigators that they did not believe their symptoms were associated with a mental health disorder, even though half of these respondents reported that their symptoms caused significant emotional pain and restricted functioning in their daily lives.

• Symptoms can be self-treated. Forty-four percent of the undiagnosed respondents who said they would not seek treatment from a professional believed that their symptoms were self-manageable. They reported self-help techniques such as prayer (41 percent), rest (38 percent), exercise (37 percent), and emotional support from family and friends (31 percent).

• Diagnosis is stigmatized. Forty-two percent of respondents who had a diagnosis reported that they were embarrassed by or ashamed of their symptoms. Only 17 percent of respondents who had symptoms but who did not have a diagnosis reported embarrassment or shame. Among those with a diagnosis, 40 percent did not believe that their symptoms meant that they had a mental health disorder.

The survey showed that many people have low expectations of treatment. Only 55 percent of respondents with a diagnosis expected that their treatment would provide relief even from initial symptoms. In addition, nearly 60 percent of those with a diagnosis were unaware of terms associated with the recovery process, such as treatment response and remission. The investigators pointed out that their unfamiliarity with such terms may indicate that professionals are not sufficiently involving patients in their treatment by educating them about the goals of treatment.

America's Mental Health Survey 2001 was conducted for NMHA by Roper Starch Worldwide, Inc., in April 2001. Telephone interviews were completed with 3,239 adults. A total of 1,319 interviews were conducted in depth, and 999 of these respondents appeared to meet diagnostic criteria for clinical depression or generalized anxiety disorder, or both. Every seventh adult who had symptoms of either illness completed further interviews; 204 had received diagnoses from a physician, and 795 had not.

News Briefs

SAMHSA directory: The Substance Abuse and Mental Health Services Administration has released an updated directory of more than 22,000 local mental health service programs in the United States. Organized by state and city, the directory is designed to be a quick reference for health and mental health professionals and the general public. Entries are grouped by type of facility. To obtain a free copy of Mental Health Directory 2000, contact the Center for Mental Health Services Clearinghouse at 800-789-2647.

Young Offender Initiative: Applications are invited for grants of up to $3.1 million under the reentry grant program of the new Young Offender Initiative. The program is a collaboration among the departments of Health and Human Services, Justice, and Labor. The grants are designed to help communities combine close supervision with services to help former offenders aged 14 to 35 become productive members of society. The reentry efforts will entail public-private partnerships that provide a range of services, including substance abuse and mental health treatment and job placement. More information is available at www.ojp.usdoj.gov/cpo/applicationkits. htm or from the Department of Justice Response Center at 800-421-6770.

NARSAD young investigator awards. The National Alliance for Research on Schizophrenia and Depression invites applications for awards of up to $30,000 a year for up to two years for advanced postdoctoral fellows or assistant professors either to extend their research fellowship training or to begin careers as independent research faculty. Research must be relevant to schizophrenia, major affective disorders, or other serious mental illnesses. Guidelines may be obtained at www.narsad.org or by contacting Audra Moran at [email protected]. The submission deadline is July 25, 2001.

NIMH Web site: The Web site of the National Institute of Mental Health (NIMH) consistently received the highest marks for accuracy and completeness of its information on depression in a study evaluating health information on the Internet. The study, published in the May 23rd issue of JAMA, was commissioned by the California Healthcare Foundation and conducted by Rand. The NIMH site (www.nimh.nih.gov) features a 27-page brochure published last year. The brochure, which is written for the general public, describes depression and its symptoms, possible causes, diagnosis, and treatment. In addition to the brochure, the site offers several booklets, fact sheets, and summaries for the public, a section with descriptions of ongoing clinical trials, and a section for researchers that provides conference and workshop summaries.

People & Places

Award: Kenneth B. Wells, M.D., M.P.H., was presented with the 2001 Distinguished Investigator Award by the Academy for Health Services Research and Health Policy at the academy's annual meeting held in June in Atlanta. The award recognizes leaders in the field of health services research—investigators who by virtue of the quantity, quality, and breadth of their research serve as role models for the field. Dr. Wells is a member of the scientific advisory committee for the American Psychiatric Association's Practice Research Network and a member of the board of directors of the American Psychiatric Institute for Research and Education. He is director of the Research Center on Managed Care for Psychiatric Disorders and director of the Health Services Research Center at the Neuropsychiatric Institute of the University of California, Los Angeles.