Friday, January 4, 2013

Suicide in Vermont

To its pride, Vermont rates higher than most other states when it comes to health, safety, a clean environment, and good schools. Test scores of Vermont students are among the highest in the country. The crime rate is low, relatively few people lack health insurance. Compared to most other states, the air and water are clean.

But here's a less happy statistic: the suicide rate is high.

According to statistics compiled by the American Foundation for Suicide Prevention, in 2010, the last year for which information is available, 106 Vermonters killed themselves. That's a rate of 16.9 per hundred-thousand people, the 12th highest rate in the country. A study from the Health Department from 1999-2005 cites suicide as the 9th ranking cause of death in the state. Over that period there was an average of 80 suicides a year, or 1.5 every week. Is Vermont doing something wrong?

Maybe not. Vermonters are more likely to be older than the residents of other states, and older people are more likely to commit suicide. According to the state's Mental Health Department, from 1985 through 2006, "Vermont's age-adjusted suicide rates varied between a high of 17.9 per hundred thousand residents in 1988 to a low of 10.3 per hundred thousand in 1999."

By those measurements, the Department reported, Vermont is right in the middle of the national pack, "25th from the highest and 26th from the lowest among states (including the District of Columbia) in overall age-adjusted suicide rates during 2006."

Even by this measurement, though, Vermont's suicide rate has been steadily higher than the national average for more than a decade, and is the highest in the Northeast, though only a little higher than neighboring New Hampshire and nearby Maine.

As to whether there is something in the state's culture, laws, or policies that might help explain the high suicide rate, experts differ.

Charles Biss, Director of the Child, Adolescent and Family Unit of the Vermont Department of Mental Health, thinks not.

"Suicide is a public health problem," said Biss. This means, he said, that "it can be prevented," and that there might be no identifiable reason why Vermont's suicide rate is higher than its neighbors. People commit suicide, he said, when they feel "isolated and disconnected. I don't thank that's a situation peculiar to Vermont."

But others, including Dr. Sandra Steingard, the medical director of the Howard Center, think there could be one reason Vermont's suicide rate is high.

"A ready access to guns," could play a role, said Dr. Steingard, noting that in general, "access to lethal means is a major factor" in high suicide rate areas.

The connection between the easy availability of guns and high suicide rates seems incontrovertible. Several academic studies cited by "Means Matter," a web site maintained by the Harvard School of Public Health show that suicide rates tend to be much higher in areas where gun ownership is more common.

But the evidence by no means proves that Vermont has a high suicide rate because guns are readily available. In fifteen other states, higher percentages of people live in homes with firearms, and while some of those states have the highest suicide rates in the country (Alaska, Montana, Wyoming), in several others, suicide is rarer than it is in Vermont. Getting a gun is easier in Vermont than in neighboring Massachusetts and New York, where the suicide rates are much lower. But there are lots of other differences between those states and Vermont, which is more rural and less diverse.

Somewhat surprisingly, suicide statistics show that with the exception of American Indians, racial minorities are less likely to kill themselves than are non-Hispanic whites. Life may be tougher for blacks and Hispanics, but they choose to end it less frequently. That appears to be one reason Vermont, where blacks and Hispanics together comprise less than three percent of the population, has a higher suicide rate than states with large minority populations.

Less surprisingly, suicide is more common in rural areas.  Guns are more common there than in the cities and suburbs, but so is that isolation and sense of feeling disconnected Charles Biss cited as the root cause of suicide. In fact, he said, the evidence shows that some people move to rural areas precisely because they feel disconnected and want fewer people around them.

Even within Vermont, rural residents are most likely to kill themselves. Mental Health Department data show that the lowest suicide rate is in Chittenden County, the highest in the rural areas to its north and east and in sparsely populated Orange County.

Suicide is also more common in northern states (and countries), perhaps because long, cold, winters can exacerbate those feelings of isolation and abandonment. But a Vermonter is more likely to commit suicide in the summer, according to the Mental Health Department.

In Vermont as elsewhere, men and boys are more likely to commit suicide, but women and girls are far more likely to think about it and to attempt it. One report by the Mental Health Department showed that for each suicide in 2006, as many as five suicides were attempted, two-thirds of them by women.

Here guns clearly help explain the difference. Women, said Dr. Steingard, are more likely to use pills or to cut themselves, giving them, in many cases, the chance to change their minds.

"You can cut yourself deeply and seriously," and still recover, she said, or overdose on pills but then "pick up the phone" to call someone who will arrange for emergency medical treatment. Men, she said, use "more lethal means," such as shooting or hanging themselves or jumping from high positions. In those cases, turning back is close to impossible.

Though suicide rates are highest among older people, mental health officials are increasingly concerned about an increase in suicide by teenagers and young adults. In Vermont, suicide is the second leading (after automobile accidents) cause of death among teenagers. As with the rest of the population, most of the youth suicides were males, and most of them used a gun. According to statistics from the Centers for Disease Control and Prevention, between 1987 and 2006, 2.12 of every hundred-thousand Vermonters under the age of 19 shot themselves to death. Maine's rate was almost as high, but in the other New England states the rate was substantially lower. New Hampshire's was 1.71.

One reason could be that though for the most part New Hampshire's gun control laws are similar to Vermont's, unlike Vermont and Maine, New Hampshire is one of 28 states that have a Child Access Prevention (CAP) law, requiring firearm owners to lock their weapons away from children when they know minors might have access to them.

Here again the evidence is inconclusive. A study of Florida's CAP law published in 2000 by the journal "Pediatrics" found that the law "was associated with a 51% reduction in unintentional firearm death rates among children," but there was "no significant combined or state-specific law effects" in other states with CAP laws.

The scholars speculated that Florida's law worked better because it was tougher, allowing felony prosecution of violators.

In 2009, 15-year-old Essex High School freshman Aaron Xue, a shot and killed himself using a gun and ammunition a classmate had taken from his father's unsecured weapons cache. Aaron's mother, University of Vermont Professor Ge Wu, tried to get the Legislature to pass a CAP bill. It went nowhere.

An analysis of data from the Centers for Disease Control and Prevention by Jill M. Harkavy-Friedman, the Senior Director of Research and Special Projects for the American Foundation for Suicide Prevention found that in 2010, 11 Vermonters between the ages of 10 and 30 killed themselves with guns. That was a rate of 6.75 per hundred-thousand, the highest in the Northeast, though Maine (6.26) and New Hampshire (6.25) were not much lower.

Charles Bass said that the total youth suicide rate could be higher than the statistics indicate.

"The medical examiners tell us some auto accidents (in which young people die) could really be suicides," Bass said.

One myth about suicide, Dr. Steingard said, is that those who attempt it once will keep trying until they succeed. In fact, she said, the suicidal impulse is often spontaneous and fleeting, and not repeated. "If we can intervene at the moment, we can have a big impact," she said.

At its core, suicide is a problem of public mental health. Among young people especially, suicide and attempted suicide are more prevalent among racial minorities, gays and lesbians, and others more likely to feel scorned.

In Vermont, officials are not merely playing defense.  Bass said young people can be taught "emotional compensatory skills" to offset their feelings. In addition, both officials and advocacy groups are trying to educate parents, teachers, and neighbors, to be on the lookout for warning signs that indicate young people may be at risk for attempting suicide.

All that, of course, requires more mental health services, and like the rest of state government, the Mental Health Department faces relentless budget challenges these days, and faces them without the help of a powerful lobby to fight in its behalf. The "isolated and disconnected" don't have a lot of political clout.

1 comment:

  1. Many years ago I heard Eleanor McQuillen, MD {the then State Medical Examiner whose license plate was "QUINCY"), speak. The gist of her speech (at least what I best recall some thirty years later) was that when she was appointed Vermont had one of the highest suicide rates, and at the same time, one of the lowest unsolved homicide rates in the nation. There were theories at the time that the long winters in Vermont made us particularly susceptible to depression and suicide. It all sounded quite plausible.
    Shortly after her appointment, those statistics were reversed. This recalls one of my favorite quotes: "Statistics don't lie, but liars use statistics." Actually we have to realize that a statistic like the suicide rate is actually an accumulation of the many judgments of the various local medical examiners, who may or may not have the information and knowledge necessary to make the kind of judgments that would inspire a high degree of confidence in the statistic. It seems that the suicide rate in Vermont in Quincy's time had been affected by the desires of the police, prosecutors, medical examiners and others at the time to give a quick final answer that required no further investigation. After all, if the decision is that there was a homicide, the medical examiner would have a bunch of people looking over his or her shoulder, and he or she would have to testify in court. There is no "suicide trial." Remember also that a large percentage of murders involve family members or domestic partners, who have a vested interest in making it appear to be a suicide. Also realize that in most cases of unattended deaths in Vermont, no autopsy is done. Even those unattended deaths that trigger the need for a medical examiner, unlike in Quincy's time, and what we have become accustomed to on TV by CSI, etc., the actual medical examiners making the call in Vermont are no longer medical doctors.
    So how are we to know that we see now is not just a regression to the earlier practices of the medical examiner's office? It would certainly be interesting to see how those two statistics have changed since "Quincy" served.