Brian L. Mishara, Ph.D., Director Centre for Research and Intervention on Suicide and Euthanasia

1. Railway Suicides in Canada and Around the World:Agendas for Prevention and Research23rd International Rail Safety Conference, Vancouver, 7 October 2013 Brian L. Mishara, Ph.D., Director Centre for Research and Intervention on Suicide and Euthanasia Professor, PsychologyDepartment mishara.brian@uqam.ca & CécileBardon, M.S., Project Coordinator Centre for Research and Intervention on Suicide and Euthanasia Université du Québec à Montréal www.railwaysuicideprevention.com

3. IMPOSSIBLE TASK: CRITICALLY SUMMARIZE RAIL SUICIDE PREVENTION in 25 MINUTES

4. Plan 1. Not quite everything you wanted to know about suicide and suicide prevention in 5 minutes 2. Where train suicides fit in 3. Some results from our recent studies in Canada 4. Conclusions 5. Recommendations for research and evaluation Thanks to our sponsor: Transport Canada, our Steering Committee as well as the railways and union and rail personnel in Canada who collaborated in our research

5. Not quite everything you wanted to know about suicide and suicide prevention • Suicide exists in every country in the world and there have always been suicides everywhere

8. Not quite everything you wanted to know about suicide and suicide prevention • Over 1,000,000 suicide deaths/year, more than in all wars, terrorist attacks and homicides combined • People who kill themselves in Europe and North America generally have serious mental health and/or alcohol/drug abuse problems • Suicide is the result of a complex interaction between risk and protective factors – there is never just one simple cause • Over half of suicides in Western countries occurunder the influence of alcohol or drugsthat compromise the ability to makereasonabledecisions. Also, mental illness and being in a crisis situation make for poorchoice of suicide as a solution to problems.

9. Not quite everything you wanted to know about suicide and suicide prevention • It takes more than having a mental health problem to commit suicide – most people with serious problems never attempt suicide and most seriously suicidal people get help and change their minds (prevention usually works) • No matter how «serious» attempters appear, they are usually happy to be saved • If « acceptable » means are not available, the risk is greatly diminished (e.g. controlled access to bridges, firearms, drugs) • Media reports on suicides, no matter how well intentioned, increase the risk of « copy cat » deaths in vulnerable people who are already at risk

10. Where train suicides fit in the picture • The accident - suicide blur: reliable data not always available, but Europe and Canada have some of the best data • Why railway suicide? • Easy access • High lethality • Can result in quick death • Violent means – can be attractive to some or repulsive to others • Impact on train drivers and personnel: severe

11. Where train suicides fit in the picture • People choose methods which • Are readily available • They think is a« good » method for them • They learn that others use (from media or conversations or knowing someone who used that method) • Are the « in » methods – you read about it a lot • In the case of Metro-subway suicides: • They think they will certainly die, they will die quickly and painlessly (Weisman et al and our current study) • (In Montrealthisis not true – most survive with handicaps) • However, people hit by open track trains rarely survive -

12. Where train suicides fit in • Attempters often tell others about their plans or give identifiable signs • May be seen as a « cry for help » • Threats are often ignored or not taken seriously – even in psychiatric institution • Sometimes « because » threats occur often • When an attempt is imminent, people often do not proceed with their plans when • Help is offered (e.g. posters & phones near bridges, interventions by rail personnel) • It is difficult to access the means, it is painful, too uncomfortable, disgusting or embarassing • They are frustrated at least temporarily in completing their plan (buys time to get help, sober up and re-think plans)

13. Overview of the global project

14. Study of suicides & accidents by rail in Canada over 10 years: • Objectives: • Determine the prevalence of railway fatalities in Canada • Better understand: • Circumstances surrounding suicides and accidents by rail • Characteristics of victims • Characteristics of train fatalities (description of incidents) • Identify hot spots and clusters of incidents

15. Accidents Driving across the tracks (97) Walking or running across the tracks (45) Does not move when train whistles (33) Walking on track facing away from train (32) Facing away from train (32) Lying on track (26) Stands or sits on track (21) Tried to get out of the way (13) Runs suddenly in front of the train (12) Sleeping on track (12) Going around barriers (11) Wearing a hoody or walkman (11) Walking along the track (11) Made contact with the side of train (10) Suicides Runs out suddenly in front of the train (99) Lying on the track (80) Stands or sits on track (79) Facing the train (57) Does not move when train whistles (53) Head on rail (40) Facing away from train (35) Looking at the driver / train engine (33) Placingarms out (22) Walkingalongtrack (19) Walking on trackfacing train (14) Drivingacrosstrack (10) Gesturingtowardscrew (10) Behaviour (N of people displaying these behaviours – information available for 671 cases)

16. Characteristics of train fatalities • By type of trains • Accidents occur more often with freight trains and suicides more with passenger trains • By type of collision • Suicides mostlyinvolve pedestrians • Accidents are more evenlyspreadbetweenvehicle and pedestrian collisions

17. Circumstances of incidents • Geographical location Accidents occur more often in rural areas and suicides in urban areas Accidents tend to be at crossings in rural areas Suicides are more often open trackrack in urban areas Accidents occur more often at crossings and suicides on open tracks

18. No very high frequency hotspots in Canada • Out of 278 incidents in clusters, only 15 clusters with 5+ incidents over 10 years (max 11 incidents) • Hotspots • Suicide clusters are more common in urban areas • Accident clusters are more common in rural areas • Suicide clusters (35.3%) are more likely to be close to a psychiatric hospital than accident clusters (10.0%) - (Chi2 = 4.54, df=1, p<.033)

19. Costs associated with train fatalities • Trafficisstopped an average of 3 hours (from 91 min. in BC to 207 min. in ON) • No variation withmanner of death, type of incident, type of train, crossing or track, rural or urban • Time off and health care • 3 days off : Average of 119 fatalities / year = 357 workdays minimum lost • Workers compensation : over 51 incidents = 2 workersstoppedcompletely, 8 took >3days (mean = 77.25 days off) • Therapy – costsdifficult to assess

20. Prevention of railway suicide A railway suicide preventionstrategyshouldbe local and combine severalactivities • Review : Severalstrategies have been implemented in different countries • With no proof of effectiveness to date • Public education on safety • Changingdesirability of train as a method of suicide • With minimal proof of effectiveness • Television surveillance • Gatekeepers in stations • Signs (withouttelephones) • Media education (workssometimes) • Chargingfamilies for clean-up • Blue Lighting • Promising (severalstudies have shown an effect) • Limitingaccess to tracks • Phones and signs (effective with bridges and parking areas) • Suicide pits (raised rails) in stations • Preventiveeducation in mental healthfacilitiesneartracks (not directlytested on rail suicides, but canprevent suicides in general)

21. Classification of activities for railway suicide prevention Technicalapproach Psychosocial approach Reducingrisk of injury Preventinginjury Limitingaccess to tracks Preventing impact Monitoring tracktrespassing Identifyingatriskpersons on railwayproperty Identifyingatrisk people in the community Preventing suicide attempts Providingaccess to help on and aroundrailwayproperty Providingaccess to help in the community Discouragingtrespassing

22. Proposals for pilot testing of railway suicide preventionadapted to the Canadian context • 1. Telephones & signs (expensive) • 1b. Signsonly (muchlessexpensive and potentialpartners, less probable impact) • 2. Training for mental health institutions (lessexpensive)

23. Overall assessment of feasibility (telephones and signs)

24. Overall assessment of feasibility (training programme)

25. Conclusions • 1) There are significant differences between TSB, Railway Police and Provincial Coroner and Medical Examiner data. It would be worthwhile to develop a mechanism to better communicate between the 3 levels to ensure that all have a complete portrait of rail deaths (suicides and accidents) in Canada

26. Conclusions • 2) Surprisingly, both suicides and accidents occur generally when visibility is good, and at any time, although accidents are more likely in snowy and icy conditions and suicides are more likely during gloomy overcast weather. There are however more accidents at night and early, before 5 am, suggesting that fatigue may play a role. Fatalities occur near home. Accidents are more likely at crossings in rural areas and involving freight trains. Suicides more often occur on open tracks in urban areas and involve passenger trains.

27. Conclusions • 3) Substance abuse (mostly alcohol) is involved in 73% of accidents and 46% of suicides.

28. Conclusions • 4) Since older adults (>60) and children are more likely to be accident victims, they could be specific target populations for prevention activities.

29. Conclusions • 5) In the case of accidents, a portrait of impairment in victims is common: • impaired judgement or • ability to get out of the way • children • older persons • alcohol and substance abuse • risk taking • late at night or early morning with possible fatique • recent conflicts or problems that may preoccupy victims • This suggests that more intensewarnings to compensate for impairments may be warranted.

30. Conclusions • 6) As found in England, a significant number of suicides were near psychiatric facilities and 35% of suicide clusters were within 2 miles of a psychiatric facility. This suggests the possibility of targeting psychiatric institutions near accessible railway tracks with prevention activities.

31. Conclusions • 6) The scene of railway deaths can be very gory: • 66% of cases the body is in more than one piece; • 1 out of 20 cases the body was decapitated • “blood everywhere” in 88% of fatalities. • The impact on railway personnel and observers, as well as emergency personnel who arrive on the scene can be traumatic. One should also be concerned about the impact upon onlookers and emergency personnel called to the scene.

32. What we need to know • More about who, where, when (including hot spots) • Motivations and beliefs of attempters • WE NEED TO EVALUATE THE IMPACT OF PREVENTION STRATEGIES USING RIGOROUS SCIENTIFIC METHODS We are currently interviewing attempt survivors in hospital to understand why they chose rail-metro suicide We are analysing video tapes of Montreal Metro suicides to identify behavioural patterns in stations and testing the validity of our identification methods We are proposing and plan to evaluate best practices to reduce the impact on railway personnel

34. The DANGER of being focussed on our own narrow interests

35. Some untested ideas inspired from research findings needing evaluation • Because of the impaired abilities of accident victims (elders, children, intoxicated, fatigue, etc.), , MUCH MUCH more intrusive warnings at crossings and of trains approaching on open tracks (visual, auditory, sensual (trembling ground?) could help avoid accidents. • Computerized video surveillance to identify at risk behaviours and precursors (e.g. our Metro Montreal study) • Emergency phones and posters at hot spots (effectiveness and what type of image and message is best needs to be determined) • Anti-suicide train bumpers (psychological effects) • Suicide Prevention protocols in mental health facilities that have multiple train suicides (near hot spots). • Decreasing sensational media reports on railway suicides • Making it embarassing, disgusting, undignified or hurtful to access tracks • and your ideas?