The Suicide Spectrum in Delaware County

1. The Suicide Spectrum in Delaware County Fredric N. Hellman, M.D., M.B.A. Chief Medical Examiner, Delaware County, PA

2. Role of the Medical Examiner • Identification: presumptive vs confirmatory • Estimation of Time of Death • Documentation of Injuries/Pathology • Collection of Trace Evidence • Determination of Cause & Manner of Death

3. Manner of Death • A classification of the way in which the cause of death came about, with special reference to social relationships and personal causation • Categories: • Natural • Accident • Suicide • Homicide • Undetermined

4. The Medical Examiner’s Role in Potential Suicide Investigation • The medical examiner is responsible for the investigation of any unexplained, unexpected, mysterious or violent death • In the case of potential suicide, the ME must attempt to ascertain, to a reasonable degree of medical certainty, both intent towards self-destruction and a subsequent lethal act

5. The Medical Examiner & You • Suicide has been a serious health problem for many years, but has only recently acquired the attention that it merits • Every year, approximately 30,000 individuals die by suicide in the U.S., and one million die worldwide • More than 650,000 people annually receive emergency treatment after a suicide attempt in this country • Suicide is the third-leading COD amongst American youth, being #11 for Americans across all ages

6. National Suicide Rates • While having remained fairly stable through time among this country’s general population (12.1/100,000 (1976); 10.8/100,000 (1996)), substantial shifts in suicide rates have been observed amongst various age, gender, & ethnic groups

7. National Suicide Rates • While females are more likely than males to attempt suicide, males are 4X as likely to be successful • White males/females accounted for over 90% of suicides in 1997, with white males alone responsible for 72% • Firearm-related deaths accounted for 58% of all suicides in 1997

8. Suicide-Regional Variation • Suicide rates have varied by geographic region, being consistently higher in the Western states • Reasons are unclear, but may reflect regional differences in certain demographic variables (Suicide rates are known to be higher for the elderly, for white males, & for certain racial/ethnic groups)

9. Suicide-Regional Variation • From 1990-1994, 154,444 persons were reported to complete suicide in the U.S. • Northeast: 23,734 (15%)-8.6/100,000 • Midwest: 34,492 (22%)-10.9/100,000 • West: 38,709 (25%)-14.1/100,000 • South: 57,509 (37%)-13.1/100,000 • Total U.S. adjusted suicide rate during this period-11.8/100,000

10. Suicide-Regional Variation • Reasons other than for possible regional differences in certain demographics: • Suicide rates are higher in communities with deficient social integration & unstable social environments • Limited economic opportunity with increased unemployment as well as residential instability may also contribute to an elevated suicide rate

11. More Suicide Statistics • Suicide rates are inversely related to level of education • The incidence of suicide is also significantly lower among married individuals than among those who are single, separated, divorced or widowed

12. Suicide Among Youth • The Problem: Rates of reported suicides among adolescents & young adults have nearly tripled between 1952 & 1996 • 1950: 4.5/100,000 • 1990: 13.5/100,000

13. Suicide Among Youth • Suicide is now the 4th leading cause of death amongst children aged 10-14 years • Suicide is the 3rd leading cause of death amongst adolescents aged 13-24 years, exceeded only by unintentional injury & homicide

14. Suicide Among Youth • Risk Factors include: • Family history of suicide • Impulsive/aggressive behavior • Social isolation • Prior suicide attempt(s) • Easier access to alcohol, illicit drugs & lethal suicide methods

15. Suicide Ideation/Attempts Among Youth • While suicide represents the 3rd leading cause of death among U.S teens, many more seriously consider suicide w/o attempting or attempt w/o completing the act

16. Suicide Ideation/Attempts Among Youth • 1999: 20% of all H.S. students acknowledged having seriously considered or attempted suicide during the prior year • 8% actually attempted suicide • Less than 3% reported an injurious episode necessitating medical attention

17. The Suicide Profile-Delaware County • Suicide rates & associated demographic data were tracked from 1990-2006 • Deaths due to suicide during this period: 933, with 904 initiated within Delaware Co. • Per annum range: 45-69, with a median=55 & a mean=56 deaths • Based upon a county population=547,651, the 1990 suicide rate per 100,000 individuals=10.4

18. The Suicide Profile- Delaware County • Utilizing the Delaware Valley Regional Planning Commission est. population in 2000(549,070): -DELCO suicide rate(2006)=10.1

19. The Suicide Profile-Delaware County • By gender & race, suicide was successfully completed by 210 females (22.5%) & 723 males (77.5%). All but 116 such acts were completed by Caucasians (88%), with the vast majority of suicides being completed by Caucasian males (71%).

20. The Suicide Profile-Delaware County • Suicide rate by race(1990/1998): • White-8.4/7.2 • Black-4.9/7.2 • Asian-0/0 • Hispanic-16.7/0

21. Suicide at the Extremes-Delaware County • Between 1990-2006, 61 individuals (6.5%) between the ages of 16-20 years completed suicide, with 153 additional suicides (16.4%) among those aged 21-30 years • At the opposing end of the age spectrum, 221 persons 61 years of age or older (18.8%) completed suicide during this period of time

22. DelawareCounty Suicide Rate (1990-2006)

23. Delaware County Demographics • A total of 65 boroughs, townships and communities comprised the study distribution of completed suicides within the county during the period 1990-2006. • Two communities were without completed suicides during this timeframe (Corcordville, Lester) • Eight communities outside of the county contributed 29 suicides during this period (inciting act versus location of pronouncement of death) • Adjusted Delaware County suicide rate (1990-2006): 9.8

24. Delaware County Demographics • Community population range (2000 census data): • Largest population: Upper Darby (81,529) • Smallest population: Ruttledge (852) • Per capita income (PCI) range: • Highest PCI: Rose Valley ($54.2K) • Suicide rate/100,000: 11.3 • Lowest PCI: Chester City ($13.1K) • Suicide rate/100,000: 12.1 • Mean PCI: $25.0K

25. Delaware County Household Demographics • Married couples (104,911) versus single-parent households (26,542): 4.0:1 • Highest ratio: Thornbury (16.1:1), with PCI = $22.0K • Suicide rate/100,000: 10.1 • Lowest ratio: Chester City (0.8:1), with PCI = $13.1K • Suicide rate/100,000: 12.1

26. Delaware County Household Demographics • Households of those 65+ years & alone: 5,792 M and 18,057 F • Highest % per total community population: Edgemont (7.3%) • Suicide rate/100,000: 20.1 • Lowest % per total community population: Bethel (1.1%) • Suicide rate/100,000: 7.6 • Average %: 4.5% • Suicide rate/100,000: 9.8

27. Delaware County Demographics Educational Level • Delaware County residents with educational attainment of bachelor’s degree or above: 109,670 out of 355,174 residents 25+ years of age (30.0%) • Community with highest % of residents with educational attainment of bachelor’s degree or above: Swarthmore (2,618/3,395 (77.1%)) • Suicide rate-13.3 • Community with lowest % of residents with educational attainment of bachelor’s degree or above: Chester City (1,804/21,174 (0.85%)) • Suicide Rate-12.1

28. Community Suicide Rate Demographics • Communities with suicide rates of 14.1/100,000 or greater: 14/65 • Range: 14.1-48.1/100,000 • Mean: 21.9/100,000 • Communities with suicide rates of 7.0/100,00 or less: 11/65 • Range: 4.2-7.0/100,000 • Mean: 5.8/100,000

29. Community Suicide Rate Demographics • Communities with suicide rates of 14.1/100,000 or greater: • PCI: $21.9K • Married : Single parent households: 3.6:1 • Households of 65+ years & alone: 4.85% • Educational attainment of bachelor’s degree or above: 18.4%

30. Communities with suicide rates of 7.0/100,000 or less: PCI: $29.4K Married : Single Parent household: 7.1:1 Households of 65+ years & alone: 4.35% Educational attainment of bachelor’s degree & above: 40.6% Community Suicide Rate Demographics

31. Suicide Risk Factors Suicide rates are higher in communities with deficient social integration & unstable social environments Limited economic opportunity with increased unemployment as well as residential instability may also contribute to an elevated suicide rate

32. Suicide Associations • Suicide rates are inversely related to level of education • The incidence of suicide is also significantly lower among married individuals than among those who are single, separated, divorced or widowed

33. Suicide Associations • Suicide rates are known to be higher for the elderly, for white males, & for certain racial/ethnic groups

34. Suicide Among Youth • Risk Factors include: • Family history of suicide • Impulsive/aggressive behavior • Social isolation • Prior suicide attempt(s) • Easier access to alcohol, illicit drugs & lethal suicide methods

35. Suicide Among the Elderly • Risk factors include: • Widowhood • Serious medical illness, with associated anxieties • Social isolation • Depression • Alcoholism & prescription drug abuse • Financial constraints

36. The Surgeon General’s Call To Action • The public health approach: • Define the problem • Identify the causes & protective factors • Develop & test interventions • Implement interventions