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 Identification: presumptive vs confirmatory Estimation of Time of Death Estimation of Time of Death Documentation of Injuries/Pathology Documentation of Injuries/Pathology Collection of Trace Evidence Collection of Trace Evidence Determination of Cause & Manner of Death 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 A classification of the way in which the cause of death came about, with special reference to social relationships and personal causation Categories: Categories: Natural Natural Accident Accident Suicide Suicide Homicide Homicide Undetermined 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 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 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 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 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 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 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 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 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% 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 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 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) 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. From 1990-1994, 154,444 persons were reported to complete suicide in the U.S. Northeast: 23,734 (15%)-8.6/100,000 Northeast: 23,734 (15%)-8.6/100,000 Midwest: 34,492 (22%)-10.9/100,000 Midwest: 34,492 (22%)-10.9/100,000 West: 38,709 (25%)-14.1/100,000 West: 38,709 (25%)-14.1/100,000 South: 57,509 (37%)-13.1/100,000 South: 57,509 (37%)-13.1/100,000 Total U.S. adjusted suicide rate during this period- 11.8/100,000 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: Reasons other than for possible regional differences in certain demographics: Suicide rates are higher in communities with deficient social integration & unstable social environments 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 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 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 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 The Problem: Rates of reported suicides among adolescents & young adults have nearly tripled between 1952 & 1996 1950: 4.5/100,000 1950: 4.5/100,000 1990: 13.5/100,000 1990: 13.5/100,000

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

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

15. Suicide Ideation/Attempts Among Youth While suicide represents the 3 rd leading cause of death among U.S teens, many more seriously consider suicide w/o attempting or attempt w/o completing the act While suicide represents the 3 rd 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 1999: 20% of all H.S. students acknowledged having seriously considered or attempted suicide during the prior year 8% actually attempted suicide 8% actually attempted suicide Less than 3% reported an injurious episode necessitating medical attention 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 Suicide rates & associated demographic data were tracked from 1990-2006 Deaths due to suicide during this period: 933, with 904 initiated within Delaware Co. 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 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 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): 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%). 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): Suicide rate by race(1990/1998): White-8.4/7.2 White-8.4/7.2 Black-4.9/7.2 Black-4.9/7.2 Asian-0/0 Asian-0/0 Hispanic-16.7/0 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 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 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. Delaware County 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. 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) 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) 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 Adjusted Delaware County suicide rate (1990-2006): 9.8

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

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

26. Delaware County Household Demographics Households of those 65+ years & alone: 5,792 M and 18,057 F Households of those 65+ years & alone: 5,792 M and 18,057 F Highest % per total community population: Edgemont (7.3%) Highest % per total community population: Edgemont (7.3%) Suicide rate/100,000: 20.1 Suicide rate/100,000: 20.1 Lowest % per total community population: Bethel (1.1%) Lowest % per total community population: Bethel (1.1%) Suicide rate/100,000: 7.6 Suicide rate/100,000: 7.6 Average %: 4.5% Average %: 4.5% Suicide rate/100,000: 9.8 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%) 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%)) 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 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%)) 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 Suicide Rate-12.1

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

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

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

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

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

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