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  Hello, my name is Alex Crosby.I work as a medical epidemiologist inthe division of Violence Prevention atthe Centers for Disease Control andPreventions Injuries Center.Today, what I'm going to talk aboutis the public health approach topreventing suicidal behavior.I wanted to thank the people atEmery University for the invitation.And what I will do,is I will try to layout foryou, the public health approachto preventing suicidal behavior.It's an important topic,as many of you may be aware.It's one of the leading causes of death inthe United States and around the world.And not just a leading cause of death butalso has a significant burdenof morbidity and mortality.Those who are made ill.Those who made suicide attempts.The families, the friends, the communitiesthat are effected by suicidal behavior.As I mentioned, why is suicidalbehavior a public health issue?Many people approach suicidal behavior asstrictly a mental illness related problem.That does limit the ability tolook at the different strategies,the different solutions,the recommendations, the research.And so by looking at suicidalbehavior as a public health issue,it broadens our ability tobring in more instruments.Bring in more disciplines.Bring in more different, diversepopulations that can be involved inthe solution of trying toaddress suicidal behavior.Why should it be addressedas public health issue?Well, one thing is the morbidity andmortality.In the United States,it is the 10th leading cause of death.In 2011, that's our most recentmortality data, accounted forover 39,000 deaths in the United States.It's estimated that almost half a million,over 480,000 emergency department visitsfor self-inflicted injury in 2012.There are many health consequencesas a result of suicidal behavior.Physical, mental, behavioral,reproductive, andsexually transmitted diseases can allbe associated with suicidal behavior.  There's an impact thatpublic health can make.If it wasn't able to do anythingthen maybe it shouldn't be part ofa public health approach.But public health can help inthe aspect of approaching andaddressing suicidal behaviorbecause of its focus on prevention.Because of the science base that'sassociated with public health, andalso because it stressesa multi-disciplinary approach.Thirdly, the mission of public healthincludes the issue of suicidal behavior.Part of the mission of public healthis to reduce the amount of disease, oradverse health conditions, premature deathand disease producing discomfort anddisability in the population.This is what the publichealth approach looks like.And oftentimes, it's depictedin these four different stages.One is assessing the problem.What's the who, what, when,where of a particular issue?Next is identifying the causes.What are the risk factors,the protective factors, the ideology?Why did it happen?Then moving on to developing andevaluating programs and policies.Trying to figure out what works andwhat doesn't, sothat you can apply it to the problem.And then, lastly,implementation and dissemination.How do you do it?How do you take what you've learned andspread the news?That's the dissemination part.How do you get information out tothe communities that are trying toaddress the problem?And then implementation,taking those programs andactually applying them in a diverserange of different locations.First, I'll talk a little bitabout assessing the problem.Here's what suicidal behavior lookedlike in the United States in 2011.These are deaths due to suicide.One thing that's remarkableabout this is that males die ofsuicide about four times higher,four times higher rate than females.And you can especially see thatkind of the two peaks in regards to  male suicide rates are among those overage of 70 and those in the middle age.But that's particularly pronounced interms of looking at females that havedied of suicide in which theirhighest rates are among those intheir forties and fifties.Another aspect of looking at assessingthe problem is what are the methods thatoccur and I've been demonstrated as thepredominant methods in regards to suicide.As you can see in the United States,over 50% of the suicides,a firearm was in the mechanism of that.Around the world you could see thatthere is quite a range in terms ofhow suicide rates affectdifferent populations.From areas in Asia that havevery high suicide rates.To those in some places in South Americathat have very low suicide rates.And so these are some of the things thatcan affect what happens in regards tosuicide and how people try to address it.Deaths are just really onepiece of the puzzle inregards to looking at suicidal behavior.In the United States, using 2011 asan example, over 39,000 deaths with a rateof 12.3, over 147,000 hospitalizations,the rate of 47.2 per 100,000.So, you can see just in regards to thosetwo aspects that the rate of deaths tohospitalizations, hospitalizationsare about four times higher.And then we look at emergency departmentvisits, over 400,000 emergency departmentvisits due to self inflicted injury,a rate of 157.4.And so the magnitude of the burdenincreases as you move from deaths,to hospitalizations,to emergency department visits.And then when we've done surveys,in which we've asked people in the past 12months have you made a suicide attempt?Those numbers tend to be even bigger.Among adolescents, about 8% ofall adolescents reported in 2013that in the past 12 months they've madea suicide attempt, about 1% of all adults.This is the data in regards toemergency department visits forself-inflicted injury.One of the contrasts here between thisdata and the data regarding deaths due tosuicide is that you can see the highestrates are among adolescents andyoung adults.  Whereas with deaths due to suicide,highest rates were among middle age andolder adults.The other thing here is,I mentioned that males die of suicideabout four times higher than females.But you can see in almost every age grouphere among emergency department visits,females have more predominancein terms of victimization.So it's important to look at the contrastbetween fatal and non-fatal behavior.Identifying the causes, why did it happen?There's much researchthat has tried to look atthe issues regarding variousaspects of suicidal behavior.One of the ways is looking atthe social ecological model.What that does is it tries tolook at individual level factors,factors that effect the family andthe peer level.The other factors that lookat the community level.And then others that lookat the societal level.The individual level might be thingslike age, like sex, like mental illness.At the family andpeer level it may be exposure toviolence or previous victimization.Or history of violence in the family.Whether that's interpersonal violence,assault related or self-inflicted violencethat others in the family havebeen victims of suicidal behavior.At the community level, it may bethings like looking at spirituality,which is actually a protective factor.Or aspects like social isolation andsocial social network and social support.Social isolation being the risk factor.Social support beingthe protective factor.And then at the societal level, it maybe inappropriate access to lethal means.Things like the economy have beendemonstrated to play a role insuicidal behavior along withaspects like geography and culture.The next aspect of the publichealth approach is developing andevaluating programs and policies.What works and what doesn't,and the various schemes fortrying to take a look at applyingprevention practice to suicidal behavior.As you see across the, the top row,universal programs that try to do
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