THE FOLLOWING INFORMATION ON 5159 IS REPRINTED FROM THE FOLLOWING LINK http://www.leginfo.ca.gov/

CALIFORNIA CODES
WELFARE AND INSTITUTIONS CODE
SECTION 5150-5157




5150.  When any person, as a result of mental disorder, is a danger
to others, or to himself or herself, or gravely disabled, a peace
officer, member of the attending staff, as defined by regulation, of
an evaluation facility designated by the county, designated members
of a mobile crisis team provided by Section 5651.7, or other
professional person designated by the county may, upon probable
cause, take, or cause to be taken, the person into custody and place
him or her in a facility designated by the county and approved by the
State Department of Mental Health as a facility for 72-hour
treatment and evaluation.
   Such facility shall require an application in writing stating the
circumstances under which the person's condition was called to the
attention of the officer, member of the attending staff, or
professional person, and stating that the officer, member of the
attending staff, or professional person has probable cause to believe
that the person is, as a result of mental disorder, a danger to
others, or to himself or herself, or gravely disabled.  If the
probable cause is based on the statement of a person other than the
officer, member of the attending staff, or professional person, such
person shall be liable in a civil action for intentionally giving a
statement which he or she knows to be false.



5150.05.  (a) When determining if probable cause exists to take a
person into custody, or cause a person to be taken into custody,
pursuant to Section 5150, any person who is authorized to take that
person, or cause that person to be taken, into custody pursuant to
that section shall consider available relevant information about the
historical course of the person's mental disorder if the authorized
person determines that the information has a reasonable bearing on
the determination as to whether the person is a danger to others, or
to himself or herself, or is gravely disabled as a result of the
mental disorder.
   (b) For purposes of this section, "information about the
historical course of the person's mental disorder" includes evidence
presented by the person who has provided or is providing mental
health or related support services to the person subject to a
determination described in subdivision (a), evidence presented by one
or more members of the family of that person, and evidence presented
by the person subject to a determination described in subdivision
(a) or anyone designated by that person.
   (c) If the probable cause in subdivision (a) is based on the
statement of a person other than the one authorized to take the
person into custody pursuant to Section 5150, a member of the
attending staff, or a professional person, the person making the
statement shall be liable in a civil action for intentionally giving
any statement that he or she knows to be false.
   (d) This section shall not be applied to limit the application of
Section 5328.


5150.1.  No peace officer seeking to transport, or having
transported, a person to a designated facility for assessment under
Section 5150, shall be instructed by mental health personnel to take
the person to, or keep the person at, a jail solely because of the
unavailability of an acute bed, nor shall the peace officer be
forbidden to transport the person directly to the designated
facility.  No mental health employee from any county, state, city, or
any private agency providing Short-Doyle psychiatric emergency
services shall interfere with a peace officer performing duties under
Section 5150 by preventing the peace officer from entering a
designated facility with the person to be assessed, nor shall any
employee of such an agency require the peace officer to remove the
person without   assessment as a condition of allowing the peace
officer to depart.
   "Peace officer" for the purposes of this section also means a
jailer seeking to transport or transporting a person in custody to a
designated facility for assessment consistent with Section 4011.6 or
4011.8 of the Penal Code and Section 5150.


5150.2.  In each county whenever a peace officer has transported a
person to a designated facility for assessment under Section 5150,
that officer shall be detained no longer than the time necessary to
complete documentation of the factual basis of the detention under
Section 5150 and a safe and orderly transfer of physical custody of
the person.  The documentation shall include detailed information
regarding the factual circumstances and observations constituting
probable cause for the peace officer to believe that the individual
required psychiatric evaluation under the standards of Section 5105.

   Each county shall establish disposition procedures and guidelines
with local law enforcement agencies as necessary to relate to persons
not admitted for evaluation and treatment and who decline
alternative mental health services and to relate to the safe and
orderly transfer of physical custody of persons under Section 5150,
including those who have a criminal detention pending.



5150.3.  Whenever any person presented for evaluation at a facility
designated under Section 5150 is found to be in need of mental health
services, but is not admitted to the facility, all available
alternative services provided for pursuant to Section 5151 shall be
offered as determined by the county mental health director.




5150.4.  "Assessment" for the purposes of this article, means the
determination of whether a person shall be evaluated and treated
pursuant to Section 5150.


5151.  If the facility for 72-hour treatment and evaluation admits
the person, it may detain him or her for evaluation and treatment for
a period not to exceed 72 hours.  Saturdays, Sundays, and holidays
may be excluded from the 72-hour period if the Department of Mental
Health certifies for each facility that evaluation and treatment
services cannot reasonably be made available on those days.  The
certification by the department is subject to renewal every two
years.  The department shall adopt regulations defining criteria for
determining whether a facility can reasonably be expected to make
evaluation and treatment services available on Saturdays, Sundays,
and holidays.
   Prior to admitting a person to the facility for 72-hour treatment
and evaluation pursuant to Section 5150, the professional person in
charge of the facility or his or her designee shall assess the
individual in person to determine the appropriateness of the
involuntary detention.
   If in the judgment of the professional person in charge of the
facility providing evaluation and treatment, or his or her designee,
the person can be properly served without being detained, he or she
shall be provided evaluation, crisis intervention, or other inpatient
or outpatient services on a voluntary basis.
   Nothing in this section shall be interpreted to prevent a peace
officer from delivering individuals to a designated facility for
assessment under Section 5150.  Furthermore, the preadmission
assessment requirement of this section shall not be interpreted to
require peace officers to perform any additional duties other than
those specified in Sections 5150.1 and 5150.2.



5152.  (a) Each person admitted to a facility for 72-hour treatment
and evaluation under the provisions of this article shall receive an
evaluation as soon after he or she is admitted as possible and shall
receive whatever treatment and care  his or her condition requires
for the full period that he or she is held.  The person shall be
released before 72 hours have elapsed only if, the psychiatrist
directly responsible for the person's treatment believes, as a result
of his or her personal observations, that the person no longer
requires evaluation or treatment.  If any other professional person
who is authorized to release the person, believes the person should
be released before 72 hours have elapsed, and the psychiatrist
directly responsible for the person's treatment objects, the matter
shall be referred to the medical director of the facility for the
final decision.  However, if the medical director is not a
psychiatrist, he or she shall appoint a designee who is a
psychiatrist.  If the matter is referred, the person  shall be
released before 72 hours have elapsed only if the psychiatrist making
the final decision believes, as a result of his or her personal
observations, that the person no longer requires evaluation or
treatment.
   (b) Persons who have been detained for evaluation and treatment
shall be released, referred for further care and treatment on a
voluntary basis, certified for intensive treatment, or a conservator
or temporary conservator shall be appointed pursuant to this part as
required.
   (c) Persons who have been detained for evaluation and treatment,
who are receiving medications as a result of their mental illness,
shall be given, as soon as possible after detention, written and oral
information about the probable effects and possible side effects of
the medication by a person designated by the mental health facility
where the person is detained.  The State Department of Mental Health
shall develop and promulgate written materials on the effects of
medications, for use by county mental health programs as disseminated
or as modified by the county mental health program, addressing the
probable effects and the possible side effects of the medication.
The following information shall be given orally to the patient:
   (1) The nature of the mental illness, or behavior, that is the
reason the medication is being given or recommended.
   (2) The likelihood of improving or not improving without the
medications.
   (3) Reasonable alternative treatments available.
   (4) The name and type, frequency, amount, and method of dispensing
the medications, and the probable length of time that the
medications will be taken.
   The fact that the information has or has not been given shall be
indicated in the patient's chart.  If the information has not been
given, the designated person shall document in the patient's chart
the justification for not providing the information.  A failure to
give information about the probable effects and possible side effects
of the medication shall not constitute new grounds for release.



5152.1.  The professional person in charge of the facility providing
72-hour evaluation and treatment, or his or her designee, shall
notify the county mental health director or the director's designee
and the peace officer who makes the written application pursuant to
Section 5150 or a person who is designated by the law enforcement
agency that employs the peace officer, when the person has been
released after 72-hour detention, when the person is not detained, or
when the person is released before the full period of allowable
72-hour detention if all of the following conditions apply:
   (a) The peace officer requests such notification at the time he or
she makes the application and the peace officer certifies at that
time in writing that the person has been referred to the facility
under circumstances which, based upon an allegation of facts
regarding actions witnessed by the officer or another person, would
support the filing of a criminal complaint.
   (b) The notice is limited to the person's name, address, date of
admission for 72-hour evaluation and treatment, and date of release.

   If a police officer, law enforcement agency, or designee of the
law enforcement agency, possesses any record of information obtained
pursuant to the notification requirements of this section, the
officer, agency, or designee shall destroy that record two years
after receipt of notification.



5152.2.  Each law enforcement agency within a county shall arrange
with the county mental health director a method for giving prompt
notification to peace officers pursuant to Section 5152.1.



5153.  Whenever possible, officers charged with apprehension of
persons pursuant to this article shall dress in plain clothes and
travel in unmarked vehicles.


5154.  (a)  Notwithstanding Section 5113, if the provisions of
Section 5152 have been met, the professional person in charge of the
facility providing 72-hour treatment and evaluation, his or her
designee, the medical director of the facility or his or her designee
  described in Section 5152, and the psychiatrist directly
responsible for the person's treatment shall not be held civilly or
criminally liable for any action by a person released before the end
of 72 hours pursuant to this article.
   (b) The professional person in charge of the facility providing
72-hour treatment and evaluation, his or her designee, the medical
director of the facility or his or her designee described in Section
5152, and the psychiatrist directly responsible for the person's
treatment shall not be held civilly or criminally liable for  any
action by a person released at the end of the 72 hours pursuant to
this article.
   (c) The peace officer responsible for the detainment of the person
shall not be civilly or criminally liable for any action by a person
released at or before the end of the 72 hours pursuant to this
article.



5155.  Nothing in this part shall be construed as granting authority
to local entities to issue licenses supplementary to existing state
and local licensing laws.



5156.  At the time a person is taken into custody for evaluation, or
within a reasonable time thereafter, unless a responsible relative
or the guardian or conservator of the person is in possession of the
person's personal property, the person taking him into custody shall
take reasonable precautions to preserve and safeguard the personal
property in the possession of or on the premises occupied by the
person.  The person taking him into custody shall then furnish to the
court a report generally describing the person's property so
preserved and safeguarded and its disposition, in substantially the
form set forth in Section 5211; except that if a responsible relative
or the guardian or conservator of the person is in possession of the
person's property, the report shall include only the name of the
relative or guardian or conservator and the location of the property,
whereupon responsibility of the person taking him into custody for
such property shall terminate.
   As used in this section, "responsible relative" includes the
spouse, parent, adult child, or adult brother or sister of the
person, except that it does not include the person who applied for
the petition under this article.



5157.  (a) Each person, at the time he or she is first taken into
custody under provisions of Section 5150, shall be provided, by the
person who takes such other person into custody, the following
information orally.  The information shall be in substantially the
following form:


     My name is ____________________________________________.
     I am a ________________________________________________.
              (peace officer, mental health professional)
     with __________________________________________________.
                          (name of agency)
     You are not under criminal arrest, but I am taking you
     for examination by mental health professionals at _____
     _______________________________________________________.
                        (name of facility)
     You will be told your rights by the mental health staff.

        If taken into custody at his or her residence, the
     person shall also be told the following information in
     substantially the following form:

        You may bring a few personal items with you which I
     will have to approve.  You can make a phone call and/or
     leave a note to tell your friends and/or family where
     you have been taken.

   (b) The designated facility shall keep, for each patient
evaluated, a record of the advisement given pursuant to subdivision
(a) which shall include:
   (1) Name of person detained for evaluation.
   (2) Name and position of peace officer or mental health
professional taking person into custody.
   (3) Date.
   (4) Whether advisement was completed.
   (5) If not given or completed, the mental health professional at
the facility shall either provide the information specified in
subdivision (a), or include a statement of good cause, as defined by
regulations of the State Department of Mental Health, which shall be
kept with the patient's medical record.
   (c) Each person admitted to a designated facility for 72-hour
evaluation and treatment shall be given the following information by
admission staff at the evaluation unit.  The information shall be
given orally and in writing and in a language or modality accessible
to the person.  The written information shall be available in the
person's native language or the language which is the person's
principal means of communication.  The information shall be in
substantially the following form:


     My name is ____________________________________________________.

     My position here is ___________________________________________.


       You are being placed into the psychiatric unit because it is
     our professional opinion that as a result of mental disorder,
     you are likely to:
       (check applicable)
         harm yourself ____
         harm someone else ____
         be unable to take care of your own
         food, clothing, and housing needs ____
       We feel this is true because
     ________________________________________________________________

            (herewith a listing of the facts upon which the
            allegation of dangerous or gravely disabled due
            to mental disorder is based, including pertinent
              facts arising from the admission interview.)

        You will be held on the ward for a period up to 72 hours.
        This does not include weekends or holidays.
      Your 72-hour period will begin ________________________________

                                             (day and time.)
        During these 72 hours you will be evaluated by the hospital
      staff, and you may be given treatment, including medications.
      It is possible for you to be released before the end of the 72
      hours.  But if the staff decides that you need continued treat

        ment you can be held for a longer period of time.  If you are
      held longer than 72 hours you have the right to a lawyer and a
      qualified interpreter and a hearing before a judge.  If you are

      unable to pay for the lawyer, then one will be provided free.

   (d) For each patient admitted for 72-hour evaluation and
treatment, the facility shall keep with the patient's medical record
a record of the advisement given pursuant to subdivision (c) which
shall include:
   (1) Name of person performing advisement.
   (2) Date.
   (3) Whether advisement was completed.
   (4) If not completed, a statement of good cause.
   If the advisement was not completed at admission, the advisement
process shall be continued on the ward until completed.  A record of
the matters prescribed by subdivisions (a), (b), and (c) shall be
kept with the patient's medical record.

Statement by Steven E. Hyman, M.D. Director, National Institute of Mental Health before the
Senate Appropriations Committee
Subcommittee on Labor, Health, and Human Services and Education

Tuesday, February 8, 2000

Mr. Chairman and Members of the Committee, thank you for the opportunity to discuss the tragic public health issue of suicide and the urgent, challenging questions associated with its prevention.

To those not suffering from depression or another mental illness, suicide is fundamentally an incomprehensible act - but for others it is all too real, and it claims the lives of some 30,000 Americans each year: people of every age, both men and women, within every group of our population. The World Bank/World Health Organization-sponsored, Global Burden of Disease study reveals that suicide was the 9th leading cause of death among developed nations in 1990. What happens to these people? How do the neurochemicals and electrical impulses that account for the function of one's brain translate into a decision about death over life? Do the methods and messages of media contribute as precipitants of suicide, or are they potentially useful tools in its prevention?

Studies from the U.S., Finland, Sweden, and the U.K., all find that 90 percent of people who kill themselves have depression or another diagnosable mental or substance abuse disorder. From studies of the prevalence of depression - that is, the number of new and existing cases of depression over a given period of time - and data on the treated prevalence of depression, we can infer that as many as one-third to a half of those individuals with depression who die by suicide likely are undiagnosed or are not receiving adequate and appropriate treatment for this potentially lethal disorder. Although I have specified clinical depression, high rates of suicide also are associated with bipolar disorder, or manic depressive illness, with schizophrenia, and with other mental disorders. Estimates of the number of suicide victims who have had psychiatric treatment in their lifetimes range from 30 to 75 percent. These estimates vary depending on gender, age, their primary psychiatric illness, and where these people lived. A smaller group, 20 to 45 percent, was receiving psychiatric treatment at the time of their deaths that, for many was inadequate. Some suicide victims who were not receiving psychiatric treatment were in contact with primary health care providers. This is particularly true for elderly persons who committed suicide; studies have shown that 70 percent of these individuals were in contact with a primary care provider within a month of their suicide.

Suicide is always tragic; but because it is, in my view, potentially preventable through timely recognition and treatment of mental illness, the tragedy is compounded.

NIMH Activities

I have been asked to describe for you what NIMH is doing to find effective ways of dealing with this very complex behavior. I will describe to you what we have learned about suicidal behavior, and tell you what directions we are heading with regard to suicide prevention efforts.

Before I discuss NIMH's efforts, however, I would like to thank you, Senator Reid, for your unwavering support of suicide prevention efforts for the Nation. Your disclosure of your own family's experience with suicide, your introduction of Senate Resolution 84 a few years ago, your Senate Resolution 99 designating November 20, 1999 as National Survivors for Prevention of Suicide Day, and your support of the first National Suicide Prevention Conference in Reno, which set the stage for our being here today.

I also would like to thank Senator Specter for his leadership in fostering interagency collaborations to deal from a public health perspective with mental health concerns of youth, including violent behavior directed at others and self in the form of suicide.

We appreciate your foresight and determination to tackle these tough, yet approachable, problems. And let me add that I deeply appreciate Dr. Satcher's having taken the initiative to issue his Surgeon General's Call to Action to Prevent Suicide. The credibility of his office and of his own voice has done and will do much to call our Nation's attention to the largely silent epidemic of suicide.

What We Know About Suicide

Obstacles to understanding and preventing suicide notwithstanding, we are continuing to learn a great deal about it.

·         We have made substantial scientific progress by determining that almost all suicidal behavior occurs in the context of a mental disorder. The risk is elevated further when mental disorders are complicated by substance use. These well-documented findings carry significant implications for prevention strategies.

·         We have known for some time that suicide rates vary dramatically by gender and ethnic group in this country. We are just beginning to understand how other risks and protective factors interact with mental disorders and substance abuse in these groups - again, information that is critical to targeting interventions more effectively. Last summer, in conjunction with an NIMH-sponsored statewide conference in Alaska, I traveled to an Alaskan Native village in an effort to better understand the conditions leading to lack of availability of mental health services. More than 95 percent of all rural villages in Alaska cannot be accessed by road and are several hours flying distance from the more populated cities of Alaska. Often, it is impossible to reach these communities due to weather conditions. High rates of unemployment, low education, and poverty render many villages in rural and frontier Alaska vulnerable to family and community violence, suicide and other health and mental health problems. It is not entirely surprising, therefore, that Alaska has the second highest rate of suicide in the nation. In fact, the State ranked second among the 50 states in suicide rates and perennially records nearly double the overall U.S. suicide rate. American Indians/Alaskan Natives, who account for about 16 percent of the state's population, are among the racial/ethnic groups that have the highest suicide rates in the U.S. Among American Indian and Alaskan Natives, suicide rates are 70 percent higher than overall U.S. rates. This is an issue that demands our attention.

·         Perhaps most importantly, our knowledge that mental disorders and substance abuse contribute to suicide risk has helped raise awareness that adequate detection and treatment of mental disorders can truly be a life or death issue. The Surgeon General's Report on Mental Health emphasizes correctly that we must intensify our efforts to address the stigma that surrounds mental disorders in order to get individuals the help they need before it is too late.

What We Know About Risk Factors

Despite the 30,000 lives that suicide claims each year, and despite the searing intensity of the act of suicide - for family members and other survivors, as well as for the victim of an attempted or completed suicide - the relative infrequency of suicide in the population at large was long believed to have stymied attempts to identify specific, reliable risk factors. In fact, we know a considerable amount about risk factors for suicide.

·         The first and most profoundly important risk factor was cited already but bears repeating: From psychological autopsy studies in which a suicide victim's medical, psychological, social history are systematically studied, we have learned that the vast majority - estimated at more than 90 percent - of suicide victims have had a mental and/or substance abuse disorder.

·         Follow-up studies of adults with mental or substance abuse disorders reveal the inordinately high risk of suicide associated with these disorders. Some 30 years ago, Guze and Robins documented that patients who had been hospitalized for affective disorders had an alarmingly high rate of suicide and subsequently estimated that persons with depression had a lifetime risk for suicide of 15 percent. Since their work, numerous other studies have followed other patients with depression - including less severely ill patients who had been treated in outpatient as well as inpatient settings - for longer periods of time. Although the revised estimates from this research are less dismal, the lifetime risk for suicide is still 6 times higher for persons with a diagnosable depression than for a person without the illness. Among persons with schizophrenia, over the typically life-long course of this illness, the risk for suicide is between 4- and 6 percent (Inskip et al, 1998; Fenton et al., 1997), but with risk higher earlier in the course of illness (Inskip et al, 1998). Approximately 7 percent of those with alcohol dependence will die by suicide. Persons with mental disorders who attempt suicide are at significantly elevated risk - 3 to 7 times greater than others with the same illnesses - for eventually completing suicide. In the U.S. population at large, an "average" American, has less than a 1 percent likelihood of dying by suicide.

Clinical risk "profiles" vary by age and gender. For example, among adolescent male suicide victims, the most common profile is depression, complicated by a pattern of problematic behavior at home and in school, including alcohol or other substance abuse, that often leads to isolation and rejection. Among adolescent females, a mood disorder is most likely, with conduct problems and substance abuse less likely. Among older white males-that is, men 55 and older, who comprise the group with the highest rates of suicide, at six times the national average-alcohol use is very infrequent, and a moderately severe, late onset depression is most common. More so than among other age groups, depression in the elderly is often obscured by symptoms of physical illness, and by loss and loneliness that all too often mar late life; thus depression is not recognized or treated adequately.

Ongoing Scientific Efforts

Efforts by NIMH-sponsored investigators to find proven and safe prevention efforts are a work in progress, and one that we strive to promote and nurture. The obstacles to such research are formidable. For one, it is challenging to convince researchers to pursue careers in suicide prevention, given the difficulty of showing a reduction in suicidal behaviors over the typical, 5-year funding period of an intervention study. To demonstrate effects, particularly within this time frame, would require trials of very large size. Also, most researchers who received funding from NIMH for clinical trials traditionally have excluded suicidal patients from clinical trials, as does the pharmaceutical industry, because these patients are seen as too "high risk" and represent potential legal liability. All of these barriers leave little opportunity to judge how effective our treatments are for persons who are suicidal.

Fortunately, attitudes are changing, and clinical researchers appear more optimistic about identifying effective ways of treating suicidal patients. This reflects, in part, remarkable gains in the safety and efficacy of treatments for severe mental disorders such as depressive illness and schizophrenia.

Perhaps more importantly and more critical to the progress that research is making, is the willingness of brave individuals to participate in treatment studies and the unwavering focus of advocacy groups made up of families and friends who have suffered the devastating loss of a loved one to suicide.

We at NIMH and in the larger research community are aware, too, of ethical problems inherent in not studying persons who are suicidal. Thus NIMH is seeking innovative ways to assist and encourage willing researchers and research participants by identifying useful measures of suicidal behavior that can be used in clinical trials, as well as developing some guidelines for consent, monitoring, and crisis protocols.

I am genuinely heartened that leaders such as the members of this Committee and the Surgeon General endorse and actively promote a public health- oriented approach to treating mental disorders. Not only is this the reasonable and effective thing to do, but it also provides the research community with opportunities to look more broadly and over longer periods of time at treatment outcomes, which should improve our assessment of how effective treatments and preventive efforts are at reducing suicidal behaviors.

Different Risk Factor Profiles

Because different age and gender groups seem to have different risk factor profiles, I will describe our current treatment and prevention efforts for reduction of suicidal behavior within specific age groups.

Youth Suicide:

·         In the area of school-based suicide awareness programs, we have learned a very important lesson: That it is critical to evaluate prevention programs. Despite good intentions to raise awareness of suicide and its risk factors among youth in schools, few programs have been evaluated to determine if, indeed, they are effective at reducing suicide. And more to the point, of those relatively few programs that were evaluated, none has proven to be effective. In fact, some programs have had unintended negative effects by making at-risk youth more distressed and less likely to seek help. By describing suicide and its risk factors, some curricula may have the unintended effect of suggesting that suicide is an option for young people who have some of the risk factors and in that sense "normalize" it - the very opposite of what we should be trying to do. Many school districts, worried about liability issues, are purchasing suicide counseling packages from entrepreneurs seeking "quick fixes" to prevent suicides. Unfortunately, most of these programs have not been evaluated, and we are very concerned about potential risks associated with participation in suicide prevention programs that have not been subject to rigorous evaluation. Because of the tremendous effort and cost involved in starting and maintaining programs, we should be certain that they are safe and effective before they are further used or promoted.

·         There are a number of prevention approaches that are less likely to have negative effects, and to have positive outcomes beyond that of reducing risk for suicide. One approach is to promote overall mental health among school-aged children by addressing early risk factors for depression, substance abuse and aggressive behaviors. In addition to the potential for saving lives, many more youth benefit from overall enhancement of academic performance and healthy peer and family relationships.

·         A second approach is to detect youth most likely to be suicidal by identifying those who have depression and/or substance abuse, combined with serious behavioral problems. Events such as recent tragic shootings in schools and other settings that capture public attention and concern are not typical of youth or adult violence, including suicide, but have focused the nation's attention on these important issues. By focusing research attention on high-risk groups, researchers have learned much about depression, substance abuse and frequently co-occurring aggressive and violent behavior. Studies have shown that all of these problems share similar risk factors and processes - that is, the same experiences and influences act to increase risk for these problems. One might reason that comprehensive programs designed to reduce these risks also will reduce the often tragic outcomes, including suicide, that often are associated with such problems. Community efforts, involving parents, school systems, law enforcements officials, and other resources must communicate and work together to provide supportive, seamless treatment for youth with mental disorders. A report of preliminary findings from one NIMH grantee who is refining a family-based treatment approach for reducing conduct disorder in adolescents notes a reduction in suicidal behaviors - both suicidal thoughts, or ideation, and actual attempts - as well as reductions in aggression towards others.

Adult Suicide:

Most of the prior and current research on suicide prevention in adults has focused on those with the highest risk of suicide - those who have made repeated suicide attempts. A few clinical research groups in the U.S., Europe, and Australia have evaluated interventions that include both medications and psychotherapy, but many of the studies did not have adequate numbers of patients to determine with any degree of certainty whether the intervention was truly effective. Fortunately, increasing numbers of researchers are becoming interested in developing treatments for such high-risk patients. Adults in the treatment system who report high rates of suicide attempts include women with borderline personality disorder; men and women with depression who also abuse drugs or alcohol; and men and women with bipolar depression. At present, NIMH is collaborating with the Centers for Disease Control and Prevention (CDC) to support a treatment trial with suicide attempters who appear at an inner city emergency room. In this study, specially trained therapists will work immediately with these individuals to address their hopelessness and depression, and also to help them obtain necessary treatments for their substance abuse disorders. This immediate, on-the-spot, high-intensity intervention will be compared to the treatment such individuals normally receive. If proven effective, our next step will be to disseminate the intervention strategy widely.

As you may be aware, NIMH has embarked on several large, clinical trials-for bipolar disorder, treatment resistant depression, adolescent depression, and best use of new antipsychotic medications. The reason for these efforts is to improve our knowledge about treatments for patients in the "real world"-those with co-occurring mental and substance abuse disorders and other, general medical illness; young and older people; and other persons who typically are encountered in diverse treatment settings. All of the trials will involve large numbers of participants - from about 430 for the study of adolescent depression, to more than 2,000 patients who will be involved in the evaluation of sequenced treatment alternatives for resistant depression. It is highly likely that there will be patients in these trials who will become suicidal. NIMH is assisting the researchers to plan and provide a high level of monitoring and care for such patients; our hope is that with adequate safeguards, fewer of these potentially suicidal patients will be excluded from the trials, more patients will be helped with the treatments being tested, and in the end, more will be learned about effective treatments for these patients.

Up to two thirds of all patients who commit suicide have seen a physician in the month before their death. However, in few adult suicide victims is a mental disorder detected, and among those, treatment is usually inadequate. Training health care professionals, particularly those in the primary care sector, to treat recognize and treat or refer mental disorders appropriately is an urgent order of business if we are to reduce suicides. No less important - and, again, a challenge to the Nation that Dr. Satcher issues most compellingly in the Surgeon General's Report on Mental Health, is to combat the stigma attached to mental disorders and to encourage persons to seek treatment for mental disorders.

Suicide Among Older Adults

Among older adults - and, particularly, among older white males - late onset depression is the mental disorder most commonly associated with suicide. This form of depression, which typically is uncomplicated by substance abuse, is among the more readily treatable depressive disorders. Yet older persons at risk for suicide, like the majority of older adults in this country, tend not to seek mental health treatment. Rather, most have seen their primary care provider within the month, if not the week, of their death.

In response to this finding, NIMH issued a request for applications (RFA) for grant support to test more effective approaches to detecting and treating depression in older adults in primary care settings. I am pleased to report that we have awarded a grant for a very promising collaboration involving three of our clinical intervention centers. Termed PROSPECT, for Prevention of Suicide in Primary Care Elderly: Collaborative Trial, this project will assess the degree to which physicians can be trained and assisted to improve detection and treatment of depression in 6 primary care clinics, and compare them to 6 "usual care" clinics. This study complements a multi-site trial supported by the John A. Hartford foundation, where comparable outcome measures will be used across all sites.

Several researchers who are involved in the PROSPECT study also are participating in a collaborative study of Aging, Mental Health, Substance Abuse and Primary Care. This cross-agency initiative involves the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration, and the Veterans Administration. The design and nature of our collaboration allows comparable measures to be used across many primary care sites. Results from this research should lead to a clearer picture of why and when older adults slip through the system without obtaining the care they need for mental disorders.

What Remains To Be Done

Although we yet have an immense amount to learn about risk reduction and prevention of suicide, we should be encouraged, I feel, by the fact that we can spell out with some certainty next steps in research. Let me suggest several of these.

One, we are increasingly hopeful that we will find effective treatments for persons at greatest risk for suicide (those who have already made a suicide attempt). But we have much more to learn about how effective treatments - both medications and psychotherapies - may reduce both the short- and long-term suicide risks for persons with depression, schizophrenia, and anxiety disorders. Early findings suggest, for example, that the new antipsychotic medications appear to reduce suicidal ideation in some treatment trials for persons with schizophrenia. Greater numbers of prescriptions of newer antidepressant drugs have been associated with lower rates of suicide in Sweden.

Two, we must encourage more investigators in more treatment studies to include more - and consistent - measures of suicidal behavior. Resulting data will help investigators think through treatment strategies that allow patients who become suicidal to be treated safely and returned to study trials.

We need to be more creative in devising tools and strategies to detect those at risk for suicidal behavior. Persons outside the mental health treatment system - for example, those who engage in domestic violence, who are failing in school or social relationships, or who are substance abusers - may benefit from consultation with a trained professional and, in some instances, may benefit from treatments at a time when they will be most effective.

Three, we need to better understand if and how prevention efforts aimed at preventing or reducing aggression, hyperactivity, depression, psychoses, and substance abuse also reduce the risk for suicidal behavior. This information is desperately needed by schools and communities with limited resources. We need to understand the most efficient, effective, and sustainable approaches to meet these goals.

Fourth, we need to encourage more minority investigators to pursue research in this area, in part to help us to understand better how "protective factors" work. For example, African American women have among the lowest rates of suicide, although they have mental disorders at rates comparable to those experienced by white women. It is important to understand the factors that protect one from suicide. We also need to examine differential suicide rates among other ethnic groups. As I mentioned earlier, American Indians/Alaskan Natives, who account for about 16 percent of Alaska's population, are among the racial/ethnic groups that have the highest suicide rates in the U.S. Among American Indian and Alaskan Natives, suicide rates are 70 percent higher than U.S. rates.

Conclusion

Mental disorders and substance abuse disorders - alone and co-occurring - are the major risk factor for allowing human beings to overcome one of nature's most compelling instincts--the urge to survive. Why do people kill themselves? We urgently need to know more. We are grateful that with the support of many people, our society is increasingly willing to address and resolve the legal and ethical issues surround clinical investigations on this topic and that for too long have been permitted to unduly complicate knowledge development. With the help of dedicated scientists, wise policy leaders, the courage of those affected by mental and substance abuse disorders, and the committed advocacy of those who genuinely care about these tragedies, we have learned a tremendous amount, and we will continue to learn more.

Thank you.