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[Senate Hearing 106-940]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 106-940

                    SUICIDE AWARENESS AND PREVENTION

=======================================================================

                                HEARING

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                       ONE HUNDRED SIXTH CONGRESS

                             SECOND SESSION

                               __________

                            SPECIAL HEARING

                    FEBRUARY 8, 2000--WASHINGTON, DC

                               __________

         Printed for the use of the Committee on Appropriations

 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

                                 ______

                    U.S. GOVERNMENT PRINTING OFFICE
63-275 cc                   WASHINGTON : 2001
_______________________________________________________________________
            For sale by the U.S. Government Printing Office
Superintendent of Documents, Congressional Sales Office, Washington, DC 
                                 20402

                      COMMITTEE ON APPROPRIATIONS

                     TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi            ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania          DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico         ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington             FRANK R. LAUTENBERG, New Jersey
MITCH McCONNELL, Kentucky            TOM HARKIN, Iowa
CONRAD BURNS, Montana                BARBARA A. MIKULSKI, Maryland
RICHARD C. SHELBY, Alabama           HARRY REID, Nevada
JUDD GREGG, New Hampshire            HERB KOHL, Wisconsin
ROBERT F. BENNETT, Utah              PATTY MURRAY, Washington
BEN NIGHTHORSE CAMPBELL, Colorado    BYRON L. DORGAN, North Dakota
LARRY CRAIG, Idaho                   DIANNE FEINSTEIN, California
KAY BAILEY HUTCHISON, Texas          RICHARD J. DURBIN, Illinois
JON KYL, Arizona
                   Steven J. Cortese, Staff Director
                 Lisa Sutherland, Deputy Staff Director
               James H. English, Minority Staff Director
                                 ------                                

 Subcommittee on Departments of Labor, Health and Human Services, and 
                    Education, and Related Agencies

                 ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi            TOM HARKIN, Iowa
SLADE GORTON, Washington             ERNEST F. HOLLINGS, South Carolina
JUDD GREGG, New Hampshire            DANIEL K. INOUYE, Hawaii
LARRY CRAIG, Idaho                   HARRY REID, Nevada
KAY BAILEY HUTCHISON, Texas          HERB KOHL, Wisconsin
TED STEVENS, Alaska                  PATTY MURRAY, Washington
JON KYL, Arizona                     DIANNE FEINSTEIN, California
                                     ROBERT C. BYRD, West Virginia
                                       (Ex officio)
                           Professional Staff
                            Bettilou Taylor
                             Mary Dietrich
                              Jim Sourwine
                        Ellen Murray (Minority)

                         Administrative Support
                             Kevin Johnson
                       Carole Geagley (Minority)

                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening statement of Senator Arlen Specter.......................     1
Statement of David Satcher, M.D., Ph.D., Assistant Secretary for 
  Health and Surgeon General, Office of Public Health and 
  Science, Department of Health and Human Services...............     2
    Prepared statement...........................................     4
Statement of Steven Hyman, M.D., Director, National Institute of 
  Mental Health, National Institutes of Health, Department of 
  Health and Human Services......................................     7
    Prepared statement...........................................     9
Opening statement of Senator Harry Reid..........................    14
    Prepared statement...........................................    15
Opening statement of Senator Paul Wellstone......................    16
Statement of John Mann, M.D., chairman, Scientific Council of the 
  American Foundation for Suicide Prevention.....................    18
Statement of John Fildes, M.D., medical director, University of 
  Nevada Medical Center Trauma Unit..............................    19
Statement of Kay Redfield Jamison, Ph.D., professor of 
  psychiatry, Johns Hopkins University...........................    21
Statement of Susan Blumenthal, M.D., M.P.A., Assistant Surgeon 
  General and Senior Science Advisor, Department of Health and 
  Human Services.................................................    23
Statement of Hon. Nancy Pelosi, U.S. Representative from 
  California.....................................................    30
Statement of Danielle Steel, best-selling novelist and author of 
  ``His Bright Light''...........................................    31
    Prepared statement...........................................    35
Statement of Jade Smalls, Evanston, Illinois, first runner-up, 
  1999 Miss America Pageant......................................    37
    Prepared statement...........................................    40
  

 
                    SUICIDE AWARENESS AND PREVENTION

                              ----------                              

                       TUESDAY, FEBRUARY 8, 2000

                           U.S. Senate,    
    Subcommittee on Labor, Health and Human
     Services, and Education, and Related Agencies,
                               Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 9:30 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Arlen Specter (chairman) 
presiding.
    Present: Senators Specter, Reid, and Wellstone.

               OPENING STATEMENT OF SENATOR ARLEN SPECTER

    Senator Specter. The hour of 9:30 having arrived, the 
Subcommittee on Labor, Health and Human Services, and Education 
will proceed with this hearing.
    Our subject today is suicide awareness and prevention. The 
hearing has been convened at the special request of our 
distinguished colleague, Senator Harry Reid, who has had a 
personal family involvement with the matter and offered a 
Senate resolution which called for a national suicide 
prevention strategy.
    Suicide certainly is a major problem in the United States, 
claiming some 31,000 lives annually, contrasted with homicide 
which claims 20,000 victims. There is a very high incidence 
among juveniles and it is an issue which has not been 
adequately addressed either in terms of national awareness or a 
strategy for prevention.
    Dr. David Satcher, our distinguished Surgeon General, has 
done extensive work in the field, as has Dr. Steven Hyman, 
Director of the National Institute of Mental Health. And the 
Surgeon General's recommendations last year in a Call to Action 
listed some 15 recommendations focused on the general topics of 
awareness, intervention and methodology.
    We have, in addition, a distinguished panel of scientists, 
and we have Ms. Danielle Steel, best-selling novelist, whose 
19-year-old son committed suicide in 1997, and Ms. Jades 
Smalls, first runner-up to the 1999 Miss America Pageant. So, 
the combination of our witnesses provides both a scientific 
background and the so-called human face on the problem to 
create awareness which should lead to a strategy for 
prevention.
    We have a very long list of witnesses, and we are going to 
have to conclude the hearing shortly in advance of 11 o'clock 
this morning because this is a very crowded schedule. Our 
custom is to allow witnesses to testify for 5 minutes. Our 
professionals, Dr. Satcher and Dr. Hyman, are used to that even 
though they bring learned treatises with them for insertion 
into the record, but they are masters of the summary at this 
point in their professional careers.
    I know a number of my colleagues will be joining us in due 
course, but we will proceed at this time because of our tight 
schedule and commitments.
STATEMENT OF DAVID SATCHER, M.D., Ph.D., ASSISTANT 
            SECRETARY FOR HEALTH AND SURGEON GENERAL, 
            OFFICE OF PUBLIC HEALTH AND SCIENCE, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
    Senator Specter. Our first witness is Dr. David Satcher, 
16th Surgeon General of the United States, only the second 
person in history to simultaneously hold the positions of 
Surgeon General and Assistant Secretary of Health. Before 
joining the administration, he was president of Meharry Medical 
College of Nashville, Tennessee for more than a decade, 1982 to 
1993.
    The biographical sketch does not include the observation of 
Dr. Koop who said that the Surgeon General was the only 
individual who was both a general and an admiral.
    I think you prefer the title Dr. Satcher, and the floor is 
yours.
    Dr. Satcher. That is fine. Thank you.
    Thank you very much, Senator Specter, for this opportunity 
to testify and for holding this very important hearing on 
suicide.
    Let me just say, as you have pointed out, that suicide is, 
indeed, a very serious public health problem in this country. 
It is the eighth leading cause of death and the third leading 
cause of death among youth and young adults. The highest rate 
of suicide is among men, in fact, men over 75 years of age.
    But it is important to point out that suicide is a problem 
that affects all ages, all races, and all ethnic groups. For 
example, while it was once thought that suicide was not a 
problem with African Americans, very clearly that is not true 
and has never been true. The rate of suicide in young black 
males has doubled between 1980 and 1996. So, the concern for 
suicide in all of our populations, I think, is a very real one.
    As you pointed out also, most people are surprised to hear 
that for every two people who are killed by homicide in this 
country, three people take their own lives.
    I think the stigma that is associated with suicide has kept 
us from addressing this issue directly until now, and that is 
why this hearing is so important.
    I want to thank people like Dr. Kay Jamison and especially 
Elsie and Jerry Weyrauch and SPAN, Senator Reid, and other 
members of your panels today who have been willing to speak out 
about their own tragic experiences. And I know it has been 
painful because I have heard from many survivors of suicide the 
struggles that they go through. So, their willingness to speak 
out and to provide leadership is really making a difference in 
this area.
    The Nation is now engaged in an open dialogue on suicide, 
and through this hearing we hope to gain a better understanding 
of the public health problem, but also to gain support for 
completing a national suicide prevention strategy.
    The national strategy that we are proposing is closely 
linked to international efforts. Work by the World Health 
Organization, the World Bank, and the Harvard School of Public 
Health produced data in 1996 pointing out that mental health 
problems were the second leading cause of disability and 
premature deaths in the world for industrialized countries, the 
second, second only to cardiovascular diseases. WHO called on 
countries throughout the world to develop strategies to address 
the problem of suicide.
    Because of this and because of the backing of organizations 
like SPAN, we called a meeting in Nevada in October 1998 to 
look at the problem of suicide, and we called together experts 
in the field, clinicians, survivors, and advocates to spend 3 
days in Reno, Nevada discussing this problem. As a result of 
that, we developed the Surgeon General's Call to Action for 
Suicide Prevention.
    Basically, the recommendations in the Call to Action are 
divided into three areas.
    One, we think it is critical that we increase the awareness 
of suicide in this country as a first step toward de-
stigmatization, and not only suicide, but the awareness of the 
mental health problems which lead to suicide. So, a major set 
of recommendations relate to increasing awareness.
    The second area is intervention. We believe that there are 
tremendous opportunities to improve the services and the 
programs in this country that could lead to a reduction in 
suicide. These are programs to enhance the mental health 
infrastructure, which starts with educating people in general.
    The third category is methodology. We believe that we must 
continue to advance the science of understanding of suicide but 
also of suicide prevention.
    So, out of this Call to Action, we have been busy within 
the Department. A team of people have been working over the 
last several months developing recommendations for a national 
strategy. There are at least 20 States in the country that are 
working on plans for their own strategy for suicide prevention. 
We have been able to visit many of these States, many local 
programs in the country, and people are working very hard to 
develop strategies.
    Of our recommendations, we believe the most important one 
is this recommendation for the development of a national 
strategy that actually calls for a public/private partnership. 
It calls for not a Federal program but a national program, a 
program in which we relate to different levels of government, 
but we also look to communities throughout this country and 
organizations in communities like churches and schools and 
fraternities and criminal justice programs and others to work 
together to develop the infrastructure requirement for a 
prevention program.
    There are two basic approaches.
    One, we have to reduce the barriers to the effective 
identification and treatment----
    Senator Specter. Dr. Satcher, I am sorry to interrupt you, 
but we are going to have to observe the time very meticulously. 
So, if you would finish your current thought, we are going to 
move on.
    Dr. Satcher. OK.
    This is the Surgeon General's report, mental health report, 
and basically it recommends reducing the barriers to effective 
identification.
    The second this is CDC is funding many efforts and 
partnering with many groups for suicide prevention using a 
model that has been used by the Air Force that has been very 
successful.

                           PREPARED STATEMENT

    So, we are recommending, of course, that we move forward. 
We have a meeting scheduled in March of outside experts to meet 
with us and give their input, and then later in the year we 
will have a major meeting of partners throughout the country to 
see where we are. We hope by the end of the year to be prepared 
to present a recommendation for a national strategy for suicide 
prevention.
    [The statement follows:]
                  Prepared Statement of David Satcher
    Chairman Spector, Senator Reid, I am pleased to be here today to 
participate in this historic hearing, advancing the discussion of 
suicide prevention in America.
    Suicide is a serious public health problem. It results in over 
30,000 premature deaths each year. In 1997, the most recent year 
statistics are available, suicide was the eighth leading cause of 
mortality in the United States and the third leading cause of death 
among youth and young adults [10-24 year olds]. Men aged 75 years and 
older actually had the highest rate of suicide of any group. Indeed, 
suicide is a national problem that affects people of all ages, races 
and ethnic origins.
    When we compare the incidence of suicide with that of homicide, 
most people are surprised to learn that suicide is by far the greater 
killer. In fact, for every two deaths by homicide in the U.S. there are 
three deaths due to suicide. And if a person dies by a firearm, that 
death is one-third more likely to have been a suicide than a homicide.
    Because of the stigma too long associated with mental illness and 
suicide, we, as a nation, have been reluctant to talk openly about this 
threat to our health and well being. We owe a great debt of gratitude 
to concerned individuals, such as: Dr. Kay Redfield Jamison, author of 
Night Falls Fast; important groups such as SPAN, the Suicide Prevention 
Advocacy Network, and its founders Elsie and Jerry Weyrauch; you, 
Senator Reid, as a leader on this issue in the Senate; and to many 
others who have stepped forward to speak out about their own personal 
loss to suicide; and more importantly, to take action to prevent loss 
of life due to this terrible killer. I am extremely pleased that we are 
now engaging in an open national dialogue on the issue of suicide. The 
goal of the discussion, of course, is an outcome we all desire--
measurable and significant decreases in deaths and suffering due to 
suicide and suicidal behavior--decreases which will be sustainable over 
the long term.
    I trust that through this hearing today, we will all gain a greater 
understanding of the scope of suicide as a public health problem and 
garner significant, official, and broad support for the work of 
completing a National Suicide Prevention Strategy.

              WHY A NATIONAL SUICIDE PREVENTION STRATEGY?
    Our goal of developing a National Strategy is linked closely with 
international suicide prevention efforts. In 1996, the World Health 
Organization, recognizing that mental illness, including suicide, ranks 
second in the burden of disease in established market economies, urged 
member nations to address suicide [WHO document: ``Prevention of 
Suicide: Guidelines for the Formulation and Implementation of National 
Strategies.''] In the past few years, Australia, Denmark, Finland, 
Norway, Sweden, New Zealand, and the UK have developed national suicide 
prevention strategies. The WHO has established its own suicide 
prevention task force to encourage national policies promoting suicide 
prevention around the world and to evaluate WHO efforts to reduce 
mortality associated with suicide. This progress in the international 
community has contributed momentum to the considerable efforts already 
underway in our own country.
    We now understand that many suicides and intentional, self-
inflicted injuries are indeed preventable. Just over six months ago, I 
issued a National Call to Action to Prevent Suicide. In that Call, I 
introduced a blueprint for addressing suicide represented by the 
acronym A-I-M, which stands for Awareness, Intervention, and 
Methodology.
  --``Awareness'' signifies our commitment to broaden the public's 
        awareness of suicide and its risk factors.
  --``Intervention'' means we will enhance services and programs, both 
        population-based and clinical care to reduce suicide.
  --And ``Methodology'' compels us to advance the science of suicide 
        prevention.
    Awareness, Intervention, Methodology--AIM--this framework for 
suicide prevention stems from work begun through a significant public-
private partnership involving the Department of Health and Human 
Services, which brought together researchers, clinicians, survivors and 
advocates, and various federal and state agencies in Reno, Nevada, a 
little over a year ago. Empowered by that first-of-its-kind meeting, 
grassroots organizers--many of whom are suicide survivors--have joined 
with state public health officials and others in at least 20 states to 
begin planning state level prevention efforts. Many are now working 
with their state legislatures in the appropriations process for these 
programs.
    I can think of no other issue with which I've been involved that 
has produced so large and so positive an outpouring of public support. 
Since issuing the Call to Action, countless people have spoken or 
written to me, sharing their grief from their own experiences with 
suicide and telling me how they are getting involved in the suicide 
prevention movement.
    I think it is critically important for those of us working this 
issue at the Federal level to fully appreciate this passionate 
groundswell for suicide prevention. Today, we have a tremendous 
opportunity to provide national leadership that will guide this 
outpouring of energy to productive ends.
    The AIM blueprint identifies 15 key recommendations that will do 
just that. Perhaps the most important of AIM's recommendations is the 
mandate to complete a comprehensive National Suicide Prevention 
Strategy. It is this comprehensive Strategy that will direct the Nation 
at the federal, regional, state, tribal, and community levels to a 
collaborative, comprehensive, coordinated response to suicide.
    Our National Suicide Prevention Strategy will outline a conceptual 
framework and courses of action to guide, promote, and support 
culturally appropriate, integrated programs for suicide prevention 
among Americans.
    I should stress that a National Strategy is not a federal-only or 
even a federally-driven project. To the contrary, a National Suicide 
Prevention Strategy must foster the myriad public-private partnerships 
necessary for effective suicide prevention in every community. We 
envision a Strategy that will define and produce an infrastructure that 
supports communities in their prevention efforts through consultative 
services, sharing of best practices, data gathering, and perhaps most 
important, program evaluation. With these supports in place, community 
level agencies and organizations will collaborate in new and more 
effective ways to mitigate the risk factors associated with suicide, as 
well as strengthen putative factors that protect people from suicidal 
risk.
    Research shows that many people who kill themselves have a mental 
or substance abuse disorder, or both. For this reason, removing the 
stigma associated with mental illness and its treatment must play a 
central role in the Strategy. In December, I released ``Mental Health: 
A Report of the Surgeon General'', the first report ever released by a 
Surgeon General addressing mental health. The report identified 
critical gaps between those who need mental health services and those 
who actually receive them. It also identified significant gaps between 
optimally effective treatment and what many individuals receive in 
actual practice settings. Clearly, we have much work to do to remove 
the barriers to optimal mental health service delivery in the United 
States.
    Suicide has multiple intersecting causes and risk factors, so 
effective prevention programs must be comprehensive in addressing 
individual, family and community-level factors. It will require 
engagement by dozens, and in some instances literally hundreds of 
stakeholders in each community: schools, faith-based groups, social and 
housing services, law enforcement, justice, youth and civic 
organizations-just to name a few. In addition to reducing risk factors, 
these community agents will play significant roles in enhancing the 
protective factors to which I just referred. These protective factors 
may be those pertaining to the individual, like resilience, 
resourcefulness, help-seeking, respect, and nonviolent conflict 
resolution skills, or those pertaining to communities, like 
interconnectedness, social support, and social services.
    We now have one example of a large-scale community-based program 
that appears to have been successful in reducing suicides. For the past 
five years, the United States Air Force has consciously promoted these 
protective factors among Air Force members and the Air Force community. 
During those same five years, the suicide rate among airmen has 
declined each year, from 16.4 down to 5.6 per hundred thousand-a 
decline of over 65 percent. The 1999 suicide rate in the Air Force was 
40 percent lower than any level recorded in the past two decades, and 
about one-fourth the national suicide rate when corrected for age, sex, 
and race. Similar declines did not occur in the other military 
services. We need to evaluate this program further to understand the 
contribution of its various components.
    CDC, working closely with states, communities, universities, 
partners in the private sector and others, has contributed in a number 
of areas to improve our understanding of suicide prevention efforts 
such as this one. For example, CDC is supporting the development of a 
suicide-prevention research center that will describe the magnitude of 
suicidal behavior, promote research, and identify prevention 
activities. In addition, CDC has funded two suicide prevention 
evaluation projects: one to enhance awareness, increase utilization, 
and assess the efficacy of telephone crisis intervention services for 
teenagers and the other to develop intervention services for adults 
over 65. CDC has also conducted a study of nearly lethal suicide 
attempts to investigate, among other things, the role of alcohol use 
and abuse, the results of which indicate that alcohol use within the 
three hours before an attempt are important risk factors for suicidal 
behavior.
    SAMHSA, through its Centers for Mental Health Services and 
Substance Abuse Treatment, is providing grants to schools and community 
organizations that have provided a plan to build consensus around and 
pilot an evidence-based program to promote healthy development and 
prevention of youth violence, including suicide. Last year funds were 
granted to 40 such organizations across the country. A new Guidance for 
Applications (GFA) will be out this spring for School Action Grants 
that will have a special emphasis on the prevention of youth suicide.
    By coupling public health interventions with disciplined research 
in the primary prevention and treatment of mental illness, we can 
reasonably expect to prevent premature deaths due to suicide throughout 
the life span, while reducing other suicidal behaviors, such as 
attempts and gestures, as well. And consequently, we will reduce the 
trauma these suicidal behaviors inflict upon families, friends and 
others in significant relationships with the suicide victims. But it 
will do still more. I believe investments in suicide prevention are 
really investments in human and social capital. The social scientists 
teach us that these investments produce wide-ranging dividends 
throughout society and achieve improvements in overall function, 
resiliency, safety and health that would not otherwise be possible.
    At this point, I'd like to talk about the progress we are making 
toward completing the National Strategy. Since releasing the Call to 
Action, a cross-cutting team of suicide prevention experts from several 
agencies within the Department of Health and Human Services has mapped 
out a systematic process that will ensure timely completion of the 
strategy. With leadership from SAMHSA, we will be bringing together the 
most knowledgeable people from outside the federal government to work 
with our DHHS team on the issue. These are experts with vast experience 
in not only suicide prevention, but also the clinical and social 
sciences, criminal and juvenile justice, public policy, business, and 
occupational health. Their primary responsibility will be to help 
translate the 15 recommendations in the Call to Action into specific 
goals and measurable objectives. Following this, a process to gather 
inputs from major stake-holders at the national, state, and local 
levels will identify activities to ensure each objective is achieved. 
At every step, we will draw on the collective expertise and wisdom of 
persons from many backgrounds and life experiences: scientists, 
prevention experts, survivors, program planners and evaluators, 
consumers of mental health services, justice experts, clinicians, 
public health leaders, educators, social services professionals, and 
religious leaders. Diversity among prevention partners should produce a 
Strategy that ensures continued investment and collaboration throughout 
the implementation phase. I am proud to tell you that we are on 
schedule to have a strategy ready for the American people before the 
end of this calendar year.
    Before I conclude, I should point out that most of the activities 
in the National Strategy will be implemented at the community level 
through existing structures. Settings such as schools, workplaces, 
clinics, physician's offices, correctional and detention centers, 
eldercare facilities, religious institutions, recreational centers, and 
community centers are natural venues for integrated suicide prevention 
activities. In fact, in many communities, several of these formal 
agencies are already committed to preventing suicides. The National 
Strategy will ensure each of these community components assumes an 
effective role in preventing suicides, and does so in a fashion that is 
tailored to the unique characteristics of their community. When this 
happens, we can expect further improvements in health and well being to 
emerge in every segment of the American population. I believe this 
collaborative community effort will have an exponential effect; that 
is, the overall improvements in community health will be far greater 
than the sum of the contributions of the individual agencies, programs, 
or interventions.
    Am I optimistic? Yes, I am. We are witnessing a convergence of 
research, practice, recognition, political will and strong grassroots 
commitment that has the potential to produce historic public health 
breakthroughs in suicide prevention. Since the mid-90's, we are seeing 
small but steady declines in suicide rates among some of our highest 
risk populations: males, both Caucasian and African-American, among 
both the elderly and youth. Interestingly, these declines appear to be 
almost entirely attributable to declines in firearm suicides. Still, 
nearly 60 percent of all suicides are attributable to firearms, and in 
men over 65, that figure is an astonishing 77 percent. These small 
declines in suicide rates, though encouraging, pale in comparison to 
the steep increases seen between 1980 and 1996 among young males, when 
for instance, the suicide rate among black males aged 15-19 increased 
105 percent.
    I would like to conclude by saying that the time is right-the 
opportunities are plentiful. The National Suicide Prevention Strategy 
will chart the course for the fruitful collaboration of government, 
advocates, communities and families, energized by the opportunity to 
realize what for many has been a long-cherished dream-real and 
sustainable decreases in the devastating consequences of suicide in our 
society.
    Thank you Mister Chairman, Senator Reid, and members of the 
committee. Again, it is very gratifying to be participating in this 
hearing today. This concludes my remarks.

    Senator Specter. Thank you very much, Dr. Satcher.
STATEMENT OF STEVEN HYMAN, M.D., DIRECTOR, NATIONAL 
            INSTITUTE OF MENTAL HEALTH, NATIONAL 
            INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH 
            AND HUMAN SERVICES
    Senator Specter. Our next witness is the distinguished 
Director of the National Institute of Mental Health, Dr. Steven 
Hyman. He has a bachelor's from Yale, masters from Cambridge, 
an M.D. from the Harvard Medical School. Prior to coming to 
NIMH, Dr. Hyman was professor of psychiatry at the Harvard 
Medical School and director of psychiatry research at 
Massachusetts General.
    I might note that the increase for the National Institute 
of Mental Health went up by some more than $123 million to an 
excess now of $633 million. In the last 3 years, Senator Harkin 
and I have taken the lead to add more than $5 billion to NIH 
funding, and yesterday we introduced a resolution with many 
cosponsors to raise National Institutes of Health funding by 
some $2.7 billion. We believe NIH is the crown jewel of the 
Federal Government. That may be the only jewel of the Federal 
Government.
    Dr. Hyman, the floor is yours.
    Dr. Hyman. Mr. Specter, you even understated the number 
that you have been generous enough to give us. We now have a 
budget, including AIDS research, of about $975 million, and for 
that we thank you and your colleagues for your support and we 
hope to be worthy of that.
    I also want to thank you because it was clear in a series 
of meetings that you conducted last year that you have taken an 
important role in putting such subjects as youth suicide and 
youth violence in the proper public health context, and this is 
very much appreciated.
    I also want to thank David Satcher who is the first Surgeon 
General to take these issues with this kind of very important 
seriousness, and it is a privilege to be here with him.
    We are all going to talk a little bit about the numbers in 
suicide, but they are absolutely staggering. I have put up a 
chart here just charting youth suicide rates because my 
colleague here emphasized, just due to the time, rates in the 
elderly.
    But what you can see is that since the mid-1960's rates of 
youth suicide have doubled until they have more recently 
plateaued, and since the 1950's--the chart just was not long 
enough--rates of youth suicide have actually tripled. It is now 
the case that among youth suicide is responsible for more than 
two times as many deaths as all natural causes combined. So, 
this indeed is an enormous national tragedy and national public 
health problem.
    I also want to acknowledge Senator Reid who, of course, has 
had an enormous impact on our suicide focus.
    In addition, in some populations, such as Alaska Natives 
and some Native American tribes, the suicide rate among youth 
is 10 times the national average, so there are some 
extraordinary problems here.
    Now, suicide is a complex phenomenon. We know--and I am not 
going to dwell on this--it involves genes as well as 
experience, but these genes are not fate. In other words, there 
are things that we can do to intervene in the course of mental 
illness and genetic predisposition to prevent and make a 
difference in suicide.
    NIMH and other research has shown that, in the United 
States and in many other countries, more than 90 percent of 
suicides reflect a mental illness, especially depression, often 
together with alcohol abuse, manic depressive illness, and also 
schizophrenia and borderline personality disorder. Just by 
naming these diagnoses, it suggests that there are 
interventions. But unfortunately, there are obstacles to 
interventions.
    In children, we have inadequate knowledge as to the safety 
and efficacy of antidepressant treatment. The NIMH is trying to 
address this. We initiated a year ago a very large scale, 
multi-center trial in the treatment of adolescent depression, 
but we still do not have in the United States an adequate 
research infrastructure to study antidepressants in younger 
children when depression often begins and we are working on 
this.
    In addition, there are other obstacles. Many studies of 
depression have actually excluded suicidal individuals because 
of ethical issues and liability issues, and we want to be 
working with some of the foundations represented here to come 
up with ethical and legal guidelines so that people who are 
suicidal will be included in treatment trials so that we will 
have precise knowledge as to how to intervene best when people 
are suicidal.
    Even where we have knowledge, however, there are tragic 
gaps. I think it is well known that more than 70 percent of 
elderly males who commit suicide saw a primary care physician 
in the last month of their life. Clearly, there is an enormous 
disconnect. We have been attempting, through research, to 
understand how to close this gap. One important multi-center 
trial called PROSPECT which is being conducted at the 
University of Pennsylvania, the University of Pittsburgh, and 
at Cornell--sorry, one is outside of Pennsylvania, Senator--is 
looking at having a mental health professional in primary care 
clinics and in closing the educational gap with providers.
    In addition, we are aware that the issue of depression in 
the medically ill is often very much under-attended to. There 
is a sense that, well, if you had a heart attack, would you not 
be depressed or if you had cancer? But in fact, we are leaving 
depression very much untreated in these individuals and also 
pain, and people should never wish for death in the context of 
a medical system that could, in fact, provide them with 
adequate treatment.
    In youth again we have many prevention programs. Very few 
of them have actually been subjected to research, and indeed we 
know from studies of some prevention programs that if anything 
is powerful enough to make a difference, it is also powerful 
enough to have side effects. And some well-intentioned programs 
aimed, for example, at de-stigmatizing suicide have actually 
had--and I will sum up--some adverse consequences. We want to 
de-stigmatize mental illness so that people get treatment and 
de-stigmatize the idea that you can ask for help, but we want 
to keep the barriers to suicide high.

                           PREPARED STATEMENT

    We have a number of announcements out and we are supporting 
research, a good deal of research, on suicide prevention and 
evaluation. And we want to work closely with the Surgeon 
General, with other Federal agencies, and also with foundations 
and non-Government partners to ensure that we have well-tested 
prevention measures out there that are being appropriately 
evaluated.
    Thank you.
    [The statement follows:]
                 Prepared Statement of Steven E. Hyman
    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 United States. 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.

    Senator Specter. Thank you very much, Dr. Hyman.
    I want to yield now to my distinguished colleague, Senator 
Harry Reid, who I said at the outset had requested this hearing 
specially because of his own family involvement in the issue. 
Senator Reid?

                Opening statement of Senator Harry Reid

    Senator Reid. Senator Specter, thank you very much. I 
appreciate your holding this hearing. You have a tremendously 
busy schedule with all of the budgetary hearings. Your 
subcommittee is responsible for most of the work because you 
cover so many different areas. I cannot say how much I 
appreciate your working this hearing into your schedule. You 
have approached this really professionally, and I am so 
grateful to you.
    I have a statement that I would like to be made part of the 
record.
    Senator Specter. Without objection, it will be made part of 
the record.
    Senator Reid. I apologize for not being here, but I had to 
open the Senate for the minority this morning.
    Dr. Satcher, thank you very much for being here. You have 
done so much for suicide prevention by adding the weight of 
your office and the stature you have on this issue. We have had 
very few people who are willing to step out in front. You have 
been willing to do that, for which I am grateful.
    I also say I appreciate every one of the witnesses being 
here, but some come at a little greater risk than others. I 
want to express my appreciation to Danielle Steel for being 
here. This is always very difficult when you have to talk about 
a loved one that has been lost, and when you are someone as 
well known as Danielle Steel, that makes it doubly difficult. 
Again, like Dr. Satcher, we appreciate very much your being 
here because the more attention we focus on this, the more we 
are going to learn.

                           PREPARED STATEMENT

    During the time that this hearing started till now, 
someplace in the United States someone killed themselves, and 
as a result of that, there are husbands and wives and children 
and friends at a total loss as to why someone would take their 
own life. That is what this hearing is all about.
    Thank you very much, Mr. Chairman.
    [The statement follows:]
                Prepared Statement of Senator Harry Reid
    Good morning Mr. Chairman and distinguished guests. I would like to 
extend my gratitude to Senator Specter for convening today's hearing. 
As one of the many Americans who has lost a loved one to suicide, this 
hearing holds special significance for me.
    Suicide is not something that only happens to other people. It is 
the 8th leading cause of death in the United States, and is ranked as 
the 3rd leading cause of death among our youth. More young adults die 
from suicide than from cancer, heart disease, AIDS, birth defects, 
stroke, pneumonia, influenza and chronic lung disease combined.
    Suicide claims the lives of 31,000 Americans annually--this means 
that every day we lose 85 people to suicide. In this country, there is 
one suicide every 17 minutes. For every suicide, there are survivors 
left to cope with tragic loss and to struggle with unanswered 
questions.
    The best place to start a story is at the beginning, so allow me to 
take a moment to bring you back a few years so you may understand my 
interest in suicide prevention.
    The year was 1972, and I had just spent a memorable afternoon with 
the legendary Muhammad Ali. When I returned to my Las Vegas law office, 
I was given an urgent message to call my mother at our home in 
Searchlight, Nevada. That is when I learned my father had shot himself.
    Prior to this moment, I had never thought of suicide as something 
that would affect my life. Suicide was something that only happened in 
other people's families.
    Over the years that followed, my family simply did not talk about 
my father's suicide. In retrospect, I guess I was somewhat embarrassed 
and even ashamed. My family and I were left alone and carried this 
experience in a very private way--- the same private and lonely way 
that many families across this country carry their pain today.
    Thankfully, through hearings like this one today, many who 
previously suffered in silence are now able to turn today's grief into 
hope for the future. Suicide is a preventable tragedy and by addressing 
this public health challenge we can change the course of the future for 
so many Americans.
    A few years ago, I was contacted by Jerry and Elsie Weyrauch from 
SPAN--The Suicide Prevention Advocacy Network. They knew I had lost my 
dad to suicide and asked if I would speak at their second annual 
suicide awareness event here in Washington. I agreed, and on the day of 
the SPAN event, I introduced a Senate Resolution that would focus 
attention on the issue of suicide in America. My resolution calling for 
a national strategy to address suicide in America passed in the Senate 
the same day it was introduced. This marked a promising first step 
towards the establishment of a national strategy for suicide 
prevention.
    In October 1998, a national conference on suicide prevention 
convened in Reno, Nevada. One result of this conference was the 
publication of the Surgeon General's ``Call to Action to Prevent 
Suicide.'' This is a blueprint for suicide prevention and I am pleased 
that the Surgeon General is here to tell us more about this effort.
    Our next step is to translate the Surgeon General's framework for 
suicide prevention into action and to increase direct spending for 
suicide prevention. We need to establish a way to ensure the money 
allocated to suicide prevention is spent wisely an in accordance with 
our national strategy. We must ensure that every dollar we spend makes 
a difference.
    Suicide is a public health challenge. It is not a topic we can 
afford to sweep under the rug and silently hope it will improve over 
time. Instead, we must dedicate ourselves to eradicating the staggering 
rate of suicides in this country. We have already begun to make a 
difference and I am optimistic about what we can accomplish through a 
National Suicide Prevention Strategy.
    We have an outstanding panel of witnesses here today. I would like 
to thank everyone for participating in this hearing, and I look forward 
to hearing from all of our distinguished guests. Thank you.

    Senator Specter. Thank you, Senator Reid.
    Senator Wellstone.

              Opening statement of Senator Paul Wellstone

    Senator Wellstone. Thank you, Mr. Chairman. I know we are 
under time constraints, so let me just thank Dr. Satcher and 
Dr. Hyman for their leadership. It is much appreciated.
    Let me thank you and Senator Reid for your engagement with 
this issue.
    Let me thank all the people that are here, all the 
panelists. I want to mention to Dr. Jamison that I read your 
book and it was a very, very important book to me and I think 
many people in the country.
    Then finally, let me just thank one organization back in 
Minnesota, Save, which is an organization that both Sheila, my 
wife, and I have done a lot of work with. As you know, Mr. 
Chairman, I am very interested in this area and I look forward 
to hearing from all the panelists.
    And that is as brief as I can be.
    Senator Specter. Thank you very much, Senator Wellstone.
    Just a couple of questions. Dr. Satcher, what advice would 
you give to someone who was thinking about suicide?
    Dr. Satcher. Well, someone who is thinking about suicide--
as a physician, of course, I would want to talk with that 
person at length to learn more about why that person is 
thinking about suicide.
    Senator Specter. Would you give that person some advice as 
to seeking professional help?
    Dr. Satcher. Yes. I am starting with myself because I am a 
professional. But, yes, I would recommend that all primary care 
providers ask their patients about depression and anxiety and 
the other mental health problems that lead to suicide and, when 
indicated, refer them to specialists in the field. But one of 
our big problems, as you know, in this country is we need the 
primary care sector more involved in identifying people who are 
at risk for suicide. So, I am sorry. When I referred to myself, 
I was speaking as a physician.
    Senator Specter. Would you think it useful to try to set up 
a hot line, an 800 number, or is there any such mechanism now 
in effect where the thought is running through somebody's mind, 
however tentatively, however tenuously, to seek help?
    Dr. Satcher. There are 800 numbers. Let me just say they 
are not well evaluated. Dr. Hyman might want to speak to that. 
CDC is now evaluating the use of crisis hot lines for 
teenagers, for example, and hopefully over a period of time, we 
will learn more about the impact that these have.
    One of the concerns, of course, is that many of the people 
who are at greatest risk for suicide do not call those numbers. 
Of course, Dr. Jamison has written about that. The problem we 
have is that the people who are at greatest risk of suicide are 
usually not the ones that call numbers seeking help. So, we 
have got to learn more.
    That is why we need programs in communities. We need 
ministers and teachers and others who are leaders in 
communities to be aware of the fact that there are many people 
who are depressed, and when we identify these problems, we need 
to make sure that people get the help they need. We have got to 
be more supportive. We have got to have a stronger 
infrastructure, and that is what we hope to do with this 
national strategy.
    Senator Specter. Dr. Hyman, picking up on those who do not 
seek help--and we know the heavy incidence of suicide among 
teenagers--what advice would you give to parents or teachers or 
anyone who has extensive contact with teenagers as to what 
danger signals to look for and what sort of precautionary 
suggestions or advice to teenagers especially?
    Dr. Hyman. I think what is really critical is the 
difficulty of telling the difference between a passing stage 
and something that is really serious. I think the advice to 
parents and teachers is that if somebody's behavior changes, if 
their grades go down, if they become disinterested, and it is 
pervasive and it lasts more than a few weeks, it is a time to 
talk to the child and perhaps bring them to a professional.
    Teachers I think would like--and we have talked about this 
before--more training in understanding warning signs both for 
depression and suicide and also for risk of violence. But Dr. 
David Satcher at Columbia has also pointed out that again many 
of the most suicidal youth actually hide very well these 
feelings.
    One of the things that has been suggested through research 
is actually screening tools that can now be administered, 
perhaps using a computer, so there is very little 
embarrassment, that might identify kids who would not otherwise 
come forward or who are not giving outward signs, and these 
screening tools then could be used to make clinical referrals.
    Senator Specter. Thank you very much, Dr. Hyman. Thank you 
very much, Dr. Satcher.
    I would like to call now our second panel: Dr. John Mann, 
Dr. John Fildes, Dr. Kay Redfield Jamison, Dr. Admiral Susan 
Blumenthal.
    While the second panel is stepping forward, let me 
acknowledge the presence among our very many distinguished 
visitors Senator Bob Packwood, a colleague, distinguished 
chairman of the Finance Committee, and an expert squash player.
    Senator Packwood. The only experience I have in self-
destruction is playing squash with you.
    Senator Specter. Would you stand and be heard, Senator 
Packwood? I would not catch all of that.
    Senator Packwood. I told him the only experience I have in 
self-destruction is playing squash with him.
    Senator Specter. He is ordinarily a good squash player 
except for the six stitches which appear under my left eye.
STATEMENT OF JOHN MANN, M.D., CHAIRMAN, SCIENTIFIC 
            COUNCIL OF THE AMERICAN FOUNDATION FOR 
            SUICIDE PREVENTION
    Senator Specter. Our first witness today on the second 
panel is Dr. John Mann who heads the Department of Neuroscience 
at New York State Psychiatric Institute and is professor of 
psychiatry and radiology at Columbia University which runs the 
clinical research center for the study of suicidal behavior. 
Thank you for joining us, Dr. Mann, and the floor is yours.
    Dr. Mann. Thank you very much, Senator Specter, for the 
opportunity to present here today.
    I am here in my academic capacity as well as in my capacity 
as chairman of the Scientific Council of the American 
Foundation for Suicide Prevention. That Scientific Council 
comprises 50 of the most distinguished experts in suicide 
throughout the country, and the foundation, which represents a 
large body of survivors, is the only private foundation in the 
United States dedicated to the funding of suicide research, 
over 200 projects in the last few years, education and support 
for survivors.
    These survivors have placed their faith in scientific 
approaches to the identification of the causes and risk factors 
for suicide and in the identification and development of 
effective treatment interventions. And I would like to focus my 
remarks on the latter, what can we do about this problem.
    We have made enormous progress in trying to understand 
causes and risk factors of psychiatric illnesses and suicide is 
a complication of psychiatric illnesses. It is not a result of 
social problems. It is a compilation of factors which 
fundamentally stem from psychiatric illness.
    But in trying to develop better treatments for psychiatric 
illness--and we have been enormously successful with the 
support of Congress in doing that--we have made relatively 
little progress in denting the tremendous toll due to suicide. 
The reason for that is that almost all of the clinical trials 
that have been conducted have specifically addressed general 
psychiatric patients and not specifically those who are feeling 
suicidal. In fact, most studies have actually excluded those 
patients. So, when the clinician is asked the question, what 
should I use for the suicidal patient, they have to extrapolate 
from other types of studies. This is really a shocking 
deficiency in our clinical armamentarium, given how 
sophisticated we are in other respects.
    The American Suicide Foundation does not have the funding 
to support these kinds of studies. Many private foundations are 
in the same situation. The only approach that will make a dent 
in the situation will be a partnership between Government and 
private foundations.
    The American Suicide Foundation has partnered, for example, 
with the Soros Foundation to conduct a treatment intervention 
study on suicide in Hungary. Hungary has three times the 
suicide rate of the United States. Certain provinces of Hungary 
are particularly vulnerable. We believe that this kind of model 
in Hungary will potentially be usable in other places. We, in 
particular, have in mind the State of Nevada which, like 
Hungary, has a very high suicide rate, double that of the 
United States, a small population, a place where we can conduct 
a manageable, affordable intervention that could be a model for 
the rest of the country.
    The second proposal that the American Foundation for 
Suicide Prevention wishes to put before the committee is a 
proposal for a national network of treatment evaluation centers 
akin to the kinds of national networks that we have for 
surgical cancer, for heart disease, and so on, centers that 
specialize in the identification, the assessment, and the 
treatment of suicidal patients. This national network would 
then be the infrastructure or the vehicle for conducting 
controlled, clinical, scientific treatment trials to develop 
strategies for treating suicidal patients.
    For example, we know there are medications that may work 
better than other medications in depression and manic 
depression for preventing suicide. In other words, these drugs 
do have properties that are valuable to these patients for 
their psychiatric illness, but they have an additional 
property, such as lithium, which may reduce the risk of 
suicidal behavior independent of improving the psychiatric 
condition.
    An analogy is when you are driving a car recklessly or very 
fast or you hit some ice or there is an accident, you need your 
seat belt system to save your life. When you develop a 
psychiatric illness, what determines whether or not you act on 
the suicidal feeling is not just the psychiatric illness but an 
inherent predisposition or vulnerability to act on powerful 
feelings. There are treatments that may well improve this 
restraint system that we all have to varying degrees and may 
help us help patients live through the crisis of the 
psychiatric illness while we are waiting for the treatment to 
work.
    There are promising treatments in the area of mood 
disorders and in psychoses and we would like to propose that 
funds be set aside for this kind of national treatment research 
network to evaluate these kinds of promising treatments as the 
step forward to actually giving clinicians the tools to save 
lives in the United States as soon as possible.
    Senator Specter. Thank you very much, Dr. Mann.
STATEMENT OF JOHN FILDES, M.D., MEDICAL DIRECTOR, 
            UNIVERSITY OF NEVADA MEDICAL CENTER TRAUMA 
            UNIT
    Senator Specter. We now turn to Dr. John Fildes, medical 
director of the University of Nevada's Medical Trauma Center, 
where he developed the Suicide Prevention Research Center 
responsible for more than 100 physicians who treat more than 
9,000 admitted patients. Thank you for joining us, Dr. Fildes, 
and the floor is yours.
    Dr. Fildes. Thank you very much, Senator.
    As a surgeon, I became interested in treating patients with 
suicide after years and years of tending to their wounds and 
knowing that I could only master part of the problem. I have 
been involved in a broad number of injury control projects 
throughout our State and region and felt that suicide 
prevention was a paramount issue.
    Senator Reid has been instrumental in supporting us in that 
effort, and we were fortunate enough to open up the Suicide 
Prevention Research Center through funding provided by the CDC.
    Nevada, as many people know, has the highest per capita 
suicide rate in the United States and has so for the past 10 
years. This only tells part of the problem. In the 
Intermountain Western States, 8 of these States make up the top 
12 highest suicide rates in the Nation, placing us in the 
center of an endemic region and being the natural home for this 
sort of research.
    The Suicide Prevention Research Center has been charged to 
fill in some of the gaps with regard to creation of tools to 
take a public health approach for injury control.
    All the information that we know about suicide and 
everything that you have heard today only tells about the 
number of deaths. There is no real-time, on-line surveillance 
system in the United States or in any individual State that can 
record the number of attempts that actually take place, and 
these outnumber completions by a large number. In order for us 
to implement effective programs and know whether those programs 
are making things better or making them worse or just remaining 
the same, we need to have an ongoing, on-line, real-time 
measurement of suicide activity, both attempts and prevention, 
throughout the United States.
    We are pioneering that task in Nevada and will spread it to 
six of the eight Intermountain States during the 3-year program 
that we have with the CDC.
    In addition, we require the need to standardize 
nomenclature. When you try to meta-analyze and compare studies 
done by different research groups at different times, it is not 
always entirely clear what is being described or how these 
studies are comparable. And operationalizing a language for 
suicide research is the second objective that we hope to 
accomplish.
    The third is to create a standardized inventory tool, one 
which can be self-administered throughout the rural and 
frontier of the Intermountain West, to follow back the intimate 
acquaintances of those who have committed suicide, as well as 
to be used on attempters and to try to characterize some of the 
risk factors, the behavioral issues, and other external forces 
that have caused these acts to take place.
    Fourth, we would hope to create an inventory of research-
proven prevention programs from around the globe so as not to 
recreate the wheel, to make these prevention programs available 
to communities that have demonstrated the highest rates, and to 
aid their implementation by identifying local experts who are 
willing to embrace and to longitudinally propagate these 
activities within their home communities with the support of 
the center.
    And finally we hope to do this by creation of an 
educational task group to help disseminate our findings, as 
well as our interventions, and to guide us through their 
implementation.
    Dr. Satcher has said that even the most well considered 
plan accomplishes nothing if it is never implemented. What I 
have shared with you today is the model of an evidence-based, 
outcome-driven, injury control model applied to the problem of 
self-directed intentional injury and death. It utilizes the 
Surgeon's General Call to Action by expanding the awareness, by 
implementing intervention programs that are practical and 
readily available, and using methodology based on public health 
and epidemiologic principles. In order for this work to be 
implemented on a broad scale, it will continue to require 
support and the attention of public and private sources.
    Suicide is not an irrational or an inevitable act. It is a 
public health problem of ever-growing proportion and requires 
the same level of commitment provided to other diseases. As a 
trauma surgeon and as a specialist in injury control and injury 
prevention, we see it as one form of intentional injury which 
can be worked on effectively and which can be reduced.
    Thank you.
    Senator Specter. Thank you very much, Dr. Fildes.
STATEMENT OF KAY REDFIELD JAMISON, Ph.D., PROFESSOR OF 
            PSYCHIATRY, JOHNS HOPKINS UNIVERSITY
    Senator Specter. Our next witness is Dr. Kay Redfield 
Jamison, professor of psychiatry at the Johns Hopkins 
University School of Medicine and co-author of the standard 
medical text on manic-depressive illness. Her list of 
accomplishments is very extensive, but one of the most 
significant is that she is the recipient of the American 
Suicide Foundation Research Award for her more recent book, 
``Night Falls Fast: Understanding Suicide.'' In the jacket of 
the book, a matter of some sensitivity, but in the public 
domain, is the comment at the age of 28, after years of 
struggling with manic depression, she attempted to kill 
herself.
    Dr. Jamison, thank you for joining us.
    Dr. Jamison. Thank you. I am a psychologist and professor 
of psychiatry at the Johns Hopkins School of Medicine, and I 
thought this morning I would talk more personally since my 
colleagues will be and have been addressing the science of 
suicide. Thank you very much for the opportunity to speak here 
today.
    Suicide has been a professional interest of mine for more 
than 20 years and a very personal one for very much longer. I 
have a hard-earned respect for suicide's ability to undermine, 
overwhelm, outwit, devastate, and destroy. As a clinician, 
researcher, and teacher, I have known or consulted on patients 
who hanged, shot, or asphyxiated themselves, jumped to their 
deaths from stairwells, buildings, or overpasses, died from 
poisons, fumes, prescription drugs, slashed their wrists, cut 
their throats. Close friends, fellow students from graduate 
school, colleagues, and children of colleagues have done 
similar or the same. Most were young and most suffered from 
mental illness. All left behind a wake of unimaginable pain and 
unresolvable guilt.
    Like many who have manic-depressive illness, I have also 
known suicide in a more private, and awful sort of way, and I 
trace the loss of fundamental innocence to the day that I first 
considered suicide as the only solution possible to an 
unendurable level of mental pain.
    I was 17 when, in the midst of my first depression, I 
became knowledgeable about suicide in something other than an 
existential and adolescent way. For much of each day, during 
several months of my senior year in high school, I thought 
about when, whether, where, and how to kill myself. I learned 
to present to others a face at variance with my mind, ferreted 
out the location of two or three nearby tall buildings with 
unprotected stairwells, discovered the fastest flows of morning 
traffic, and learned how to load my father's gun.
    The rest of my line at the time fell into a fast and black 
night. Everything seemed a ridiculous charade to endure, a 
hollow existence to fake one's way through as best one could. 
But gradually, layer by layer, the depression lifted, and by 
the time my senior prom and graduation came around, I had been 
well for months. Suicide had withdrawn to the back squares of 
the board and become once again simply unimaginable.
    Over the years, though, my manic-depressive illness became 
much worse and the reality of dying young from suicide became a 
dangerous undertow in my dealings with life. Then when I was 28 
years old, after a particular damaging and psychotic mania, 
followed in turn by a prolonged and violent siege of 
depression, I took a massive, lethal overdose of lithium. I 
unambivalently wanted to die and I nearly did. Death from 
suicide had become a possibility, if not a probability, in my 
life.
    This time it was not a very long walk from personal 
experience to clinical and scientific investigation. I was a 
young assistant professor in a department of academic 
psychiatry. I studied everything I could about my disease and I 
read all I could about the psychological and biological 
determinants of suicide. As Dr. Satcher and Dr. Hyman have made 
clear this morning, there is a great deal known about these 
psychological and biological determinants, but there is a 
terrible gap between what we know and what we do about it. And 
this gap is lethal.
    And there is, in fact, much we know about suicide that is 
strangely heartening. As a clinician, I believe there are 
treatments that can save lives. As one surrounded by scientists 
whose explorations of the brain are elegant and profound, I 
believe our basic understanding of the brain's biology is 
radically changing how we think both about mental illness and 
suicide. And as a teacher of young doctors and graduate 
students, I feel the future holds out great promise for the 
intelligent and compassionate care of the suicidal mentally 
ill.
    All of these things I deeply believe. The science is of the 
first water. It is fast-faced and it is laying down pixel by 
pixel, gene by gene the dendritic mosaic of the brain. 
Psychologists are deciphering the motivations for suicide and 
throughout the world, from Scandinavia to Australia, public 
health officials are mapping a clearly reasoned strategy to cut 
the death rate of suicide. We are fortunate--and I cannot say 
how fortunate we are--in this country to have had and continue 
to have the superb leadership of the Surgeon General, Dr. David 
Satcher.
    Still, the effort seems remarkably unhurried. Every 17 
minutes in America someone commits suicide. And I will wrap up. 
Where is the public outrage? Where is the public concern?
    I have become more impatient--and I am generally 
impatient--and more acutely aware of the problems that stand in 
the way of denting the death count. I cannot rid my mind of the 
desolation, confusion, and guilt I have seen in the parents, 
children, friends, and colleagues of those who kill themselves. 
Nor can I shut out the images of the autopsy photographs of 12-
year-old children or the prom photographs of adolescents who 
within a year's time will put a pistol in their mouths or jump 
from the top floor of a university dormitory building.
    Like many of my colleagues who study suicide, I have seen 
time and again the limitations of our science and been 
privileged to see how many good doctors there are and appalled 
by the callousness of others. Mostly, I have been impressed by 
how little value our society puts on saving the lives of those 
who are in such despair as to want to end them. It is a 
societal illusion that suicide is rare. It is not rare. 
Certainly the mental illnesses most closely tied to suicide are 
not rare. They are common conditions and unlike cancer and 
heart disease, they disproportionately affect and kill the 
young.
    We need to do more, far more, and now. Thank you.
    Senator Specter. Thank you very much, Dr. Jamison, for 
sharing your personal experiences.
STATEMENT OF SUSAN BLUMENTHAL, M.D., M.P.A., ASSISTANT 
            SURGEON GENERAL AND SENIOR SCIENCE ADVISOR, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
    Senator Specter. We next turn to Dr. Susan Blumenthal, Rear 
Admiral, Assistant Surgeon General, and Senior Science Advisor, 
Department of Health, national expert in suicide research and 
prevention and has written extensively on the health concern, 
including a major volume, ``Suicide over the Life Cycle.'' From 
1982 to 1985, Dr. Blumenthal served as head of the suicide 
research unit at the National Institute of Mental Health, and 
as the Nation's first Deputy Assistant Secretary for Women's 
Health, she is credited for putting women's health on the 
national policy agenda.
    Thank you for joining us, Dr. Blumenthal, and we look 
forward to your testimony.
    Dr. Blumenthal. Good morning and thank you, Chairman 
Specter, Senator Reid, Senator Wellstone, for your outstanding 
leadership and commitment throughout your careers in Congress. 
You have worked tirelessly to raise awareness and to convene 
members of the Federal Government and private sector to work on 
major public health problems like violence and suicide. It is 
an honor to participate in this hearing today.
    I also want to commend the work of our Surgeon General, Dr. 
David Satcher, and Dr. Hyman, Director of the NIMH, for their 
work and to the scientists here, the grassroots advocates, and 
families who contribute so much to raising awareness about this 
public health problem.
    I am here today in my private capacity.
    Senator Specter, it is over 15 years ago that I first 
testified before you on this issue in 1985 when I was head of 
the suicide research unit at the National Institute of Mental 
Health. At that time several clusters of youth suicides had 
occurred in communities across our Nation, including 
Westchester County, New York and in Plano and Dallas, Texas, 
running through these communities like a lethal, infectious 
disease, leaving the Nation heartbroken and perplexed about the 
reasons for these tragedies and urgently in need of strategies 
to help prevent future loss of life in ways not unlike our 
communities have been ravaged recently by school violence where 
young people have killed their classmates and then killed 
themselves.
    You see, as you have heard, since 1950 there has been a 
tripling in suicide rates for our Nation's young people, ages 
15 to 24, but the sharp upturn in rates of suicide among 
adolescent and young adults in the United States that began in 
the 1950's and emerged as one of the most highly visible and 
alarming public health trends of the 1980's perhaps obscured 
also the fact of the pervasiveness and persistence of suicide 
and suicidal behavior in all other age groups of the population 
throughout the course of the 20th century and the fact that 
risk factors for suicide appear to differ across the life 
cycle.
    Suicide is a complex human behavior. It reflects many 
determinants, biological, psychological, and environmental, 
present in the absence of protective factors. Thus, preventing 
suicide requires multifaceted interventions, individual, 
medical, community-based and environmental. Suicide occurs 
across the life cycle and its risk increases with age. It 
occurs in both men and women and across racial and ethnic 
groups. Yet, many people who commit suicide have exhibited 
warning signs to friends, parents, teachers, colleagues, and 
doctors, but their symptoms have not been recognized and they 
have not received appropriate intervention. Thus, as concerned 
citizens, educators, legislators, and health care 
professionals, we all have a critical role to play in suicide 
prevention.
    In the testimony today, you are hearing what we have 
learned over the past 15 years about suicide and how to prevent 
it and the challenges ahead if suicide rates are going to be 
reduced further in the future.
    Perhaps the most significant achievement during this time 
period has been the important progress made in our ability to 
diagnose and treat mental and addictive disorders that are so 
disproportionately represented in the life histories of those 
who commit suicide. You see, research tells us that as many as 
90 percent of people across the life cycle who end their lives 
by suicide are suffering from a mental and/or addictive 
disorder.
    But as Dr. Jamison underscored, unfortunately what we know 
from best practices does not get translated into ordinary 
practice in our communities around the Nation, that people are 
not getting detected, that they are not being referred for 
appropriate treatment, and because of the shameful stigma that 
exists in our society that treats mental illnesses like 
personal weaknesses or character flaws rather than real, 
disabling illnesses just like heart disease or diabetes, for 
which there are extremely effective treatments.
    Over the past decade, we have finally witnessed an opening 
of understanding about these illnesses that has resulted in 
more effective treatments and in people seeking help. Over the 
past century, the rates of suicide have remained remarkably 
stable, although in the past decade we have seen about a 10 
percent drop in suicide rates.
    To put a framework around what we know and to stimulate 
collaborative actions to prevent this tragic loss of human 
lives, in the 1980's we fostered a public health approach to 
suicide prevention, saying that it was not a result of just 
social and environmental factors. It encompasses a strategy to 
maximize the benefits and efforts and resources for prevention 
across this Nation, and this is the approach that has been 
taken by our Surgeon General's Call to Action.
    The public health approach has been used widely to respond 
to epidemics of infectious disease and over the past decades 
has been used to address other challenging health problems such 
as chronic diseases like the fight against heart disease. In 
public health, there are three levels of prevention, primary, 
secondary, and tertiary.
    Primary prevention is like vaccinating for the prevention 
of infectious disease--and I will wrap up in a minute--doing 
community-based interventions, for example, to prevent smoking, 
encourage a healthy diet and physical activity for heart 
disease. To prevent suicide, it means de-stigmatize mental 
illness and educating the public and health care providers 
about mental illness and substance abuse. It means providing 
every child with a healthy start, promoting mental health 
across the life span, including school-based interventions to 
foster problem solving skills, conflict resolution, and 
resiliency.
    Secondary prevention means identifying high risk people and 
intervening.
    Senator Specter. Dr. Blumenthal, are you summing up now?
    Dr. Blumenthal. I am.
    In heart disease, it means detecting those with high blood 
pressure or cholesterol. To prevent suicide, it means detecting 
those who have suffered a loss who are at high risk, who are 
depressed, and intervening.
    And tertiary prevention means intervening with people who 
have exhibited suicidal behaviors, as we would with people with 
heart disease. And again, studies are underway to find the most 
effective treatment strategies.
    We also must promote better surveillance of the problem, 
avoid inadvertently glamorizing suicide in educational programs 
and in the media. We need to establish community task forces to 
respond before a crisis occurs. We need to build coalitions 
between grassroots, between the public, between policymakers, 
health care leaders. We need to decrease access, easy access, 
to lethal methods in our homes.
    Well, in closing, Voltaire has said that the man--let us 
also make that the woman--who, in a fit of melancholy, kills 
himself today would have wished to live had he waited a week. 
Our understanding of suicide is benefitting from rapid advances 
in the neurosciences and the behavioral sciences from the kind 
of public awareness that is coming from this hearing, from the 
Surgeon General's Call to Action to Prevent Suicide, and 
hopefully with it will come hope in the future, hope that we 
will further reduce suicide, an untimely loss of human life, in 
the 21st century.
    Thank you for the opportunity to be here today.
    Senator Specter. Thank you very much, Dr. Blumenthal.
    Senator Reid.
    Senator Reid. Thank you very much, Mr. Chairman.
    Coming here today, in addition to this being a unique 
opportunity to have our first congressional hearing of this 
magnitude dealing with suicide, has been personally very 
rewarding for me because over here on the wall--and I did not 
know it was going to be here--is a quilt that had a number of 
people from Nevada who committed suicide, and one of those is 
my father. Just walking over there and visiting with my dad for 
a few seconds was important to me.
    And also it brought to my mind, even though my father was 
uneducated--he didn't graduate from the eighth grade not 
because he was not smart enough; he just did not have the 
opportunity--maybe in his death there was some meaning because 
I am sure that he would be surprised if we had all these 
eminent scientists here talking about one of his problems or 
talking about his problem--and that is, in effect, what you are 
doing. So, in his death, today maybe I see the benefit of 
speaking out on this subject because we are talking more about 
it.
    I think the question I would like to ask this panel, Mr. 
Chairman, is in my opinion the biggest problem with suicide is 
there needs to be public awareness that it happens all the 
time. Suicide always happens to someone else. Since my dad 
killed himself, I really focus on suicide. It is all around us. 
Well, it happens every 17 minutes here in America, four times 
as much, we were told earlier today, in Hungary. It is a real 
problem in America and the world.
    So, my question is what can we do, what should we do to 
allow the American public know that 31,000 people die every 
year? Do you have any ideas, any of you?
    Senator Specter. Dr. Blumenthal.
    Dr. Blumenthal. Well, I think that we need to do more 
educational campaigns, but I think we have to start with 
educating about the incredible prevalence of mental and 
addictive disorders in America because one out of five 
Americans will have a mental illness in any year-period.
    I think our Surgeon General's Call to Action about suicide 
and mental health is an important step forward. We had a White 
House conference on mental health. That is an important step 
forward. We need to educate our health care providers to 
understand that suicide is the most tragic complication of 
undiagnosed and treated mental illness.
    But shamefully in our country there are disparities in 
terms of coverage for mental illness that treats them like they 
are not other physical illnesses. And I think we have to 
rectify that. We have to encourage people to seek help, but we 
have to ensure that help is state of the art, and we have to 
ensure that all Americans have access to lifesaving treatment 
and health care.
    Senator Reid. We have public service announcements about 
wearing seat belts. Not nearly as many people are killed every 
year by virtue of not wearing seat belts as die from suicide. I 
personally have not seen any public service announcements about 
suicide.
    Dr. Mann. I think that is a very important point. People 
who are feeling suicidal need to understand that there is help 
out there, and we need to focus specifically on this group 
because this is the group that is at risk for dying. Patients 
who have psychiatric illnesses but do not have suicidal 
thoughts are at extremely low risk in terms of suicide. So, the 
ones who are at risk are having these thoughts. Somehow we have 
to reach out to them and we have to reach out to their families 
because they tell their families about the fact that they are 
feeling suicidal.
    At the same time, it is a bit like World War II. The first 
thing we have to do is stop retreating. The next thing we have 
to do is to build enough tanks so that we can go on the 
offensive, developing treatment strategies that are shown to be 
specifically beneficial for the suicidal patient in the main 
conditions that are associated with suicide like manic 
depression or bipolar disorder, unipolar disorder, 
schizophrenia, and substance abuse.
    We have to give the clinician the tools. We talk about 
educating the public. We talk about educating the clinician, 
but the clinician knows that they need specific tools for this 
problem, and to get those tools, we need factories that make 
those tools. The factories that make those tools are 
specialized centers that know about suicidal patients, that are 
used to looking after them, that conduct, in the safest 
possible way, the treatment trials to determine what treatments 
work best for them.
    Senator Reid. Thank you, Mr. Chairman.
    Senator Specter. Thank you very much, Senator Reid.
    Senator Wellstone.
    Senator Wellstone. Mr. Chairman, I will try and be brief.
    Let me, first of all, just say to Dr. Jamison your words: 
``that there is a gap between what we know and what we do and 
that gap is lethal'' I think sort of rings out to me and I hope 
to the country.
    I want to sort of talk about two issues. It is less in the 
form of a question, but just a comment.
    First of all, on the whole issue of discrimination. We have 
gone through this in my own State. The Governor of Minnesota, 
Governor Ventura, said in an interview, ``I've seen too many 
people fight for their lives. I have no respect for anyone who 
would kill themselves. If you're a feeble, weak-minded person 
to begin with, I don't have time for you.'' So, we have a ways 
to go in terms of just dealing with some of the insensitivity 
or lack of knowledge. I can think of other words. But I think 
that that is one challenge.
    But, Mr. Chairman, I want to make a comment first about 
Senator Reid and then about you.
    First on Senator Reid, you were talking about your dad. I 
think what your father might be most proud of is not the 
experts that are here, but that you are here as U.S. Senator. I 
think that is what he is looking down from heaven and seeing, 
especially with your outspokenness and your courage to talk 
about your own family and the way in which you have brought 
that before the country.
    And, Senator Specter, everybody has said this. Dr. 
Blumenthal said it. Everybody has said it in one way or 
another. Dr. Satcher said it. Dr. Hyman. There is a direct 
connection also between suicide and people who are struggling 
either with mental illness or with substance abuse or 
addiction. You, Mr. Chairman--and very few people have been 
willing to do this--you have now been willing to cosponsor the 
Fairness in Treatment Act which essentially says when people 
are struggling with substance abuse, we have to treat this. You 
cannot view it as a moral failing. You have been the one who 
has been willing to step forward, and I appreciate your effort 
to do this with me.
    Senator Specter. Do not forget yourself. It is your bill.
    Senator Wellstone. I usually do not pass bills here. I 
always need some help.
    Senator Domenici and I are working together on this Mental 
Health Equitable Treatment Act.
    My point is, first of all, what we are not doing goes back 
to what Dr. Jamison said, the gap. There is too much 
discrimination. We are not covering this with health insurance. 
We are not getting the treatment to people, especially 
children, especially minorities, especially poor, especially 
rural areas, especially seniors. At the minimum, we ought to 
end that discrimination and make sure there is the coverage for 
the treatment.
    Then the second point is even if you end the 
discrimination, for those who cannot afford any coverage at 
all, we have got to make sure there is some coverage.
    Then finally, even if you have got the coverage, quite 
often there are communities where we do not have the 
infrastructure of the men and women and the people to deliver 
the care.
    To me, we can do this. We can do this. We have to. That is 
my statement.
    Senator Specter. Thank you very much, Senator Wellstone.
    Dr. Jamison, my first question is for you. We thank you 
specially for sharing with us your own personal experiences, 
which are very, very powerful. As Senator Reid has, it has 
unique meaning when you come forward and tell us what happened 
to you. That is very, very authoritative, obviously.
    Your statement has much to commend it, but I would like you 
to amplify on one line where you said, referring to suicides, 
``Most were young and suffered from mental illness. All left 
behind a wake of unimaginable pain and unresolvable guilt.'' 
Would you amplify that?
    Dr. Jamison. Yes. Actually I had no intention of writing a 
book about suicide because I thought it would be, from a 
scientific point of view, overwhelming and, from a personal 
point of view, something I just did not want to do.
    I did a book tour for a book I had written about my manic 
depression, and every single place I went, someone came up to 
me--and usually four or five people would come up with 
photographs of 15- or 17- or 20-year-old kids who had killed 
themselves. The cumulative effect of that was--it is one thing 
to read the statistics and another thing to go to town after 
town, city after city across the United States and see the 
death toll and see the guilt, the unresolvable guilt, 20, 30 
years later. What could I have done differently? What ought I 
have done? What can I do to protect my other children? It just 
seemed to me an appalling indictment of somewhere in society, 
given what we know about the scientific basis, the biological 
basis of the illnesses that are responsible for suicide, that 
people would feel so personally accountable for them.
    I just think that unless you have been there, there is no 
way of knowing the kind of guilt that people feel because there 
is always something that somebody could have done differently. 
I mean, that is just a given. Whether it is a friend or a 
colleague or a family member, we all know we could have done 
something more or different.
    You are asking about what can people do. One of the things 
I am struck by is people will send their kids off to college, 
and they will go check out the libraries. They will go check 
out the graduate record scores. They will go check out the 
admissions into law school rates. They will check out 
everything. But they will not check out the mental health 
facilities at the campuses. They will not sit down and talk 
with their kids about, look, we have got depression in our 
family, or your uncle committed suicide. You are a little bit 
at risk. What can we do about it? Let us talk about it. There 
are things that people can do now within families and 
communities that are not being done, much less at the 
government level. That is what I find, I guess, so awful.
    Senator Reid. Mr. Chairman, would the chairman yield just 
for a brief statement?
    Senator Specter. Sure.
    Senator Reid. We talk about every 17 minutes someone 
killing themselves. Those are the reported suicides. The 
automobile accidents and the many other things that happen that 
are not counted as suicides that really are would increase that 
number. Would you agree?
    Dr. Jamison. Yes, absolutely. I spent a fair amount of time 
with medical examiners over the last several years, and they 
talk about a child who was 17 years old and had a gunshot wound 
to the head, wrote a suicide note. The parents will still say 
it was an accident because they cannot bear to live with the 
fact that it was a suicide and put pressure on the medical 
examiner's office to classify it as an accident.
    Senator Specter. Thank you, Dr. Jamison.
    Dr. Mann, you talk about studies which you would like to 
undertake. What response are you getting from the National 
Institute of Mental Health on your applications? The $5.2 
billion increase in the last 3 years ought to have given some 
extra leeway. Are you having much luck?
    Dr. Mann. Well, thanks to your leadership and your 
colleagues', there has been a very significant increase in 
funding at the NIMH.
    Senator Specter. Is it filtering down?
    Dr. Mann. Yes. In fact, we have had a meeting with Steve 
Hyman not so long ago, and he has been very supportive and 
forthcoming in terms of creative funding mechanisms and 
arrangements to try and implement the kind of treatment trials 
that we have been talking about today. So, we are very 
optimistic, with your support and working with the NIMH, that 
we will see some of this bearing fruit in the very near future.
    Senator Specter. Dr. Hyman is still here. He liked that 
comment.
    Dr. Hyman. Yes. This is a very well-funded man speaking.
    Senator Specter. Perhaps even better in the future.
    Dr. Fildes, what would you recommend to a parent who sees 
some danger signals in his or her child?
    Dr. Fildes. I have the opportunity to actually treat 
patients like this, and we have these patients and their 
families talk about the problem and do so with the help of 
professionals.
    There are many, many times when I treat a young patient, or 
even an elderly individual, who has had a very serious, serious 
suicide attempt and saved their lives, only for a few days 
later for them to say, oh, I cannot believe what I have done. I 
do not understand what I have done, but I will never do it 
again. In that moment, that crystallizes the elements of the 
cure that we are talking about, that we are all trying to find 
and apply across the numbers of patients around the United 
States.
    Senator Specter. Dr. Blumenthal, the red light is on. I do 
want to ask you one final question for this panel. You were 
here, as you noted, 15 years ago. What has been the extent of 
the progress on dealing with suicide, if any progress in fact 
has been made? And is it adequate?
    Dr. Blumenthal. Well, I think we have seen progress. We 
have seen recent declines in some of the suicide rates over the 
past decade for certain populations, although others have gone 
up, for example, young black males. We have seen more 
systematic research being conducted at the NIMH and at CDC, the 
testing of new intervention trials in SAMHSA. But clearly, much 
more needs to be done.
    I just want to underscore that suicide is a complex human 
behavior. It requires interventions that are multiple, targeted 
to those risk factor domains. For example, most people who 
commit suicide have a mental illness, but most people with 
mental illness do not commit suicide. Therefore, we need to 
strengthen the protective factors for people. We need to 
increase social supports, decrease access to lethal methods in 
the homes, such as guns. We need to promote resiliency and 
educate young people about mental health in the schools, and we 
need to, again, increase access to mental health services in 
our country.
    Senator Specter. Thank you very much, Dr. Blumenthal, Dr. 
Jamison, Dr. Fildes, Dr. Mann. We appreciate very much your 
being here.
    We now go to our final panel: Ms. Danielle Steel and Ms. 
Jade Smalls. Congresswoman Nancy Pelosi will introduce Ms. 
Danielle Steel.
STATEMENT OF HON. NANCY PELOSI, U.S. REPRESENTATIVE 
            FROM CALIFORNIA
    Senator Specter. First we will call on Congresswoman Pelosi 
for the introduction. She is serving her seventh term in the 
House, representing California's 8th congressional district, 
won her last election by a narrow margin, with 86 percent of 
the vote. She is a member of the House Select Intelligence 
Committee and is a member of the House Appropriations Committee 
and serves on the Subcommittee of Labor, Health and Human 
Services, where we have all collaborated on a great many 
appropriations matters.
    Congresswoman Pelosi.
    Ms. Pelosi. Thank you very much, Mr. Chairman. Thank you 
for your leadership on this issue, to you, to Senator Reid, to 
this committee, for facing this issue head on. There is so much 
denial about it in the country.
    Senator Wellstone extended his regrets in having to go to 
another meeting, but you pointed out his tremendous leadership, 
in addition to Senator Reid's and yours, on this issue.
    Mr. Chairman, Senator Reid, I am here this morning as a 
proud Representative of San Francisco, proud of my constituent, 
Danielle Steel, and delighted that I can say that she is a 
personal friend for many, many years.
    She is a household word in many homes in America, but she 
is a very private person.
    When I think of Danielle Steel, I think of one word: 
mother. She is first and foremost a mother of a beautiful 
family. Many of her children are with her today at this 
hearing.
    This is a real act of courage on the part of Danielle 
Steel. She is a very, very private person although, as I say, 
well known. She shared her apprehension with me about facing 
this committee, and I told her she had nothing to fear, that it 
would be painless. But that is the small part of the courage. 
The larger part of the courage is her being here to tell the 
personal story of Nick Traina. It is in that spirit of Danielle 
as a mother that I am proud to sit with her and present her to 
the committee.
    Thank you, Mr. Chairman.
    Senator Specter. Thank you very much, Congresswoman Pelosi.
STATEMENT OF DANIELLE STEEL, BEST-SELLING NOVELIST AND 
            AUTHOR OF ``HIS BRIGHT LIGHT''
    Senator Specter. Ms. Steel, as noted, is a world-renowned 
author, 77 books. The Guinness Book of World Records noted that 
one of her books was on the New York Times Best Seller List for 
381 consecutive weeks. Her most important piece of work perhaps 
is the one she wrote in honor of her son Nick who committed 
suicide at the age of 19. The book, entitled ``His Bright 
Light,'' was written to remove the stigma associated with 
mental illness.
    She is the mother of nine children and comes before us 
today to comment about her very extensive and tireless efforts 
to help other children who suffer from emotional distress.
    Thank you for joining us, Ms. Steel.
    Ms. Steel. Thank you very much, and thank you for the 
lovely introduction.
    I would like to thank the ladies and gentlemen of the 
Senate Appropriations Committee for having me here today. I do 
not ever speak publicly, but it was an honor and an invitation 
that was impossible to resist.
    I also feel better being here today because all of my 
children assured me that I am not famous.
    I was asked to speak about my son Nick. It is a huge 
challenge to paint a portrait of him for you in so little time. 
Brilliant, charming, wonderful, loving, talented, funny, 
outrageous, tormented, unforgettable.
    Senator Specter. Ms. Steel, we have moved rather 
expeditiously. Senator Reid has weighed in in your favor for an 
extra 5 minutes, and we have the time. So, take 10.
    Ms. Steel. Thank you very much. I was frantically crossing 
things off before I sat down.
    He was a magical child, an extraordinary boy. He suffered 
from manic depression all his life and committed suicide at 19.
    As a baby, when people would ask his name, he would answer, 
I'm incredible. Because people said it of him so often, he 
thought that was his name. He was a remarkable child and became 
an even more remarkable young man.
    By the time he was 2, I knew something was wrong with him. 
He was like a record playing on the wrong speed, way, way too 
fast. By 4, I know now that he was manic. I feared even then 
that he was sick. At 7, I was convinced of it. He was 
brilliant, had good grades, but was moody, troubled, easily 
enraged. I turned to doctors and psychiatrists throughout his 
early childhood and was always told that he was fine. I felt in 
my heart that was not true, although I wanted it to be true. I 
sensed that there were terrible demons lurking deep within. I 
cannot even tell you how I knew, but I knew.
    At 12, his best friend died in an accident. Nick was doing 
well in school, but he began dabbling in drugs and he was 
deeply depressed much of the time, sitting in the dark in his 
room. He was full of contrasts. Sometimes he would be jubilant. 
He was loving and funny. Sometimes he was too depressed to 
move. Often he was awake all night, sometimes till 8 a.m. 
Nonetheless, the psychiatrists we saw insisted he was fine. 
They were charmed by him.
    By 13, Nick's life began to fall apart. From then on, his 
life was a constant merry-go-round of schools where he could 
not conform, psychiatrists, special programs for emotionally 
disturbed kids, and brief stays in mental hospitals to evaluate 
him. They said he was difficult and blamed it on his high IQ.
    He remained undiagnosed and unmedicated until 15 when I was 
told he had attention deficit disorder. By 15, I believed he 
was suicidal, although he never put it in words. My instincts 
were right. When I read his journals after his death, I 
discovered that from the age of 11 on, he wrote about killing 
himself every single day.
    At 15, he became more and more impossible to manage. He 
spent 5 months in mental hospitals, and we could not get him 
functional enough to come home. Yet, through it all, he was 
brilliant, charming, affectionate, angry, confused. We tried 
three different hospitals in 1 year. No one was able to do 
anything for him. By the end of that time, he was curled in a 
ball, terrified and sick.
    At 16, he was finally diagnosed bipolar and put on lithium. 
Within 3\1/2\ weeks, he was sane, whole, functional, and back 
in school getting straight A's.
    Life began for Nick at 16. He said that on lithium he felt 
normal for the first time in his life. He did well in school. 
He began in earnest a music career that he had longed for and 
worked towards for years. Music was his passion and his joy. He 
had huge charisma and talent, and in the next 3 years, he 
released nine CD's, played hundreds of concerts, did two 
national tours with his band, appeared on MTV, and was 
scheduled to tour Europe and Japan. He was a lyricist, 
composer, musician, and lead singer of an increasingly 
successful punk rock band.
    He became then the boy I knew and loved so fiercely who was 
not only my son, but became my best friend. He had compassion, 
wisdom, joy, and a sense of humor about others and himself. He 
worked tirelessly. He had a quick tongue and a big heart, and 
where he saw pain, he would reach out a hand.
    His hospital stays then were to readjust his medications. 
He had two psychiatrists, a live-in psychiatric counsellor, and 
took three medications daily, upon which his life and well-
being relied. He had nurses from the age of 14 to accompany and 
protect him from his lack of impulse control. Once on lithium, 
he was virtually drug-free.
    From 16 on, Nick lived in a cottage of his own with his 
nurses and the psychiatric counsellor who oversaw everything he 
did.
    He graduated from high school and did one term of junior 
college, and his life in his late teens was a whirlwind of 
rehearsals, concerts, and road tours. Wherever he went, he was 
accompanied not only by his fellow musicians and his equipment, 
but by his nurses, his counselor, his medications, and his 
disease. Wherever he was, even on tour, we checked his lithium 
levels, with blood tests weekly, to make sure that they were 
high enough. We tested him daily for drugs to make sure that he 
was not dabbling, and with rare, rare exceptions he was not.
    We thought we were home free. Only in reading his journals 
later did I realize how constantly tormented he still was and 
how close to the abyss he always lived. On medications, he 
appeared balanced and happy most of the time. He insisted, and 
we wanted to believe, that he was fine. That outward appearance 
of fineness even fooled him.
    At 18, Nick decided he no longer needed medication. He felt 
great. He stopped taking lithium, became almost instantly 
manic, and within 5 weeks attempted suicide by taking a virtual 
arsenal of drugs. It left him with damaged kidneys, liver, 
spleen, heart, temporarily deaf, briefly incoherent, and 
paralyzed both his legs.
    Before he had even recovered, 10 days later he tried again 
in a locked suicide ward while on suicide watch. And he 
attempted suicide yet again for a third time 2 months after 
that.
    We got him back on Prozac and lithium and he finally 
accepted the seriousness of his disease. From then on, he 
handled his illness and medications extraordinarily well, with 
maturity and responsibility, telling us if he did not feel 
right. When that was the case, we would put him in the hospital 
for a few days to readjust his meds.
    Five months after his third suicide attempt, Nick was on 
medication, healthy, strong, in great spirits, the best he had 
ever been. On a 3-month tour with his band, exhaustion set in 
and he began to get depressed and spiral down. Ten days before 
the end of the tour, he knew he had to leave. He was too sick 
to stay. He knew his health and life were in jeopardy, and in 
despair, he left the tour and quit the band. He flew home and 
took to his bed for 5 weeks. I had never seen him as down.
    Determined to rise from the ashes, he started another band 
immediately and, in a short time, played two local concerts and 
recorded a new CD. But he still did not feel right and asked to 
be put in the hospital. Two hospitals refused to admit him, 
said there was no reason to, that he was fine.
    Ten days later, Nick took a massive overdose of morphine, a 
substance to which he knew he was fatally allergic, and this 
time his attempt was successful. He died at 19.
    I believe he did it because he could not bear to sink to 
the depths again and knew he would one day. He did it because 
he knew he could no longer tour and was not strong enough to 
endure the rigors of his musician's life, which he loved so 
much. He felt he had no other choice. It was his only way out. 
His final freedom from pain.
    Nick taught me to let go of every preconceived idea I ever 
had. He forced me to be open and creative in new ways every day 
of his life. He taught me to focus on what he could do rather 
than what he could not, to celebrate and value his 
accomplishments and accept his defeats with grace. He was a 
lesson in accepting people who are different and loving them as 
they are. Even with his illness, he accomplished more than most 
people I know. His life was a victory in so many ways.
    I tell you his story not so you can mourn him or pity me, 
but because his story needs to be heard. He was not alone in 
his illness or his outcome. He is unusual perhaps only because 
he had a family which was so fiercely devoted to him. He had 
loving parents and eight siblings who adored him and a team of 
supporters who worked tirelessly to keep him happy and alive. 
We had enormous resources and energy with which to support him. 
For as long as we could, in every way we could, we would not 
let Nick die. I no longer feel that we lost him early, although 
his life was certainly far too short, but I feel that we kept 
him alive for 8 years longer than he planned.
    A great number of manic depressives attempt suicide and 
many of them succeed. What we need to think of now is how to 
best serve others like him. The question is: How do we rouse 
psychiatrists to diagnose and medicate bipolars early enough to 
make a difference to save lives?
    Five years ago, it was a rarity for Nick to get lithium at 
16. It is a miracle if children are being diagnosed and 
medicated now, and if so, I believe it will improve and maybe 
even save their lives. If Nick had been treated at 5 or 6, he 
would have been spared 10 years of agony and might perhaps be 
alive today. I believe that early diagnosis and medication are 
crucial to the well-being and survival of kids like Nick; and 
to give them a better chance.
    I am turning to you now, asking you to open eyes in this 
country, the eyes of the public, the eyes of the doctors who 
treat them. Open not only eyes but hearts. You have the power 
to affect how and when and in what ways mental illness is 
treated. Together we can change how it is perceived. Each of us 
in some way is touched by a life like Nick's. Use us, use me, 
use Nick as an example. Use others like him to cast a bright 
light into the dark abyss where people like Nick live. It is no 
longer good enough to diagnose bipolars in their 20's, as was 
the tradition. They are sick long before that. They need help 
long before that. They need medication long before that. They 
die long before that.

                           PREPARED STATEMENT

    Nick Traina is one boy, one child, one life lost. But he 
speaks for an army of people out there who need your help, not 
only people who are themselves sick, but people who love them 
and care about them, mothers, brothers, fathers, sisters, 
husbands, wives, friends, daughters, sons. Let us all reach out 
to help. Let us make a difference for even one life. And may 
God bless you for your courage, your wisdom, and your kindness. 
On behalf of Nick and my family and those of us who have lost 
loved ones, and particularly those who are still struggling 
with them, I give you my thanks for the lives you will touch 
and save.
    [The statement follows:]
                  Prepared Statement of Danielle Steel
    I would like to thank the ladies and gentlemen of the Senate 
Appropriations Committee for having me here today. I do not ever speak 
publicly, but it was an honor and an invitation that was impossible to 
resist.
    I was asked to speak about my son Nick. It is a huge challenge to 
paint a portrait of him for you in so little time. Brilliant, charming, 
wonderful, loving, talented, funny, outrageous, tormented, 
unforgettable. He was a magical child, an extraordinary boy. He 
suffered from manic depression all his life, and committed suicide at 
nineteen.
    Nick spoke English and Spanish fluently before he was one. He 
walked at eight months, loved disco music before he could walk, and 
when people would ask his name, he would answer, ``I'm incredible!'' 
because people said it of him so often, he thought that was his name. 
He was a remarkable child, and became an even more remarkable man.
    By the time he was 2, I knew something was wrong with him. He was 
like a record playing on the wrong speed, way, way too fast. By four, I 
know now that he was manic. I feared even then that he was sick. At 
seven, I was convinced of it. He was brilliant, had good grades, but 
was moody, troubled, easily enraged. I turned to doctors and 
psychiatrists throughout his early childhood, and was always told he 
was fine. I felt in my heart that that was not true, although I wanted 
it to be true. I sensed that there were terrible demons lurking deep 
within. I cannot even tell you how I knew, but I knew.
    At 12, his best friend died in a car accident. Nick was still doing 
well in school then, but he began dabbling in drugs, and he was deeply 
depressed much of the time, sitting in the dark in his room. He was 
full of contrasts. Sometimes he would be jubilant, he was loving and 
funny, sometimes he was too depressed to move. Often he was awake all 
night, sometimes til 8 a.m., nonetheless, the psychiatrists we saw 
insisted he was fine. They were charmed by him.
    In his early teens, Nick's life began to fall apart. By 13, Nick's 
demons were in full swing. From then on, his life was a constant merry 
go round of schools where he couldn't conform, psychiatrists, special 
programs for emotionally disturbed kids, and brief stays in mental 
hospitals to evaluate him. They said he was difficult, and blamed it on 
his high IQ.
    He remained undiagnosed and unmediated until 15, when I was told he 
had Attention Deficit Disorder. He was put on Prozac then. By 15, I 
believed he was suicidal. He never put it in words, but was so often 
depressed and so isolated that I was afraid to go into his room, sure 
that I would find him dead, by his own hand. I know now that my 
instincts were right. When I read his journals after his death, I 
discovered that from the age 11 on, he had written about killing 
himself every single day. It took another eight years to accomplish it.
    At 15, his life was a shambles. He became more and more impossible 
to manage. He spent five months in mental hospitals, and we couldn't 
get him functional enough to come home. Yet through it all, he was 
brilliant, charming, affectionate, angry, confused. We tried 3 
different hospitals in one year. No one was able to do anything for 
him. By the end of that time, he was curled in a ball, terrified and 
sick.
    At 16, we took him to UCLA, and he was finally diagnosed bi-polar, 
and put on Lithium. It was a miracle drug for him. Within three and a 
half weeks, he was sane, whole, functional, loving, funny, and back in 
school, getting straight A's.
    Life began for Nick at sixteen. He said that on Lithium, he felt 
normal for the first time in his life. He did well in school. He began, 
in earnest, a music career that he had longed for, and worked towards 
for years. Music was his passion and his joy. He had huge charisma and 
talent, and in the next three years, he released 9 CD's, played 
hundreds of concerts, did two national tours with his band, appeared on 
MTV, and was scheduled to tour Europe and Japan. He was a lyricist, 
composer, musician, and lead singer of an increasingly successful punk 
rock band. And he became then, the man I knew and loved so fiercely, 
who was not only my son, but became my best friend. The depths to which 
he had been gave him an understanding, compassion, wisdom, joy, and a 
sense of humor about others and himself. He worked tirelessly. He had a 
quick tongue and a big heart, and where he saw pain, he would reach out 
a hand, he could never pass a homeless person without buying them a 
meal. And despite the angelic qualities we see so clearly now, there 
were undeniably times when, much as we loved him, he drove us up the 
wall.
    His hospital stays then were only to readjust his medications. He 
had two psychiatrists, a live-in psychiatric counsellor, and took three 
medications daily, upon which his life and well-being relied. He had 
constant nurses from the age of fourteen, to accompany and protect him 
from his lack of impulse control, which could cause him to walk across 
a freeway, or hang too far out a window. Once on Lithium, he was 
virtually drug-free. But there was a fragile quality to Nick, an 
ephemeral sense that he could break easily, or his life could instantly 
slip away.
    From 16 on, Nick lived in a cottage of his own, with his nurses, 
and the psychiatric counsellor who oversaw everything he did.
    He graduated from high school and did one term of junior college 
and his life in his late teens was a whirlwind of rehearsals, concerts, 
and road tours, driving endless hours across the country in a van to 
play with his band. Wherever he went, he was accompanied, not only by 
his fellow musicians and his equipment, but by his nurses, his 
counsellor, his medications, and his disease. Wherever he was, even on 
tour, we checked his Lithium levels with blood tests, weekly to make 
sure that they were high enough. We tested him daily for drugs, to make 
sure that he wasn't dabbling, and with rare, rare exceptions, he was 
not. We thought we were home free. Only in reading his journals later 
did I realize how constantly tormented he still was, and how close to 
the abyss he always lived. On medications, he appeared balanced and 
happy most of the time. He insisted, and we wanted to believe, that he 
was fine. That outward appearance of ``fineness'' even fooled him.
    At 18, Nick decided that he no longer needed medication. He felt 
great. He stopped taking Lithium, became almost instantly manic, and 
within five weeks attempted suicide by taking a virtual arsenal of 
drugs. It left him with damaged kidneys, liver, spleen, heart, 
temporarily deaf, incoherent briefly, and paralyzed both his legs. 
Before he had even recovered, ten days later he tried again, in a 
locked psychiatric ward, while on suicide watch. And he attempted 
suicide yet again, for a third time, two months after that.
    We got him back on Prozac and Lithium, and sometimes a third 
medication. He himself finally accepted the seriousness of his disease, 
and that it would be not only a life-time battle, but a lifetime 
maintenance issue for him. I compared it to diabetes, which made sense 
to him. From then on, he handled his illness and medications 
extraordinarily well, with maturity and responsibility, telling us if 
he didn't feel right. When that was the case, we would put him in the 
hospital for a few days to readjust his meds.
    Five months after his third suicide attempt, Nick was on 
medication, healthy, strong, and in great spirits, the best he had ever 
been. And he left on a 3 month tour with his band. But with the rigors 
of the tour, exhaustion set in, and he began to get depressed and 
spiral down. Ten days before the end of the tour, he knew he had to 
leave. He was too sick to stay. He knew his health and life were in 
jeopardy. And in despair, he left the tour and quit the band. He flew 
home and took to his bed for 5 weeks. I had never seen him as down.
    Determined to rise from the ashes, he started another band 
immediately, and in a short time, played two local concerts, and 
recorded a new CD. But he still didn't feel right, and asked to be put 
in the hospital. Two hospitals refused to admit him, and said there was 
no reason to. Ten days later, Nick took a massive overdose of morphine, 
a substance to which he knew he was fatally allergic, and this time his 
attempt was successful. He died at nineteen.
    Nick committed suicide in the 90 minute window in his nursing 
schedule at 4:30 a.m. On the only night in five years that his 
counsellor in charge, who loved him dearly, had gone away. I believe he 
did it because he could not bear to sink to the depths again, and knew 
he would one day. He did it because he knew he could no longer tour, 
and was not strong enough to endure the rigours of his musician's life, 
which he loved so much. He felt he had no other choice. It was his only 
way out. His final freedom from pain.
    Nick taught me to let go of every preconceived idea I ever had. He 
forced me to be open and creative in new ways every day of his life. He 
taught me to focus on what he could do, rather than what he could not, 
to celebrate and value his accomplishments, and accept his defeats with 
grace. He was a lesson in accepting people who are different, and 
loving them as they are. Even with his illness, he accomplished more 
than most people I know. His life was a victory in so many ways.
    I tell you his story not so you can mourn him, or pity me, but 
because his story needs to be heard. He was not alone, in his illness, 
or his outcome. He is unusual perhaps only because he had a family 
which was so fiercely devoted to him. He had loving parents and 8 
siblings who adored him, and a team of supporters who worked tirelessly 
to keep him happy and alive. We had enormous resources and energy with 
which to support him. For as long as we could, in every way we could, 
we would not let Nick die. I no longer feel that we lost him early, 
although his life was certainly far too short, but I feel that we kept 
him alive eight years longer than he planned.
    A great number of manic-depressives attempt suicide, and many of 
them succeed. What we need to think of now is how to best serve others 
like him. The question is: How do we rouse psychiatrists to diagnose 
and medicate bi-polars early enough to make a difference to save lives? 
There are other questions as well: How do we offer mental health care 
to people who cannot spend what we did? How do we reach out among the 
homeless and figure out who is mentally ill, and give them the medical 
attention they need? How do we erase the stigma of an illness so 
vicious, so brutal, and so costly, so that people will no longer be 
embarrassed or afraid to get help, either for themselves, or the people 
they love?
    In the two years since Nick has been gone, I have heard of a few 
early diagnoses, of children as young as 5 or 6 being diagnosed bi-
polar, and being given Lithium. Five years ago, it was a rarity for 
Nick to get Lithium at 16. It is a miracle if children are being 
diagnosed and medicated now, and I believe it will improve and maybe 
even save their lives. If Nick had been treated at 5 or 6, he would 
have been spared 10 years of agony, and might perhaps be alive today. I 
believe that early diagnosis and medication are crucial to the well-
being and survival of kids like Nick; and to give them a better chance.
    I am turning to you now, asking you to open eyes in this country. 
The eyes of the public, the eyes of the doctors who treat them. Open 
not only eyes, but hearts. You have the power to affect how and when 
and in what ways mental illness is treated. Together we can change how 
it is perceived. Each of us, in some way, is touched by a life like 
Nick's. Use us, use me, use Nick as an example, use others like him to 
cast a bright light into the dark abyss where people like Nick live. It 
is no longer good enough to diagnose bi-polars in their twenties, as 
was the tradition, they are sick long before that. They need help long 
before that. They need medication long before that. They die long 
before that.
    Nick Traina is one boy, one child, one life lost. But he speaks for 
an army of people out there who need your help, not only people who are 
themselves sick, but people who love them and care about them, mothers, 
brothers, fathers, sisters, husbands, wives, friends, daughters, sons. 
Let us all reach out to help, let us make a difference, for even one 
life. And may God bless you for your courage, your wisdom, and your 
kindness. On behalf of Nick, and my family, and those of us who have 
lost loved ones, and particularly those who are still struggling with 
them, I give you my thanks for the lives you will touch, and save.

    Senator Specter. Thank you very much, Ms. Steel, for that 
very powerful testimony, and thank you for the book about Nick 
and sharing it with so many other people. We thank you.
    Congresswoman Pelosi, we know of your busy schedule, so 
whenever you feel like departing, you are obviously free to go.
STATEMENT OF JADE SMALLS, EVANSTON, ILLINOIS, FIRST 
            RUNNER-UP, 1999 MISS AMERICA PAGEANT
    Senator Specter. We next turn to Ms. Jade Smalls, currently 
taking a year off from her studies as a senior at Northwestern 
University to serve as Miss Illinois. At the Miss America 
Pageant where she was first runner-up, she promoted youth 
suicide prevention as her platform, and she continues to speak 
statewide and nationally on the topic. She has conducted 
research in the area of suicide prevention with institutions 
such as the National Institute of Mental Health and the Center 
for Disease Control. Thank you very much for joining us, Ms. 
Smalls, and we look forward to your testimony.
    Ms. Smalls. Thank you and I am definitely honored to be 
here amongst all these experts and humbled by the courage of 
the survivors. I will be honest and let you know that I tend to 
run about 22 to 34 seconds over. I hope that you can forgive me 
for that in advance.
    Senator Specter. That is fine. Thank you.
    Ms. Smalls. About 5 years ago, I did lose a classmate in a 
very unnecessary way, and it began with her dating an older boy 
who was a bad influence and suddenly turned into the two of 
them going on a cross-country crime spree that left an innocent 
bystander dead. In the end, it ended in a tragic double suicide 
where my friend and her boyfriend ended their own lives. Five 
years ago, this would have been an isolated incident, but here 
we are today and can we even count the number of times that we 
have seen suicide and homicide combine within our schools?
    As Miss Illinois, I have been blessed with the amazing 
opportunity to speak in schools about suicide prevention. And I 
have to tell you that not so long ago, I would have never been 
allowed there because we thought that suicide should not be 
discussed with students. But now things are changing, and if 
anything good has come from these recent tragedies in our 
schools, it would have to be the newfound willingness now of 
these administrations to address issues that they had either 
pretended or had not realized existed.
    Of course, there is still some hesitation on the part of 
school administrators, and who can blame them? But that does 
not mean that they do not want to be a part of the solution. I 
am here to ask for the funding that is going to provide them 
with the resources they need to help them become the lifesavers 
we know they can be. And I am here because I have seen the 
faces of children affected by suicide and I have heard the 
voices of teens that are crying out for help not only for 
themselves, but for their peers around them. Most importantly, 
I am here to make sure that we use this opportunity wisely. 
Right now our schools are eager to help and because of the 
Surgeon General's initiatives, our Government has the means and 
the research now more than ever to bolster the spread of 
information.
    I think you have heard every single panelist here talk 
about suicide having a stigma, being a silent killer. When I go 
to schools, sometimes I ask the kids to raise their hands if 
they have ever broken an arm or a leg before, and they all 
raise their hands. Then I ask them if they were ashamed to have 
to wear a cast or if their first reaction was to pretend like 
nothing was wrong or did they try to fix their broken leg by 
themselves. And, of course, they look at me in disbelief 
because they know that when they are hurting, they are supposed 
to ask for help. But why is it so different for mental illness? 
Students agreed that mental illness and depression were often 
viewed as things to be ashamed of or issues that they should 
work out by themselves. But we do not tell cancer patients to 
snap out of it or we do not tell AIDS patients to get over it.
    In one high school with an audience of over 2,000, a girl 
raised her hand and shared that she had been diagnosed with 
manic depression. She had suffered for years by herself and had 
in her own words experienced the shame attached to her illness. 
Right there that day in her own school she broke down so many 
walls of stigma that had been built up, and she told her 
student body that it was okay to ask for help. Her comments 
brought forth confessions of past suicide attempts, opened 
doors to healing for survivors of suicide in her school, and 
helped to close the gap between the student body and the 
faculty. But she should not have to bear this burden alone.
    My work in the schools has convinced me that the need is 
great and the tools of solution are few. I think we should 
provide funding that will institute, as we heard said before, 
self-check opportunities and depression screening in our 
schools so students can be diagnosed early. Let us provide 
funding to develop mental health curriculums for school aged 
children to teach the language of mental health and to bring 
awareness to the signs of depression and suicide.
    Only 1 percent of suicide prevention curriculum has 
actually reached the schools. Nevertheless, we have 
organizations like the Ronald McDonald House Charities who has 
already created a suicide prevention CD-ROM to give out to 
schools. But they are only one organization in the private 
sector and they cannot possibly reach the countless numbers of 
schools. I suggest that maybe our Government agencies like the 
Department of Health and Human Services, the Department of 
Education, and the National Institute for Mental Health 
collaborate to create mental health cd-rom's that will provide 
in-school resources and, of course, could be distributed on a 
faster and farther scale. Schools also need funding initiatives 
to support behavior modification programs aimed at breaking 
stereotypes that are inhibiting our children from seeking help.
    I am really here to let you know that young people want to 
help their peers. YM magazine, a young women's magazine with a 
readership between the ages of 13 and 19, recently ran an 
article on suicide, and they listed the toll-free number for 
SPAN for anyone interested in fighting the war against suicide. 
I spoke with Elsie Weyrauch, founder of SPAN and survivor of 
suicide, and she told me of the overwhelming response by young 
people under the age of 25 who wanted to help. But in 
particular, there was one girl, and she wanted to learn how to 
help a friend who had repeatedly attempted suicide. Elsie told 
me that that little girl was only 12 years old, and that said 
so much. She is obviously younger than the average readership 
of YM magazine.
    When we think of little children, we associate them with 
things like Disney or bicycles and Barney, but through my 
research, I learned of a 5-year-old boy. He committed suicide 
and he left his note in crayon. I am trying to imagine this 
little guy who had probably only begun to learn how to write, 
and there he was forming his little fingers around that crayon, 
writing those final words. We cannot wait any longer.
    So, the reason I am here is to stand before you 
representing that 5-year-old little boy and that 12-year-old 
little girl and the thousands of kids that we have lost this 
week alone to suicide. I also represent the thousands of living 
young people who want to be a part of the solution.

                           PREPARED STATEMENT

    I want to make sure that that little girl will never again 
have to call Marietta, Georgia to find out how she can help her 
loved ones. So, I am here to call you to action and ask you for 
the funding that is going to allow these initiatives to become 
not yet another document that is one of those ones that sit on 
the shelves and collect dust, but one that is going to help 
save many, many lives. And I believe the time to act is now.
    [The statement follows:]
                   Prepared Statement of Jade Smalls
    About five years ago, I lost a classmate in a very unnecessary way. 
It began with her dating an older boy who was a bad influence and 
suddenly turned into a real life nightmare. The two of them went on a 
cross-country crime spree that left an innocent bystander dead. After 
finally being cornered by police, my friend and her boyfriend refused 
to surrender and instead they killed each other inside of the car they 
had stolen. Five years ago, this would have been an isolated incident. 
But here we are today and can we even count the number of times we have 
seen suicide and homicide combine within our schools?
    As Miss Illinois, I am blessed with the amazing opportunity to 
speak in the schools and spread the message of suicide prevention. Not 
so long ago, there would have been no place for me in these schools 
because it was thought that suicide was not a topic to be discussed 
with students. Now things are changing. If we can find that anything 
good has come from these recent tragedies in our schools it would have 
to be the newfound willingness of these schools and their 
administrations to address issues they had pretended or had not 
realized existed.
    Of course, there is still some hesitation on the part of school 
administrators and who can blame them? But that does not mean that they 
do not want to be a part of the solution. I am here to ask for the 
funding that will provide them with the resources they need to help 
them become the lifesavers we know they can be. I am here because I 
have seen the faces of kids who have been effected by suicide. I have 
heard the voices of teens that are crying out for help not only for 
themselves but for their friends as well. Most importantly, I am here 
to make sure that we use this window of opportunity wisely. Right now 
our schools are eager to help and--because of the Surgeon General's 
initiatives--our government has the means and the research now more 
than ever to bolster the spread of information on suicide prevention to 
our nation's youth.
    Some of you have heard suicide previously referred to as the 
``quiet epidemic''. Suicide is such an effective silent killer because 
of the stigma that surrounds it. I often ask students to raise their 
hands if they've ever broken an arm or a leg before. Many hands go up. 
When I ask them if they were ashamed to have to wear a cast or if their 
first reaction was to pretend like nothing was wrong, to hobble around 
with a dislocated joint, or to try and fix the bone themselves they 
look at me in disbelief. They know that when they are hurting they are 
supposed to ask for help. So why is it so different for mental illness? 
Students agreed with me that mental illness and depression were often 
viewed as things to be ashamed of, issues that should be worked out 
within the individual himself. Yet no one tells a cancer patient to 
``snap out of it'' or an Aids patient to ``get over it''.
    In one high school, with an audience of two thousand, a girl raised 
her hand and shared that she had been diagnosed with manic depression. 
She had suffered for years by herself and had, in her own words, 
``experienced the shame attached to her illness''. She wanted her 
student body to know that it was okay to ask for help. That day she 
broke down walls of stigma that had been built up in her own life and 
in her own school. Her comments brought forth confessions of past 
suicide attempts, opened doors to healing for survivors of suicide in 
her school, and helped to close the gap between the student body and 
the faculty. But she should not bear that burden alone.
    My work in the schools has convinced me that the need is great and 
the tools of solution are few and far between. Let us provide funding 
that will institute self-check opportunities and depression screening 
in our schools so students can be diagnosed early enough to receive 
proper care. Let us provide funding to develop mental health 
curriculums for all of our school aged children to teach the language 
of mental health, to help students become aware of the signs and 
symptoms, and to provide educators with links to those agencies 
available to save our children. Sadly, only 1 percent of suicide 
prevention curriculum has reached our high schools. The Ronald McDonald 
House Charities has taken a step in the right direction by creating a 
suicide prevention cd-rom, called ``Team Up to Save Lives'', to be 
distributed in schools. They are doing their part in many communities 
but as one private sector foundation they cannot possibly reach the 
countless number of schools in need. I suggest that our government 
agencies such as the Department of Health and Human Services, the 
Department of Education and the National Institute for Mental Health 
collaborate to create mental health cd-roms that will provide in-school 
resources, information and prevention strategies that could be 
distributed faster and farther on a national scale. Schools also need 
funding initiatives to support behavior modification programs aimed at 
breaking stereotypes that inhibit our children from seeking help.
    I am here to let you know that young people want to help keep their 
peers alive. YM magazine--a young women's magazine with a readership 
between the ages of 13 to 19--recently ran an article on suicide and 
listed the toll free number for SPAN, the Suicide Prevention Advocacy 
Network, for anyone interested in fighting the war against suicide. I 
spoke to Elsie Weyrauch, founder of Span and survivor of suicide, and 
she told me of the overwhelming response from young people who wanted 
to know how they could help. She remembered one particular call from a 
little girl who said she wanted to help a friend who had repeatedly 
attempted suicide. That little girl was only 12 years old. She was 
younger than the average readership for YM magazine.
    When we think of little children we associate them with Disney, 
bicycles and Barney. Through my research I learned of a little boy, who 
was only 5 years old. He committed suicide and he left his note in 
crayon. I am trying to imagine this little guy who had probably just 
learned to form his fingers around that crayon. Yet, there he was 
writing those final words. We cannot wait any longer! That is why I am 
standing before you, speaking for that 5 year old boy, the 12 year old 
girl and the young people who have died this week and over the years by 
suicide. I also represent the thousands of living young people who want 
to be a part of the solution.
    Let us make sure that that little girl will never again have to 
call Marietta, Georgia to learn how she can help a friend. We are 
calling you to action, asking you to fund the initiatives set forth by 
the Surgeon General to assure that this document does not become yet 
another article that collects dust, but a living breathing one that 
saves lives. The time to act is now.

    Senator Specter. Well, thank you very much, Ms. Smalls.
    The request that you have made is work in progress. We are 
seeking to increase NIH funding by $2.7 billion. It is now 
right at $19 billion. It has come up $5 billion in 3 years. 
Those are astronomical increases because we believe that the 
National Institute of Mental Health and other agencies require 
that kind of help.
    As Dr. Hyman commented, a special initiative was put into 
effect last year reallocating more than $700 million for school 
violence which is very closely associated with these kinds of 
problems.
    Senator Reid, we are going to have to close within the next 
2 minutes.
    Senator Reid. Mr. Chairman, I just wanted to again express 
my appreciation to you. I do not think that we need to ask 
questions to these witnesses. They are here because of who they 
are. And you have focused attention on an issue that needs 
focusing. We are grateful to you and we look forward to working 
with you down the road to make sure that some of the things we 
talk about become realities to stop suicides every 17 minutes.
    Ms. Smalls. Thank you.
    Ms. Steel. Thank you so much.
    Senator Specter. Senator Reid, thank you very much, and 
thank you very much, Ms. Steel and Ms. Smalls. Your testimony 
is very powerful, obviously.
    Ms. Steel, as you recounted the sequence of events with 
your son, you did so very much. I do not know what more you 
could have done. When you bring the insight about starting at 
the age 5, I think that is a very telling factor.
    Ms. Steel. I think we wait too long very often and people 
hesitate to brand children with the label ``mental illness,'' 
and I think that is the issue of stigma, as Ms. Smalls says. We 
need to treat it like diabetes or any other physical condition.
    Senator Specter. And when Miss America runner-up puts her 
fame, fortune, and beauty on the line, that speaks eloquently 
and loudly.
    This hearing is only one step of many activities which this 
subcommittee and the full committee and the Congress will 
undertake.
    So, we thank you very much.
    Ms. Steel. Thank you very, very much. Thank you, Senator.

                         CONCLUSION OF HEARING

    Senator Specter. Thank you all very much for being here, 
that concludes our hearing. The subcommittee will stand in 
recess subject to the call of the Chair.
    [Whereupon, at 11:02 a.m., Tuesday, February 8, the hearing 
was concluded and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]

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