March 31, 2011

Bridges, Barriers, Environments and Lives

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A year of bridge barriers soon will be upon us. I served as one of three consultants to consider whether the ugly chain link fences erected in late March 2010 should stand and eventually be replaced by permanent emplacements.

Cornell and Ithaca have come far since the late-1960s, when I was an undergraduate. Discussion of suicide was taboo. While the entire community mourned the students lost in an April 1967 fire, there was near silence about suicides. Now there is a community of caring and mutual concern, and a frankness of discussion that was not evident four decades ago.

I direct the department of psychiatry at the University of Rochester Medical Center, which treats hundreds of suicidal people annually. My research and much of my teaching focuses on public health approaches to suicide prevention. Most people who have died by suicide either did not signal their intentions or sought to avoid detection near the time of their death. Moreover, more than 99 percent of people having so-called “warning signs” (e.g., very significant clinical depression) do not kill themselves in the near term, and very few of them die by suicide in the long run. Thus, even as we must make caring services readily available and reach out to those whom we see as needing help, there are scant data to suggest that such approaches change population-level suicides rates. Yet no one would suggest that we deny mental health services to those suffering pain and distress.

In contrast to clinical approaches, the scientific literature regarding means restriction is robust. Means matter! Their use reflects access, local customs and intent; they often are copied, being subject to contagion or fashion. Two examples: After cooking gas high in carbon monoxide content was introduced into the U.K. in the late-19th century, suicide increased dramatically during the early-20th century as men and later women adopted its inhalation as the primary method of self-inflicted death. Until the late-1990s, burning charcoal in an enclosed room to produce carbon monoxide was unknown as a method of suicide in Hong Kong. Within several years it accounted for more than 25 percent of deaths. These were additive to the total, not substitutions for other methods. When the amount of carbon monoxide was reduced in cooking gas in the U.K. and in Denmark as well, the rates of suicide dropped dramatically. Similarly, initiatives to change drug packaging and substitute less lethal pesticides have reduced the population-level rates of suicide.

The situation with bridge barriers is more complex. Again and again, authors have reported that barriers radically reduce or eliminate deaths on specific bridges. However, bridge jumping typically comprises a tiny portion of a region’s or a country’s overall suicides, and as a consequence, they have had little impact on regional or national rates — the numerator is too small in comparison to the denominator. From this perspective, the situation in Ithaca is unique. Suicides by jumping are proportionally much higher. Nearly half of the suicides of Cornell students over the past 20 years have been the result of jumps from the high bridges on East Hill. Here, unlike other regions, bridge impediments have the potential to change the regional suicide rate.

“Means substitution” always has the potential of confounding efforts to restrict access to a specific method. We surmise intuitively that, when people have great intent, they will find another method — any means possible — if they are truly committed to dying. That has not been substantiated. Suicide often is an ambivalent act, and ample data show that individuals who use one method do not universally resort to another. That contributes to the explanation that when a major method is precluded, we see a decline in suicides at the population level, if that method had accounted for a significant percentage of the overall suicide burden.

At the same time, I have no doubt that some of the people who are impeded from jumping will try other methods. The most common involve drugs and poisons, which have very low fatality rates in comparison to jumping from the heights of Ithaca’s bridges. Remember that it is possible to interrupt or treat people who have taken overdoses, but once someone jumps, room for intervention is gone. Thus, barriers can prevent deaths from the bridges and have the potential to ”steer” those who seek alternatives to less lethal methods.

I look forward to seeing architectural designs for the bridges. We cannot compare something with nothing — ugly fences versus the uncluttered views of the past. Preserving the beauty of Ithaca should not be inconsistent with protecting lives. From 1966 to1969, I often walked to campus across the Stewart Avenue Bridge near the Chapter House. When I looked far away beyond the railing, I thought of the extraordinary beauty of the region and felt privileged to be part of the environment. But when I looked through the open grating beneath my feet, I thought of those who had died.

Dr. Eric Caine ’69 has been consulting with the University on means restriction since last spring and is the chair of the department of psychiatry at the University of Rochester medical center. He can be reached at  [email protected]. Dr. Caine will be one of the panelists at two forums on means restriction Monday; one at 12:15 p.m. in Bache Auditorium in Mallott Hall; the other at 4:30 p.m. at St. Paul’s Methodist Church, 402 N. Aurora St., in downtown Ithaca. The same presentation will be offered at both forums. Guest Room appears periodically this semester.

Original Author: Eric Caine