Harvard Public Health Review
Spring 2006

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Injury Control

Death by Violent Means: Who's at Risk?

A CDC database piloted by HSPH is galvinizing prevention efforts

One late-November day in a suburban Connecticut town, 13-year-old Gregory Brown climbed onto his bed, cocked his father's shotgun, and shot himself in the head. He had told his friends of his intention, giving away pieces of a Dungeons & Dragons game and tossing his schoolbooks at a playground across the street. At a tennis court, he had scrawled a macabre message: "Greg Brown was here the day he died."

That very public message failed even to hint at why this young teen ended his life on that day, of all days. According to news reports and legal testimony, Brown had forged his report card to hide his failing grades and was on the brink of getting caught. The morning of his death, his skeptical parents planned to verify his grades with the school. By all appearances, the boy, in quiet crisis, chose death over confrontation. And the means, a gun, was too readily at hand.
Approximately 30,000 Americans kill themselves each year. Remarkably, these suicides significantly outnumber homicides, which claim 20,000 lives. Yet little is known about the context in which these violent deaths--especially suicides--occur. While individual case files may be rich in detail, police departments, medical examiners, and coroner's offices gather data in different ways and have limited ability to share information.

But a software program and data-tracking system for monitoring violent deaths piloted by HSPH from 2000 to 2005 is bringing all these data together. The system is rolling out across the country, yielding surprising new insights.

Dissecting Suicide
The National Violent Death Reporting System (NVDRS), put into the field by the U.S. Centers for Disease Control and Prevention (CDC) in 2003, collects and links information about homicides, suicides, and unintentional firearm deaths. Perhaps most important, the system has begun to illuminate patterns and risk factors for suicide, the eleventh leading cause of death in the United States.

In 1999, then U.S. Surgeon General David Satcher identified suicide prevention as a priority for the nation. In 2001, he spearheaded the release by the U.S. Department of Health and Human Services of a National Strategy for Suicide Prevention, which the Bush administration has incorporated into the President's New Freedom Commission on Mental Health.

Satcher's original plan reflected what was known at the time: that women are far more likely than men to attempt suicide, while men have the dubious distinction of being at least four times more likely to die; that between 1952 and 1996, suicides among adolescents and young adults nearly tripled; and that firearms are the most common means used. Noting gaps in the data, Satcher called for a reporting system. Two reports from the Institute of Medicine did the same: Reducing Suicide: A National Imperative (2002) and Firearms and Violence: A Critical Review (2004).
These calls have been answered by the NVDRS. The HSPH-guided pilot on which the system is based has revealed these findings:

Alcohol and teen suicide While about one-third of 18- to 24-year-old suicide victims test positive for alcohol, only five percent of victims under age 18 do so. One conclusion: Reducing underage drinking is an important goal, but should not be the main strategy for preventing high-school-age suicides.

Intimate partner violence and suicide Two-thirds of men who shoot their wives or girlfriends to death kill themselves in the same incident. Implication: Intervening with homicidal men may save both women's and men's lives.

Grief-related suicides While some suicides follow the death of a loved one, the interval between deaths is often not days or weeks, but years. Implication: Counselors and support groups may need to continue supporting vulnerable survivors for far longer than is generally believed necessary.

Health problems and suicide For about 24 percent of suicides in all age groups, investigation reports included mention of a health problem. Among the elderly, the proportion is much higher. Suggestion: The elderly may be at particular risk if their health is failing.

College-age youth and suicide Federal funds for suicide prevention prioritize college students, yet HSPH's pilot data has found that only 20 percent of reported suicide victims between the ages of 18 and 24 were students. Consideration for policymakers: Reaching out to young people not in college is crucial.

Building the Network
HSPH's pilot system, originally called the National Violent Injury Statistics System, was spearheaded by the Harvard Injury Control Research Center (HICRC). Funding was provided by six private foundations.

The CDC version, initially funded in 2002, involved six states. Eleven more were eventually added, bringing the roll call to Alaska, California, Colorado, Georgia, Kentucky, Massachusetts, Maryland, North Carolina, New Jersey, New Mexico, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin. The CDC aims to include all 50 states, provided that the agency can increase Congressional support from $3.34 million in 2006 to $20 million annually--a small sum compared to, say, the $5 billion in annual costs researchers have linked to treating assault injuries alone.

"When the CDC adopted the pilot, it was a water-shed moment," says HICRC Director David Hemenway, professor of health policy. "Creating the system has been a true public health movement. Many key stakeholders recognized the need and became advocates for this system."
Adds Hemenway's colleague, Catherine Barber: "Our project was always envisioned as a bridge to a nationally funded and directed system. We needed to prove it would deliver timely data without overburdening agencies. That's part of the beauty of the system: The data were always there. We found a way to tap existing resources that weren't linked or standardized."

How the System Works
NVDRS pulls together data from four main sources: death certificates, coroner/medical examiner reports, crime laboratories, and police reports. State agencies, typically departments of health, assemble information using CDC-supplied software, and forward it to the national database.
No other database on violent deaths combines as many pieces of information as does the NVDRS.

For example, the FBI's National Incident-Based Reporting System covers homicide, but not suicide. And death certificates, the only other key source on suicides, fail to capture such important details as whether victims were receiving mental health treatment.

The NVDRS notes a victim's relationship to the offender, circumstances leading to the injury, where the event occurred, and demographics, such as ethnicity, employment status, and education level. Suicide victims' physical and mental health, substance abuse problems, treatment status, and recent life crises are also recorded. For firearm deaths, the data include weapon type, make, model, and caliber. For deaths involving an under-age shooter, agencies attempt to document how the child obtained the weapon.

"Until this system, we knew how many suicides there were and where they occurred. But we didn't know, for example, that most youth firearm suicides are committed with a family gun, or that school-related crises among youth are common," notes Deborah Azrael, co-director of HSPH's pilot system. "By combining these sources, we're giving everyone--from community members to public health professionals--the textured understanding of suicide they need to make a difference."

One NVDRS goal is to make ongoing case counts available within six months of a violent death, a lightning-fast pace compared to other national databases. Linked information containing more details, such as a toxicology report for a suicide, will be available within 18 months. The system plans to get data stripped of names and other identifying information to researchers and the public at large by July 2006. More elaborate (but still anonymous) data will be made available to researchers by application, possibly by the end of the year.

Can the System Make a Difference?
Not two hours before Gregory Brown died, his friend had called the fire department about Brown's suicide threat. According to news reports and legal testimony, police went to the Brown house and found a calm young man, home alone while his parents worked. Assuming the phone call had been a prank, and finding no weapon after a cursory search, the officers left, saying they'd return after Brown's parents came home. Only after the father discovered his son's body did he and his wife learn of the officers' visit.

No one could have known, in 1984, that one-third of teen suicide victims experience some triggering event--a bad report card, say, or an argument with a parent--within 24 hours of killing themselves. People were also unaware that more than half of teens kill themselves with guns, and that 82 percent of them use their parents' firearms. Neither his parents nor the police knew that Brown--whose mental health had reportedly been evaluated by a local clinic four years earlier--fit the profile of a crisis-motivated teen suicide.

"It is critically important to address violent deaths in this country," says James Mercy, associate director for science at the Division of Violence Prevention at the CDC. "But if we don't first identify and describe them, how will we ever prevent them? That's why a National Violent Death Reporting System is so important."

For more information on the NVDRS, see http://www.cdc.gov/ncipc/profiles/nvdrs/facts.htm

Christina Roache is assistant director for internal communications and editor of Harvard Public Health NOW, the School's biweekly newsletter. HPH NOW can be read online at www.hsph.harvard.edu/now.

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Copyright, 2006, President and Fellows of Harvard College