A
Public Health Approach to Suicide Prevention SAMUEL P. OAST
III,
MD
ARTHUR ZITRIN, MD
A public health model is applied to the problem of suicide prevention.
Background The development of a public health program in the area of suicide prevention stemmed primarily from recognition that suicide is a leading cause of death for which there has been no such program. The presumption was that suicide should be a concem of public health. However, it was recognized that the nature of the problem was fundamentally different from problems generally considered within the scope of public health. Suicide is a cause of death rather than a disease state. Agent, host, and environmental factors are multiple and ill defined. There are few reliable predictors of outcome. In the traditional public health model, on the other hand, disease determinants can be identified and outcome can be better
target population is followed by three levels of program. The first level is identification and reporting of the target group. The second is maintaining contacts with cases during a period of general surveillance. The third is rendering an accepted mode of treatment. The parallel model for suicide cases was seen as follows: The most suitable target population, based on high risk and feasibility of contact, was suicide attempt cases admitted to a municipal psychiatric facility. The first phase in program was the identification and reporting of cases. The second phase was reaching out contacts to maintain cases under general surveillance following discharge from the psychiatric facility. The third phase was to make available specific services when needed during the postdischarge period.
predicted.
Specific suicide prevention programs generally have been organized on the model of emergency service and have emphasized service to the motivated patient. However, suicidal patients admitted to public mental hospitals present a range of psychopathology and socioeconomic difficulties which generally interfere with their capacity to reach out for help to such programs. The question asked, therefore, was whether a preventive service for less accessible patients at high risk for suicide could be devised by using an approach basically different from that of the crisis telephone service. We decided to test the applicability of a traditional public health approach using both the infectious and chronic disease models. In the secondary prevention model, selection of a Dr. Oast's current address is: 310 East 55th Street, New York, New York 10022. Dr. Zitrin is with the Department of Psychiatry, New York University Medical Center, and the Psychiatric Division, Bellevue Hospital, New York, New York. This work was supported by U.S. Public Health Service Grant MH 17152. 144
AJPH FEBRUARY, 1974, Vol. 65, No. 2
Results Identification and Reporting A major problem in reporting was defining the various categories of suicidal behavior simply enough to facilitate reporting by a large number of admitting physicians. The condition to be reported was suicidal behavior-attempt, gesture, or threat related to the current admission. The decision as to the degree of intention involved in the behavior and whether the attempt was related to the admission was left to the judgment of the admitting physician. There were approximately 17,700 admissions to the Bellevue Psychiatric Hospital during the 18 months of the project operation, of which approximately 2,900 were reported. Roughly one-half of the reports were suicide attempts and gestures while the remainder were reports of verbal suicide threats. From the 2,900 new cases, a sample of 495 cases was selected for the project sample after
meeting criteria for suicide attempt or gesture and residence in the project catchment area. The 495 cases were randomly divided into a study group of 265 cases and a control group of 230 cases.
Reaching Out The main objective in the postdischarge phase was to maintain study cases under general supervision after discharge from Bellevue. In the ideal model, the project staff would establish rapport with the patient while in the hospital and obtain sufficient information to facilitate postdischarge tracing. The first step was to have the patient return for an evaluation or check-up visit within 2 weeks after discharge at the project site, a health department center. The evaluation was carried out by social workers and consisted of a psychosocial review of the patient's current situation to determine whether further help was needed. Generally, evaluations were completed within one to three interviews. The specific procedures in the reaching out approach were the following. The initial step was to send a letter requesting the patient to contact the project for an appointment. If there was no response, a second letter and a telephone call followed a week later. If there still was no response, a registered letter was sent asking the patient to telephone or write. If this was unsuccessful, relatives and collateral agencies also were contacted. A home visit was employed as the final procedure in tracing patients when all else failed. Of the 265 cases in the study group there was postdischarge contact in 139 cases (52 per cent) and no direct contact in 126 cases (48 per cent) of the study group. In 69 of the 139 cases in which there was contact (26 per cent of the entire sample of 265 cases), the case needs and the available resources were such that a referral could be made for continued care. For the most part these cases were the better integrated, more easily motivated patients. Many of these patients had had prior experience in outpatient care. In 70 cases (26 per cent of the entire study group), it was possible to make one or more direct contacts in the reaching out process, but the patient later refused referral for continued care. The content of these more limited contacts covered a spectrum from a few direct refusals of interview to failure to follow through on a referral even though the need had been acknowledged by the patient. In the negative responses, reactions to a variety of aspects of the hospitalization for the suicide attempt were seen. Some individuals maintained that the hospitalization was a mistake; others claimed that it was no evidence of a continuing problem. Some were resentful of the treatment that they had received in the hospital. Still others felt that they were being stigmatized in being followed up on the basis of their earlier suicidal behavior. In general, this group viewed all government and public services with suspicion and saw the project as as arm of such services. Prior in-hospital contacts with the project did not appear to have
been sufficient to counteract the negative feelings associated with the suicide attempt and hospitalization. Further along the spectrum were individuals who cooperated with all aspects of the evaluation procedure and agreed to referral but for whom, for a variety of reasons, referral was not consummated. Among these cases were some whose problems were multiple and chronic so that a resource was difficult to locate. As an example, some cases should more appropriately have been handled in a transitional facility rather than on an outpatient basis. However, in an appreciable number of these cases the major obstacle to continued care was the patient's crisis orientation to medical attention. These patients contacted the project in several crisis situations and then when the crisis subsided they broke off contact and resisted referral for continuing help. In 126 cases (48 per cent of the study group), there was no direct contact subsequent to hospital discharge. However, some indication of the status of these cases was obtained through third party sources and from indirect reactions to the reaching out procedures. The first group of 40 cases (15 per cent of the total sample) were institutionalized at the time of the first reaching out contacts. Because reaching out was not relevant to their status, these cases were not the target of the same procedures as other cases. Another group of 17 cases (6 per cent) were traced to the point where they left New York City. A third group of 36 cases (14 per cent of the study group) were untraceable with the tracing information at hand. These patients, during initial hospital contacts, had been generally unable or unwilling to provide the names of friends or relatives as alternative means of contact. In addition, they often had a history of frequent changes of address. These cases as a group had the highest percentage of chronic problems. For a similar group of 31 cases (11 per cent of the study group), the project had other tracing leads, but a decision was made not to pursue the case further. In these cases it seemed appropriate to respect the patient's resistance and to discontinue active follow-up. Two cases in the study group died during the period shortly following admission to the sample. The first death occurred in the hospital in an elderly confused patient where the circumstances suggested a mixed picture of accidental and suicidal elements. A second case was an apparent overdose suicide within 3 weeks of discharge. This case was one that had been in the hospital a short time and was discharged prior to being interviewed by the project. According to a third party the patient received project letters after discharge but was reluctant to respond. This case underscored the difficulty of conducting successful reaching out procedures without a relationship with the patient based on in-hospital contact.
Specific Services Rendered to Suicide Attempt Cases As indicated above, in 69 cases (26 per cent of the entire sample) a specific referral for continuing care could be made. In two-thirds of these cases a referral was made to a mental hygiene clinic. Small percentages were referred to SUICIDE PREVENTION
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private psychotherapists, medical facilities, Alcoholics Anonymous, social agencies, drug programs, and residential facilities, in order of frequency. Another aspect of the experience in providing service to this population is the extent to which the project was used in crisis situations in which the patient initiated a call for help. For a 6-month pilot period, the project provided a crisis telephone line utilizing a commercial telephone answering service backed by project staff. The existence of this line was made known to 95 project patients. Nineteen cases (20 per cent of the group) placed 35 telephone calls. Of these, 26 were defined by the caller as emergency. Six of these were considered by the project as requiring some emergency action. Eight patients (42 per cent of the calling group) made more than one call; four patients made two calls and four patients made three or more calls. The latter group appeared to be making inappropriate use of the service.
Discussion The general goal of the project was to develop a public health program involving services in the area of suicide prevention in which the target population were patients admitted to a large municipal psychiatric facility after a suicide attempt. Impressions gained from two areas merit discussion: (1) the efficacy and feasibility of specific services organized following a suicidal act as the basis of the initial contact; and (2) the problems in applying public health methodology to suicide prevention. It was feasible to identify a group of suicide attempt cases having many of the characteristics of a high risk group. Regular reporting of such a group was secured in a municipal hospital setting through special staff and careful supervision. The postdischarge surveillance was initiated through an in-hospital initial interview as soon as possible after admission. In a municipal facility geared to emergency care and brief hospitalization this proved difficult to achieve, and cases with a length of stay under 3 days were sometimes discharged prior to project contact. From the experience in the follow-up generally, and in the suicidal death cited previously, the in-hospital contact is seen as an absolute requirement for the success of a subsequent follow-up process. Furthermore, discussion of the circumstances surrounding the suicide attempt should be carried out as soon as possible after the event. Because of the defensive feelings of individuals toward a past suicidal act, the matter becomes relatively inaccessible to inquiry within a relatively short period of time. Patients deal best with this area while still hospitalized. In the case of patients institutionalized elsewhere, when there was an interval of several months before a postdischarge contact, the patients seemed threatened by follow-up procedures. What do the results of the reaching out procedures indicate about the feasibility of a specific program for suicide attempt cases admitted to a municipal psychiatric hospital? In the group that remained in contact with the 146
AJPH FEBRUARY, 1974, Vol. 65, No. 2
project staff but not under active care, a principal concern of the patients appeared to be distrust of government and public services. The basic orientation of these people was primarily to emergency service and concrete help. The concepts involved in psychological help and talking through of problems did not find ready acceptance. To achieve a more useful degree of contact with this group would require a program of more substance and flexibility. In-hospital contacts would need to be of greater frequency and depth. Postdischarge service would need to provide greater options in the use of environmental support than we offered. It would be appropriate to rely more on such outreach procedures as the home visit. The half of the sample group with whom there was no postdischarge contact presents more complex problems and would require program changes of a substantially different nature to have impact. This group consists primarily of individuals with multiple chronic problems in psychological and social areas. The needs of this group fall between what is offered in emergency hospitalization and what is available on an outpatient basis. This group would require transitional facilities with much more extensive supportive services than are currently available in order to be maintained under continued care. What can be said regarding the application of public health methodology to individuals with a history of suicide attempt? The bulk of public health practice is based on the infectious disease model where there is a primary disease determinant, clear signs or tests for disease, and a precise method of treatment. These characteristics of such a model make an aggressive public health outreach approach appropriate. Moreover, there is often potential threat to the health of others in addition to the individual directly
concerned. On the other hand, suicide has poorly defined determinants and few clear signs and is without precise treatment. Although in our society action is taken to prevent suicide as a matter of public policy the basic nature of the problem remains a personal one rather than a threat to the public health. Because of these factors the attitudes and methods fundamental to public health follow-up procedures are not applicable to suicide prevention without significant modifications. One principal change is the adoption of a less aggressive posture and more personal approach in follow-up procedures. A second is to respect the right of the patient to discontinue contact when the acute problem abates.
Conclusion A suicide attempt provides a suitable focal problem about which to initiate contacts and begin follow-up with multiproblem, high risk cases. Early in contact, however, the case focus must shift from suicide to the underlying problems. Accessibility to the broad range of treatment and supportive services these require must be available. In working with individuals prone to emotional crisis and separated from the usual community services by
various social and cultural barriers, special services emphasizing easy access are essential. However, for these services to have major impact they should be but one aspect of an integrated operation providing comprehensive rather than fragmented service. Basic to the perspective on suicide is the view that it is a personal problem as opposed to a threat to the public
health. We must also recognize that in general we know more about the problems on which public health practice is based than we do about disorders of primarily emotional nature. In light of this fact public health methods when applied to suicide prevention require substantial modification of traditional procedures.
HOW I STOPPED SMOKING ... (Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
BE PSYCHOLOGICALLY PREPARED Quitting smoking for me was a three-stage operation that involved: * A conviction that to quit.would be a good idea, maintained over a number of years in the face of advertising and other kinds of pressure; * Another conviction that the time to quit was not just any time. Occasions would develop when quitting had a good chance of working out, and hence strategy dictated patience until such time as conditions were right; * Most important of all, practice. The thing to do is to quit for a day or so every now and then, without any intention of making a serious effort, just to get accustomed to the deprivation and develop a familiarity with it. Everyone adjusts to hot weather in the summer (or cold weather in the winter). This way, things are accepted in a sort of piecemeal process. Further, if one makes a serious effort to quit-and fails-it can be written off as practice or as useful experience-one more block in the process of accommodating to life without cigarettes. And so, after smoking for over 30 years, I quit 7 years ago, and it was not any real problem since I was both emotionally and psychologically prepared for the problems I had before me. Stephen V. Fulkerson Mt. Carroll, IL
SMOKING CAUSED DIZZINESS Fifteen years ago I saw a patient in my office whose complaint was a feeling of dizziness while smoking. He had been to several doctors and each one merely told him to quit smoking in order to get better. I realized that telling him to quit would fail. I made a morning appointment with him to come to the office with his cigarettes but not to smoke until after my examination. I took his pulse, respiration, and blood pressure and recorded them. Then I asked him to start smoking. After several minutes he said, "I feel slightly dizzy." I then repeated the pulse count, respiration, and blood pressure. I showed him on the record that each figure had risen slightly. He then took his pack of cigarettes, crushed it, and threw it in the wastebasket. I saw this man recently and learned that he had quit smoking for good following that simple office demonstration. Benjamin B. Rosenthal, MD Director of Health Milford Health Department Milford, CT
SUICIDE PREVENTION
147
Public Health Approach to Suicide Prevention SAMUEL P. OAST
III,
MD
ARTHUR ZITRIN, MD
A public health model is applied to the problem of suicide prevention.
Background The development of a public health program in the area of suicide prevention stemmed primarily from recognition that suicide is a leading cause of death for which there has been no such program. The presumption was that suicide should be a concem of public health. However, it was recognized that the nature of the problem was fundamentally different from problems generally considered within the scope of public health. Suicide is a cause of death rather than a disease state. Agent, host, and environmental factors are multiple and ill defined. There are few reliable predictors of outcome. In the traditional public health model, on the other hand, disease determinants can be identified and outcome can be better
target population is followed by three levels of program. The first level is identification and reporting of the target group. The second is maintaining contacts with cases during a period of general surveillance. The third is rendering an accepted mode of treatment. The parallel model for suicide cases was seen as follows: The most suitable target population, based on high risk and feasibility of contact, was suicide attempt cases admitted to a municipal psychiatric facility. The first phase in program was the identification and reporting of cases. The second phase was reaching out contacts to maintain cases under general surveillance following discharge from the psychiatric facility. The third phase was to make available specific services when needed during the postdischarge period.
predicted.
Specific suicide prevention programs generally have been organized on the model of emergency service and have emphasized service to the motivated patient. However, suicidal patients admitted to public mental hospitals present a range of psychopathology and socioeconomic difficulties which generally interfere with their capacity to reach out for help to such programs. The question asked, therefore, was whether a preventive service for less accessible patients at high risk for suicide could be devised by using an approach basically different from that of the crisis telephone service. We decided to test the applicability of a traditional public health approach using both the infectious and chronic disease models. In the secondary prevention model, selection of a Dr. Oast's current address is: 310 East 55th Street, New York, New York 10022. Dr. Zitrin is with the Department of Psychiatry, New York University Medical Center, and the Psychiatric Division, Bellevue Hospital, New York, New York. This work was supported by U.S. Public Health Service Grant MH 17152. 144
AJPH FEBRUARY, 1974, Vol. 65, No. 2
Results Identification and Reporting A major problem in reporting was defining the various categories of suicidal behavior simply enough to facilitate reporting by a large number of admitting physicians. The condition to be reported was suicidal behavior-attempt, gesture, or threat related to the current admission. The decision as to the degree of intention involved in the behavior and whether the attempt was related to the admission was left to the judgment of the admitting physician. There were approximately 17,700 admissions to the Bellevue Psychiatric Hospital during the 18 months of the project operation, of which approximately 2,900 were reported. Roughly one-half of the reports were suicide attempts and gestures while the remainder were reports of verbal suicide threats. From the 2,900 new cases, a sample of 495 cases was selected for the project sample after
meeting criteria for suicide attempt or gesture and residence in the project catchment area. The 495 cases were randomly divided into a study group of 265 cases and a control group of 230 cases.
Reaching Out The main objective in the postdischarge phase was to maintain study cases under general supervision after discharge from Bellevue. In the ideal model, the project staff would establish rapport with the patient while in the hospital and obtain sufficient information to facilitate postdischarge tracing. The first step was to have the patient return for an evaluation or check-up visit within 2 weeks after discharge at the project site, a health department center. The evaluation was carried out by social workers and consisted of a psychosocial review of the patient's current situation to determine whether further help was needed. Generally, evaluations were completed within one to three interviews. The specific procedures in the reaching out approach were the following. The initial step was to send a letter requesting the patient to contact the project for an appointment. If there was no response, a second letter and a telephone call followed a week later. If there still was no response, a registered letter was sent asking the patient to telephone or write. If this was unsuccessful, relatives and collateral agencies also were contacted. A home visit was employed as the final procedure in tracing patients when all else failed. Of the 265 cases in the study group there was postdischarge contact in 139 cases (52 per cent) and no direct contact in 126 cases (48 per cent) of the study group. In 69 of the 139 cases in which there was contact (26 per cent of the entire sample of 265 cases), the case needs and the available resources were such that a referral could be made for continued care. For the most part these cases were the better integrated, more easily motivated patients. Many of these patients had had prior experience in outpatient care. In 70 cases (26 per cent of the entire study group), it was possible to make one or more direct contacts in the reaching out process, but the patient later refused referral for continued care. The content of these more limited contacts covered a spectrum from a few direct refusals of interview to failure to follow through on a referral even though the need had been acknowledged by the patient. In the negative responses, reactions to a variety of aspects of the hospitalization for the suicide attempt were seen. Some individuals maintained that the hospitalization was a mistake; others claimed that it was no evidence of a continuing problem. Some were resentful of the treatment that they had received in the hospital. Still others felt that they were being stigmatized in being followed up on the basis of their earlier suicidal behavior. In general, this group viewed all government and public services with suspicion and saw the project as as arm of such services. Prior in-hospital contacts with the project did not appear to have
been sufficient to counteract the negative feelings associated with the suicide attempt and hospitalization. Further along the spectrum were individuals who cooperated with all aspects of the evaluation procedure and agreed to referral but for whom, for a variety of reasons, referral was not consummated. Among these cases were some whose problems were multiple and chronic so that a resource was difficult to locate. As an example, some cases should more appropriately have been handled in a transitional facility rather than on an outpatient basis. However, in an appreciable number of these cases the major obstacle to continued care was the patient's crisis orientation to medical attention. These patients contacted the project in several crisis situations and then when the crisis subsided they broke off contact and resisted referral for continuing help. In 126 cases (48 per cent of the study group), there was no direct contact subsequent to hospital discharge. However, some indication of the status of these cases was obtained through third party sources and from indirect reactions to the reaching out procedures. The first group of 40 cases (15 per cent of the total sample) were institutionalized at the time of the first reaching out contacts. Because reaching out was not relevant to their status, these cases were not the target of the same procedures as other cases. Another group of 17 cases (6 per cent) were traced to the point where they left New York City. A third group of 36 cases (14 per cent of the study group) were untraceable with the tracing information at hand. These patients, during initial hospital contacts, had been generally unable or unwilling to provide the names of friends or relatives as alternative means of contact. In addition, they often had a history of frequent changes of address. These cases as a group had the highest percentage of chronic problems. For a similar group of 31 cases (11 per cent of the study group), the project had other tracing leads, but a decision was made not to pursue the case further. In these cases it seemed appropriate to respect the patient's resistance and to discontinue active follow-up. Two cases in the study group died during the period shortly following admission to the sample. The first death occurred in the hospital in an elderly confused patient where the circumstances suggested a mixed picture of accidental and suicidal elements. A second case was an apparent overdose suicide within 3 weeks of discharge. This case was one that had been in the hospital a short time and was discharged prior to being interviewed by the project. According to a third party the patient received project letters after discharge but was reluctant to respond. This case underscored the difficulty of conducting successful reaching out procedures without a relationship with the patient based on in-hospital contact.
Specific Services Rendered to Suicide Attempt Cases As indicated above, in 69 cases (26 per cent of the entire sample) a specific referral for continuing care could be made. In two-thirds of these cases a referral was made to a mental hygiene clinic. Small percentages were referred to SUICIDE PREVENTION
145
private psychotherapists, medical facilities, Alcoholics Anonymous, social agencies, drug programs, and residential facilities, in order of frequency. Another aspect of the experience in providing service to this population is the extent to which the project was used in crisis situations in which the patient initiated a call for help. For a 6-month pilot period, the project provided a crisis telephone line utilizing a commercial telephone answering service backed by project staff. The existence of this line was made known to 95 project patients. Nineteen cases (20 per cent of the group) placed 35 telephone calls. Of these, 26 were defined by the caller as emergency. Six of these were considered by the project as requiring some emergency action. Eight patients (42 per cent of the calling group) made more than one call; four patients made two calls and four patients made three or more calls. The latter group appeared to be making inappropriate use of the service.
Discussion The general goal of the project was to develop a public health program involving services in the area of suicide prevention in which the target population were patients admitted to a large municipal psychiatric facility after a suicide attempt. Impressions gained from two areas merit discussion: (1) the efficacy and feasibility of specific services organized following a suicidal act as the basis of the initial contact; and (2) the problems in applying public health methodology to suicide prevention. It was feasible to identify a group of suicide attempt cases having many of the characteristics of a high risk group. Regular reporting of such a group was secured in a municipal hospital setting through special staff and careful supervision. The postdischarge surveillance was initiated through an in-hospital initial interview as soon as possible after admission. In a municipal facility geared to emergency care and brief hospitalization this proved difficult to achieve, and cases with a length of stay under 3 days were sometimes discharged prior to project contact. From the experience in the follow-up generally, and in the suicidal death cited previously, the in-hospital contact is seen as an absolute requirement for the success of a subsequent follow-up process. Furthermore, discussion of the circumstances surrounding the suicide attempt should be carried out as soon as possible after the event. Because of the defensive feelings of individuals toward a past suicidal act, the matter becomes relatively inaccessible to inquiry within a relatively short period of time. Patients deal best with this area while still hospitalized. In the case of patients institutionalized elsewhere, when there was an interval of several months before a postdischarge contact, the patients seemed threatened by follow-up procedures. What do the results of the reaching out procedures indicate about the feasibility of a specific program for suicide attempt cases admitted to a municipal psychiatric hospital? In the group that remained in contact with the 146
AJPH FEBRUARY, 1974, Vol. 65, No. 2
project staff but not under active care, a principal concern of the patients appeared to be distrust of government and public services. The basic orientation of these people was primarily to emergency service and concrete help. The concepts involved in psychological help and talking through of problems did not find ready acceptance. To achieve a more useful degree of contact with this group would require a program of more substance and flexibility. In-hospital contacts would need to be of greater frequency and depth. Postdischarge service would need to provide greater options in the use of environmental support than we offered. It would be appropriate to rely more on such outreach procedures as the home visit. The half of the sample group with whom there was no postdischarge contact presents more complex problems and would require program changes of a substantially different nature to have impact. This group consists primarily of individuals with multiple chronic problems in psychological and social areas. The needs of this group fall between what is offered in emergency hospitalization and what is available on an outpatient basis. This group would require transitional facilities with much more extensive supportive services than are currently available in order to be maintained under continued care. What can be said regarding the application of public health methodology to individuals with a history of suicide attempt? The bulk of public health practice is based on the infectious disease model where there is a primary disease determinant, clear signs or tests for disease, and a precise method of treatment. These characteristics of such a model make an aggressive public health outreach approach appropriate. Moreover, there is often potential threat to the health of others in addition to the individual directly
concerned. On the other hand, suicide has poorly defined determinants and few clear signs and is without precise treatment. Although in our society action is taken to prevent suicide as a matter of public policy the basic nature of the problem remains a personal one rather than a threat to the public health. Because of these factors the attitudes and methods fundamental to public health follow-up procedures are not applicable to suicide prevention without significant modifications. One principal change is the adoption of a less aggressive posture and more personal approach in follow-up procedures. A second is to respect the right of the patient to discontinue contact when the acute problem abates.
Conclusion A suicide attempt provides a suitable focal problem about which to initiate contacts and begin follow-up with multiproblem, high risk cases. Early in contact, however, the case focus must shift from suicide to the underlying problems. Accessibility to the broad range of treatment and supportive services these require must be available. In working with individuals prone to emotional crisis and separated from the usual community services by
various social and cultural barriers, special services emphasizing easy access are essential. However, for these services to have major impact they should be but one aspect of an integrated operation providing comprehensive rather than fragmented service. Basic to the perspective on suicide is the view that it is a personal problem as opposed to a threat to the public
health. We must also recognize that in general we know more about the problems on which public health practice is based than we do about disorders of primarily emotional nature. In light of this fact public health methods when applied to suicide prevention require substantial modification of traditional procedures.
HOW I STOPPED SMOKING ... (Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
BE PSYCHOLOGICALLY PREPARED Quitting smoking for me was a three-stage operation that involved: * A conviction that to quit.would be a good idea, maintained over a number of years in the face of advertising and other kinds of pressure; * Another conviction that the time to quit was not just any time. Occasions would develop when quitting had a good chance of working out, and hence strategy dictated patience until such time as conditions were right; * Most important of all, practice. The thing to do is to quit for a day or so every now and then, without any intention of making a serious effort, just to get accustomed to the deprivation and develop a familiarity with it. Everyone adjusts to hot weather in the summer (or cold weather in the winter). This way, things are accepted in a sort of piecemeal process. Further, if one makes a serious effort to quit-and fails-it can be written off as practice or as useful experience-one more block in the process of accommodating to life without cigarettes. And so, after smoking for over 30 years, I quit 7 years ago, and it was not any real problem since I was both emotionally and psychologically prepared for the problems I had before me. Stephen V. Fulkerson Mt. Carroll, IL
SMOKING CAUSED DIZZINESS Fifteen years ago I saw a patient in my office whose complaint was a feeling of dizziness while smoking. He had been to several doctors and each one merely told him to quit smoking in order to get better. I realized that telling him to quit would fail. I made a morning appointment with him to come to the office with his cigarettes but not to smoke until after my examination. I took his pulse, respiration, and blood pressure and recorded them. Then I asked him to start smoking. After several minutes he said, "I feel slightly dizzy." I then repeated the pulse count, respiration, and blood pressure. I showed him on the record that each figure had risen slightly. He then took his pack of cigarettes, crushed it, and threw it in the wastebasket. I saw this man recently and learned that he had quit smoking for good following that simple office demonstration. Benjamin B. Rosenthal, MD Director of Health Milford Health Department Milford, CT
SUICIDE PREVENTION
147
