Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Saturday, June 28, 2014

A Bridge to Cross

The Golden Gate Bridge has been approved for a $76 million suicide safety net. As I recall, installing a protective structure has been in discussion for a lot of years. Families of people who have jumped off the bridge are understandably happy about it. I can certainly see how they'd want to do something proactive to prevent the kind of suffering they and their loved ones have experienced.

But I have a problem with it, and I hope this isn't interpreted as a lack of empathy towards those families, or towards Kevin Hines, who jumped off the bridge in 2000, at age 19, and miraculously survived.

The statistic in the linked article, which is consistent with my understanding, is that 1400 people have died jumping off the "bridge of death" since it opened in 1937. That's roughly 18 people per year. Again, I don't want to minimize the suffering involved, but to put it in perspective, according to the American Suicidology Association, 39, 518 people killed themselves in 2011, the most recent year for which statistics were available on the site. In other words, 0.05% of all suicides in 2011 were committed by jumping off the Golden Gate Bridge.

What I'm curious about is how much money the federal government devotes to suicide prevention. I poked around online, and I found out the the NIH spent $21 million on suicide prevention in 2013, with a projected spending of the same amount for each of 2014 and 2015.

In 2012, the National Strategy for Suicide Prevention Plan devoted $55 million dollars in federal funds to state, tribal and community prevention efforts.

I found a document, I believe from 2001, with some relevant financial figures:

In 2002, the NIMH offered $2.5 million for stigma-related research.

"SAMHSA provide(d) $5.4 million for a three-year collaborative effort with states to develop and evaluate public education approaches for overcoming barriers to mental health treatment and encouraging community participation for persons with psychiatric disabilities."

"SAMHSA provides funding support to Signs of Suicide (SOS), a peer program that teaches students to recognize depression in peers..." (no figure provided)

"By providing $3.0 million in funding annually over three years, SAMHSA sponsors the Hotline Evaluation and Linkage Project (HELP)."

"SAMHSA is overseeing the launch of the National Suicide Prevention Technical Resource Center in late 2002. Funded at $7.5 million over its first three years, the Center will be dedicated exclusively to suicide prevention..."

"Several HHS operating divisions fund technical assistance efforts aimed at suicide prevention." (no figure)

It was hard to find more information about funding. When I googled, the main link was to the Golden Gate Bridge story.

A few more stats:

At the upper end, there were 19,990 suicides by firearms in 2011. At the lower end, 354 suicides by drowning. And a total of 3996 suicides in California.

And in 2011, there were 987,950 non-fatal suicide attempts in the US.

So this is my problem. The federal government is handing over $76 million to build a net that will prevent roughly 18 people per year, NOT from committing suicide, but from committing suicide by jumping off the Golden Gate Bridge.

I think a lot has to do with the iconic nature of the bridge. As it turns out, about 6 people per year jump off the George Washington Bridge. But no one cares about the GW because it's a rubbish bridge.

A jump from the Golden Gate is dramatic, no doubt. I don't quite understand how people get there on foot. There's Golden Gate Park on one side, and Sausalito on the other, and it's been a while since I've been in the Bay Area, but I think you pretty much have to drive to get close. What I'm trying to say is that it takes some planning.

I just think they're building the wrong kind of net. It's a dramatic gesture for a dramatic structure, but I doubt it'll accomplish much. I think the money would be better spent on catching people before they purchase guns, or down a bottle of pills, or set foot on the Golden Gate, or any other bridge.


  1. I live and work near the Golden Gate Bridge. First, a few facts: there is a sidewalk on the bridge, and people use it all the time. Tourists stroll across, runners jog, bicyclists cycle. The railing is about 4 feet high, an easy hop over. A large majority of jumpers jump from the east side, facing the city on the way down. Statistically, jumping from the GGB is more surely fatal (98%) than shooting oneself in the head. Bodies are not always recovered immediately, and sometimes wash up onshore.

    More controversial is whether thwarting a specific jump truly stops a suicide. A suicide barrier on the Duke Ellington Bridge in Washington DC did not result in increased jumps from other nearby bridges, leading researchers to posit that specific places have iconic value, and are not simply replaced by the next available method. On the other hand, a suicide barrier on the Bloor Viaduct in Toronto (2nd to the GGB in jumping fatalities) did not lower the city's overall suicide rate, nor the suicide rate by jumping. My own opinion, and it is only that, is that suicide is often impulsive, and that thwarting an immediate impulse can make a big difference. That's why we ask suicidal people to remove guns from their homes. Yes, they could always run in front of a bus instead — but as a matter of fact, they don't.

    Government spending to save lives is routinely irrational. How much money was spent locking down Boston to catch the Boston Marathon bombers? How much was spent on "9/11"? How much did it cost to save one man, Sgt. Bowe Bergdahl, held by the Taliban? How much do we spend giving terminal patients a few more months of life, and how many starving children could that save instead? The point is, it's never a rational numbers game. If there's one place where 25 people die every year, it's cause for great concern. If 30,000 people die every year, but they die in different places, via different means, with no obvious connection to one other, well that's just an abstract statistic.

    You think the money would be better spent stopping people from buying guns, taking pills, or strolling across the GGB on a beautiful sunny day like today? How would that work exactly?

    1. "You think the money would be better spent stopping people from buying guns, taking pills, or strolling across the GGB on a beautiful sunny day like today? How would that work exactly?"

      I don't know how it would work. Perhaps $76 million could help figure that out.

    2. Sorry, I think I misread your last line. I pictured a literal screening process of the hundreds of people who walk onto the GGB on any nice day. Now I see that you meant "catching" suicidal people by hospitalizing or otherwise treating them, regardless of the means they have in mind to kill themselves. I don't disagree with that, it's just politically less viable to fund. Plus we don't know how to do it.

      Here in SF, some patients say they may "go to the bridge" as a synonym for feeling suicidal. It's an everyday issue for mental health professionals here. As a means of suicide, the GGB is very available/accessible: it would be like your suicidal patients telling you they pass a "free guns and ammo" booth every day on the way to work. But more than that, the GGB attracts jumpers for symbolic reasons: the failed promise of idealized SF, narcissistic identification with the landmark bridge, saying goodbye to the city, ending one's life in a beautiful place, etc.

      By the way, the barrier is not all federal money: $20M in bridge tolls, $7M in state mental health funds, $49M federal. Yes, it's still a lot of money.

    3. I'm now curious about the difference between suicides, and the reactions to these suicides, on the GGB and the GWB. People bike, jog, and walk across the GW every day, too. the bridge itself is crappy, but the views are great. But the GW doesn't have that iconic quality. Maybe that would be more like jumping off the Empire State Building, which does have barriers on the 86th floor observatory.
      I just googled, and 30 people have killed themselves by jumping off the building over the years. 2 people jumped and survived, by landing on the 85th floor. Beyond the preventive barriers, there's just less square footage than the GGB, and there's lots of security, especially since 9/11. Also, it closes at night. And I don't think those barriers were terribly complicated or expensive to build. Oh, and one woman killed herself by jumping out a 39th floor office window, so that could have been any building.
      Beyond "catching" suicidal people by hospitalizing or treating them, I think money needs to be devoted to more extensive prevention-figuring out who is likely to jump off a bridge, making inexpensive and accessible services available to people who are likely to be in danger. And I don't know how those things would work, but I do know we need money to find out.

  2. Couple of thoughts:

    At an APA meeting about 5 years ago I was at a screening of the movie The Bridge (Eric Steele - Director). It is a stark documentary about suicide by jumping off the Golden Gate Bridge. They basically kept the bridge under active surveillance in that they called the police at the first sign of any person who appeared like they were going to jump. There is footage of people jumping off and a discussion of why people might choose to jump off the bridge, the types of problems they may have had, and the impact on survivors. It supports your idea that the iconic nature is important. From what I recall they also discuss failed barriers that were erected over part of the span.

    There was an editorial in Nature a few weeks ago by (May 22) by Aleman and Denys called "A road map for suicide research and prevention." Although I disagree with some of their interpretations, neglect of suicide is undeniable. We are still using the same risk assessment approach that we have been using for the past 50 years. They suggest defining suicide as a distinct disorder, understanding the mechanisms, funding research and promoting prevention. They point out that $32 million was invested in the reduction of fatal road accidents but only $1.5 million over three years in suicide research. Their economic analysis was that for every 600 suicides prevented $952 million was saved compared with treatment and prevention costs of about $18 million.

    The other issue of course is that nobody has explained the phenomenon of fairly constant suicide rates despite better treatments and research. The common interpretation is that we have not made progress and while that might be true - a competing interpretation that fragmented systems of care complicate the treatment of this complex problem has not been investigated.

    1. I think I read about that documentary-they kept a camera running.
      It's just painful to me to see this bug chunk of money being spent on something I don't think will be that helpful, and where there might be something else that would be more helpful. I guess there are just different pools of funding, and I need to accept it.
      The constancy of suicide rates really supports your thesis that there is no "care" in managed care. And if there's a huge push towards the use of antidepressants instead of more expensive and slower acting treatments, and these same antidepressants don't actually work very well, or even cause suicidality, that would add to the explanation.