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Stopping suicide before the attempt
By Dan Even

The string of highly publicized suicides leaves Lior Carmel no time to rest - he is set to launch a pilot for a national suicide-prevention program in three weeks.

Entertainer Dudu Topaz's dramatic death in Nitzan Prison in August was the opening salvo. A month later, detainee Asaf Goldring, suspected of killing his 3-year-old daughter Noa in a highly publicized case, managed to commit suicide in jail as well. Last week Maccabi Tel Aviv's famed manager, Moni Fanan, hanged himself in his Tel Aviv apartment.
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Carmel believes the timing of these cases is no coincidence. Preliminary data gathered by Magen David Adom shows that since August, calls regarding attempted suicides have increased 24 percent.

Israel's first anti-suicide pilot program is being launched, under the auspices of the Health Ministry and the Joint Distribution Committee. The program seeks to identify potentially suicidal people in advance, in order to reduce the number of suicide attempts.

"At first they glorified Moni Fanan as Maccabi Tel Aviv's great hero, and only later did they address his improprieties," says Carmel. This kind of media coverage may encourage more suicides, he says.

At the end of the week, another detainee at Hasharon Prison, Hamara Temisgin, also committed suicide, a few days after he was arrested for allegedly murdering his wife.

"People may say to themselves that if Moni Fanan didn't succeed, then they won't either. Apparently, Fanan got himself into trouble, and thought there was no way out of it. But there was a way out. If the people around Fanan had had the appropriate professional training to identify suicidal tendencies, it might have been possible to offer him help in time."

Carmel's program relies on this assumption, which has been backed by studies.

For the past few years, the Health Ministry has been working on the suicide prevention program, which is based largely on those in Ireland and Scotland. The pilot will start, at a cost of NIS 6.3 million, in Rehovot and Ramle, which have large elderly and Ethiopian immigrant populations, considered at-risk groups; and in Kafr Kana in the Galilee, due to the increase in suicide attempts among Arab youth.

The program will be considered successful if in a year and a half, cooperation has been established among the suicide prevention organizations, and suicides are down 10-15 percent.

The full scale of suicides in Israel is not known, and one of the objectives of the pilot is to create a reliable database to address this. For that purpose, the Health Ministry's Center for Disease Control, headed by Prof. Tami Shochat will review medical files in the Tel Aviv District of people whose cause of death is unclear.

"When someone dies of a drug overdose, falls from the fourth floor or drowns, if we look into the case and discover, for example, a history of psychological problems, we can determine whether it is a suicide," said Yemima Goldberg, the Health Ministry's chief psychologist and a partner in preparing the program. "We will try to debrief the families with great sensitivity."

In the meantime, the program's organizers have mapped out venues that attract suicides, known as "hot spots."

"These are places that attract people with suicidal tendencies," said Goldberg. "One example used to be Tel Aviv's Shalom Tower, because people often jumped to their death." She is not willing to disclose current hot spots, for fear that their appeal will increase (studies have shown correlations between available information on suicide methods and the number of people who use them).

"Such venues can be tall towers, hotels or railroad tracks; any place with easy public access," she said. Several general hospitals in the center of the country also have turned into suicide venues.

Fencing off the hot spots may help reduce suicides. "According to studies, when access to the hot spot was blocked, its cache declined and no new spot appeared to take its place," said Goldberg. In Austria, for example, one subway station was a hot spot for suicides, but after it was fenced off, the suicide attempts were not relocated. There will not be any fencing installed as part of the pilot.

As a matter of course, the program considers family doctors the primary collaborators in suicide prevention. However, it also focuses on community "gatekeepers," a broad spectrum of people: social workers at boarding schools, group hostels, welfare offices and old-age homes; workers at absorption centers, Israel Prisons Service representatives and army commanders; and National Insurance Institute evaluators, who visit the elderly at their homes.

These people will be taught to identify signs of distress, such as depression.

Teachers and school guidance counselors will also be involved.

All of them, program officials believe, can warn of distress and make referrals to supportive frameworks. The program will also attempt to identify at-risk students using questionnaires prepared by Columbia University, targeting non-heterosexual students.

The program will also incorporate in medical clinics and hospitals. "Studies around the world have shown that 60 percent of people considering suicide contact family doctors in the six months prior with somatic complaints, such as stomach pains and headaches," said Goldberg. "Family doctors are usually afraid to touch the subject and make a referral to a psychiatrist, but they too can provide help."

They will be asked to help identify early signs of suicidal tendencies in the elderly and among teens, such as insomnia, decreased appetite, self isolation, bad moods and restlessness, which herald depression. Among youths there are other preliminary indicators: keeping to oneself, and saying goodbye to friends in letters and poems.

"The doctor can find out from the patient about his mood, if there have been any behavioral changes, and in many cases, just asking the question already leads to a change," said Goldberg. "When you help a patient, he understands people are taking an interest in him, and the suicidal tendencies recede."

Later on the physician can offer the patient anti-depressants or refer him to professional treatment.

Carmel believes there is room to expand the training beyond the doctors. "A patient can have a personal conversation with the secretary while waiting for the doctor, or with the nurse who takes a blood sample. If the secretary at the clinic just asks the patient how he is doing, which generally does not happen, the concern and interest may lead to the desired change."

Later on, the program's formulators hope to enlist gatekeepers from the private sector, such as taxi drivers, hairdressers and manicurists - anyone who gets into intimate conversations during the course of their work, even security guards. Parents will also be mobilized.

"The ultimate gatekeeper is a relative," said Carmel. "Parents should be instructed on how to spot suicidal tendencies like they take an interest in signs of attention deficit disorders, alcohol addiction, drug use and violence."

And what happens when the gatekeepers find suicidal tendencies? "We have no intention of referring people to lengthy mental health treatment," Goldberg said. They will be referred to a dozen sessions of cognitive-behavorial treatment (CBT) or dialectic-behavioral treatment (DBT).

Carmel, a former director general of the National Road Safety Authority, sees his new position as a direct continuation of his previous one. "The state invests a lot more money in preventing accidents as opposed to preventing suicides, even though suicides are a major cause of death," said Carmel. "I believe there are more deaths from suicide than from road accidents."

JDC director general Amnon Mantver said, "As a social welfare organization, we look at the weaker segments in society, such as senior citizens, immigrants, at-risk children and teens, and it turns out that one of the dangers these people face is themselves. We would like to move the government ministries to act together to combat this phenomenon," says Mantver, "when there is an effort to create an interventional continuum, at several junctures along the way it is possible to prevent suicides more effectively."
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