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Brian L. Mishara, Ph.D., Director Centre for Research and Intervention on Suicide and Euthanasia Professor, Psychology Department mishara.brian@uqam.ca & Ccile Bardon, M.S., Project Coordinator Centre for Research and Intervention on Suicide and Euthanasia Universit du Qubec Montral www.railwaysuicideprevention.com

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IMPOSSIBLE TASK: CRITICALLY SUMMARIZE RAIL SUICIDE PREVENTION in 25 MINUTES

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Plan 1. Not quite everything you wanted to know about suicide and suicide prevention in 5 minutes 2. Where train suicides fit in 3. Some results from our recent studies in Canada 4. Conclusions 5. Recommendations for research and evaluation Thanks to our sponsor: Transport Canada, our Steering Committee as well as the railways and union and rail personnel in Canada who collaborated in our research

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Not quite everything you wanted to know about suicide and suicide prevention Suicide exists in every country in the world and there have always been suicides everywhere

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Not quite everything you wanted to know about suicide and suicide prevention Over 1,000,000 suicide deaths/year, more than in all wars, terrorist attacks and homicides combined People who kill themselves in Europe and North America generally have serious mental health and/or alcohol/drug abuse problems Suicide is the result of a complex interaction between risk and protective factors there is never just one simple cause Over half of suicides in Western countries occur under the influence of alcohol or drugs that compromise the ability to make reasonable decisions. Also, mental illness and being in a crisis situation make for poor choice of suicide as a solution to problems.

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Not quite everything you wanted to know about suicide and suicide prevention It takes more than having a mental health problem to commit suicide most people with serious problems never attempt suicide and most seriously suicidal people get help and change their minds (prevention usually works) No matter how serious attempters appear, they are usually happy to be saved If acceptable means are not available, the risk is greatly diminished (e.g. controlled access to bridges, firearms, drugs) Media reports on suicides, no matter how well intentioned, increase the risk of copy cat deaths in vulnerable people who are already at risk

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Where train suicides fit in the picture - The accident - suicide blur: reliable data not always available, but Europe and Canada have some of the best data - Why railway suicide? - Easy access - High lethality - Can result in quick death - Violent means can be attractive to some or repulsive to others - Impact on train drivers and personnel: severe

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Where train suicides fit in the picture People choose methods which Are readily available They think is a good method for them They learn that others use (from media or conversations or knowing someone who used that method) Are the in methods you read about it a lot In the case of Metro-subway suicides: They think they will certainly die, they will die quickly and painlessly (Weisman et al and our current study) (In Montreal this is not true most survive with handicaps) However, people hit by open track trains rarely survive -

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Where train suicides fit in Attempters often tell others about their plans or give identifiable signs May be seen as a cry for help Threats are often ignored or not taken seriously even in psychiatric institution Sometimes because threats occur often When an attempt is imminent, people often do not proceed with their plans when Help is offered (e.g. posters & phones near bridges, interventions by rail personnel) It is difficult to access the means, it is painful, too uncomfortable, disgusting or embarassing They are frustrated at least temporarily in completing their plan (buys time to get help, sober up and re- think plans)

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Overview of the global project PeriodPhaseObjectivesResults 2009- 2010 1Detailed analysis of all railway suicides over 10 years in Canada Comprehensive database of railway fatalities ( 1999-2008) Analysis of railway suicides and comparison with accidents (report Phase 1) Production of a Google map layer (2011) 2009- 2010 2Analysis of the impact of suicides on train crew members Interview study and qualitative analysis of the impact of railway fatalities Recommendations for support to employees (report Phase 2) 2010-20113aLiterature review on railway suicide preventive measures Review of preventive strategies around the world and their effectiveness (report Phase 3a) 2010-20113bLiterature review of measures to reduce the impact of fatalities on train crew members Review and evaluation of strategies and treatments implemented throughout the world to reduce the impact of fatalities and critical incidents on crew members (Report Phase 3b) 20114Development of proposals for intervention for the Canadian railway network Identification of 3 potentially effective strategies to reduce railway suicide and 2 strategies to reduce the impact of fatalities on crew members (report Phase 4) 2012-20145Knowledge application strategy Develop and implement a comprehensive knowledge application strategy to promote the new information gathered with stakeholders and help the industry and its partners implement suicide prevention strategies. Seek funding for pilot programmes.

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Study of suicides & accidents by rail in Canada over 10 years: Objectives: Determine the prevalence of railway fatalities in Canada Better understand: Circumstances surrounding suicides and accidents by rail Characteristics of victims Characteristics of train fatalities (description of incidents) Identify hot spots and clusters of incidents

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Behaviour (N of people displaying these behaviours information available for 671 cases) Accidents Driving across the tracks (97) Walking or running across the tracks (45) Does not move when train whistles (33) Walking on track facing away from train (32) Facing away from train (32) Lying on track (26) Stands or sits on track (21) Tried to get out of the way (13) Runs suddenly in front of the train (12) Sleeping on track (12) Going around barriers (11) Wearing a hoody or walkman (11) Walking along the track (11) Made contact with the side of train (10) Suicides Runs out suddenly in front of the train (99) Lying on the track (80) Stands or sits on track (79) Facing the train (57) Does not move when train whistles (53) Head on rail (40) Facing away from train (35) Looking at the driver / train engine (33) Placing arms out (22) Walking along track (19) Walking on track facing train (14) Driving across track (10) Gesturing towards crew (10)

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Characteristics of train fatalities By type of trains Accidents occur more often with freight trains and suicides more with passenger trains By type of collision Suicides mostly involve pedestrians Accidents are more evenly spread between vehicle and pedestrian collisions

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Circumstances of incidents Geographical location Accidents occur more often at crossings and suicides on open tracks Accidents occur more often in rural areas and suicides in urban areas Accidents tend to be at crossings in rural areas Suicides are more often open trackrack in urban areas

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No very high frequency hotspots in Canada Out of 278 incidents in clusters, only 15 clusters with 5+ incidents over 10 years (max 11 incidents) Hotspots Suicide clusters are more common in urban areas Accident clusters are more common in rural areas Suicide clusters (35.3%) are more likely to be close to a psychiatric hospital than accident clusters (10.0%) - (Chi2 = 4.54, df=1, p

Costs associated with train fatalities Traffic is stopped an average of 3 hours (from 91 min. in BC to 207 min. in ON) No variation with manner of death, type of incident, type of train, crossing or track, rural or urban Time off and health care 3 days off : Average of 119 fatalities / year = 357 work days minimum lost Workers compensation : over 51 incidents = 2 workers stopped completely, 8 took >3days (mean = 77.25 days off) Therapy costs difficult to assess

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Prevention of railway suicide 20 Review : Several strategies have been implemented in different countries With no proof of effectiveness to date Public education on safety Changing desirability of train as a method of suicide With minimal proof of effectiveness Television surveillance Gatekeepers in stations Signs (without telephones) Media education (works sometimes) Charging families for clean-up Blue Lighting Promising (several studies have shown an effect) Limiting access to tracks Phones and signs (effective with bridges and parking areas) Suicide pits (raised rails) in stations Preventive education in mental health facilities near tracks (not directly tested on rail suicides, but can prevent suicides in general) A railway suicide prevention strategy should be local and combine several activities

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Providing access to help in the community Identifying at risk people in the community Providing access to help on and around railway property Identifying at risk persons on railway property Discouragin g trespassing Monitoring track trespassing Limiting access to tracks Reducing risk of injury Technical approachPsychosocial approach Preventing impact Preventing suicide attempts Preventing injury Classification of activities for railway suicide prevention

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Proposals for pilot testing of railway suicide prevention adapted to the Canadian context 22 1. Telephones & signs (expensive) 1b. Signs only (much less expensive and potential partners, less probable impact) 2. Training for mental health institutions (less expensive)

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23 Overall assessment of feasibility (telephones and signs) Advantagesdifficulties Technical feasibility Public telephone and signage technologies are well established throughout all concerned provinces The maintenance of telephones equipment might be a challenge Vandalism on telephones and signs may be an issue that would reduce access to help. It may also be a problem for the telephone service provider who might be reluctant to be associated with a suicide prevention project if a suicidal person died after trying to use a damaged telephone to call for help Public telephones are currently being withdrawn everywhere. Therefore, the use of existing telephones to implement a direct line may prove ineffective Financial feasibility Public telephone companies seem willing to help share costs of installing dedicated telephones through their community involvement programmes The costs are very high and maintenance costs very difficult to anticipate It is financially not possible to install telephones in more remote rural areas. Potential to prevent railway suicides Direct and easy access to help has proved to be a good means to prevent suicide attempts, when distressed persons in proximity to a means to kill themselves. By placing telephones in strategic places along the tracks, it is possible to increase help seeking behaviour and reduce the number of attempts It is not possible to install telephones at every access point to tracks, therefore, the effect will necessarily be limited, especially outside of urban areas. Potential effects in other areas The signs and telephones may increase overall public access to a helpline, not just potential rail suicide victims. This may increase help seeking by distressed people in general and reduce global rates of suicides and suicide attempts by other means than train

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Overall assessment of feasibility (training programme) 24 AdvantagesDifficulties Technical feasibilityThis project does not involve any specific technical equipment or ability that the research team does not already possess It will be difficult to monitor the number of cases of railway suicide risk that will be identified by trained staff. Monitoring in such contexts is notoriously difficult. Financial feasibilityThe project has a relatively low cost. Parts of the training could potentially be financed by local mental health governing bodies such as CSSS in Qubec. An unexpected cost may be associated with the relatively high turnover rate that mental health and community services face. More training sessions than expected may have to be conducted. Potential to prevent railway suicides Identifying at risk patients is a well recognised way to improve suicide prevention. The present project also aims at training professionals from psycho-social and community services, increasing the chances of reaching suicidal people who do not seek medical help. Since not all suicide victims consult a mental health professional prior to their death, a prevention strategy that targets mental health services will not identify of all potentially suicidal people. Potential effects in other areasTraining professionals, and offering refresher sessions helps renew and maintain their attention to the problem of evaluating suicide risk in patients. This increased awareness will apply to all patients, and should benefit all suicidal persons, whether or not railway suicide is of concern.

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Conclusions 1) There are significant differences between TSB, Railway Police and Provincial Coroner and Medical Examiner data. It would be worthwhile to develop a mechanism to better communicate between the 3 levels to ensure that all have a complete portrait of rail deaths (suicides and accidents) in Canada

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Conclusions 2) Surprisingly, both suicides and accidents occur generally when visibility is good, and at any time, although accidents are more likely in snowy and icy conditions and suicides are more likely during gloomy overcast weather. There are however more accidents at night and early, before 5 am, suggesting that fatigue may play a role. Fatalities occur near home. Accidents are more likely at crossings in rural areas and involving freight trains. Suicides more often occur on open tracks in urban areas and involve passenger trains.

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Conclusions 3) Substance abuse (mostly alcohol) is involved in 73% of accidents and 46% of suicides.

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Conclusions 4) Since older adults (>60) and children are more likely to be accident victims, they could be specific target populations for prevention activities.

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Conclusions 5) In the case of accidents, a portrait of impairment in victims is common: impaired judgement or ability to get out of the way children older persons alcohol and substance abuse risk taking late at night or early morning with possible fatique recent conflicts or problems that may preoccupy victims This suggests that more intense warnings to compensate for impairments may be warranted.

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Conclusions 6) As found in England, a significant number of suicides were near psychiatric facilities and 35% of suicide clusters were within 2 miles of a psychiatric facility. This suggests the possibility of targeting psychiatric institutions near accessible railway tracks with prevention activities.

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Conclusions 6) The scene of railway deaths can be very gory: 66% of cases the body is in more than one piece; 1 out of 20 cases the body was decapitated blood everywhere in 88% of fatalities. The impact on railway personnel and observers, as well as emergency personnel who arrive on the scene can be traumatic. One should also be concerned about the impact upon onlookers and emergency personnel called to the scene.

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What we need to know More about who, where, when (including hot spots) Motivations and beliefs of attempters WE NEED TO EVALUATE THE IMPACT OF PREVENTION STRATEGIES USING RIGOROUS SCIENTIFIC METHODS We are currently interviewing attempt survivors in hospital to understand why they chose rail-metro suicide We are analysing video tapes of Montreal Metro suicides to identify behavioural patterns in stations and testing the validity of our identification methods We are proposing and plan to evaluate best practices to reduce the impact on railway personnel

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The DANGER of being focussed on our own narrow interests

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Some untested ideas inspired from research findings needing evaluation Because of the impaired abilities of accident victims (elders, children, intoxicated, fatigue, etc.),, MUCH MUCH more intrusive warnings at crossings and of trains approaching on open tracks (visual, auditory, sensual (trembling ground?) could help avoid accidents. Computerized video surveillance to identify at risk behaviours and precursors (e.g. our Metro Montreal study) Emergency phones and posters at hot spots (effectiveness and what type of image and message is best needs to be determined) Anti-suicide train bumpers (psychological effects) Suicide Prevention protocols in mental health facilities that have multiple train suicides (near hot spots). Decreasing sensational media reports on railway suicides Making it embarassing, disgusting, undignified or hurtful to access tracks and your ideas?

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