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Should we invest in suicide prevention programs?
The Journal of Socio-Economics 37 (2008) 262–275
Should we invest in suicide prevention programs? Nazmi Sari a,∗ , Sahily de Castro b , Frederick L. Newman b , Gerry Mills c a
University of Saskatchewan, Department of Economics and SPHERU, Arts 815, Saskatoon SK S7N 5A5, Canada b Florida International University, USA c Mercer University, USA Accepted 1 December 2006
Abstract Suicide is the third leading cause of death among college aged youths in Florida. However, there is no prevention program targeting this population group. This paper examines the potential impact of making two prevention programs, general suicide education and peer support programs, available for college students. The results show that both programs increase social welfare by creating social benefits which exceed the costs of the programs. These results hold true even with conservative estimates for effect rates and benefits of the programs. © 2007 Elsevier Inc. All rights reserved. JEL classification: I18; H43 Keywords: Suicide; Suicide prevention; Cost–benefit analysis; Human capital approach
1. Introduction Suicide is a major cause of death in the world. It is the 13th leading cause of death worldwide and even higher among younger people. In 2000, the global mortality rate due to suicide was 14.5 per 100,000 population, or one death about every 40 s (World Health Organization, 2002). It is also high among youth in the US. For instance; the suicide rate for persons 20–24 years old in 2003 was 68% higher than that of adolescents 15–19 years old (Centers for Disease Control and Prevention, 2006). The National College Health Risk Behavior Survey evaluated the incidence of suicide ideation among college students, aged 18–24 years, and concluded that during the first year preceding the survey, approximately 10% of the students had seriously considered attempting ∗
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suicide (Brener et al., 1999). As the suicide rate among young adults continues to rise, the economic burden imposed on society due to loss of life increases as well. However, investment decisions for prevention programs should depend on net return, i.e., the impacts of programs in preventing death or suicide attempts compared to the costs of the programs. Suicide prevention programs have been implemented at junior and high schools targeting this age group, but there is no program, to our knowledge, targeting youths between the ages of 18 and 24 in Florida. In this study, we examine the economic implications of suicide prevention programs if implemented at colleges and universities. Colleges and universities are concerned with imparting education, striving to amplify quality, fostering and supporting research and adequately training students. However, in some instances these institutions overlook the implications and demands of higher education on students’ mental health. According to Schwartz (1990), the size and prestige of the campus, and academic disappointment are factors that increase student suicide rates. It is likely that the students confront a variety of potential suicide high-risk situations such as depression, stress, drug/alcohol abuse, and societal/parental pressures. Gutierrez et al. (2000) suggest that suicidal ideation, non-lethal attempts and completed suicide are legitimate areas of concern for the university student population. A survey of 962 college students by Westefeld and Furr (1987) indicate that the incidence and prevalence of depression and suicide in college students is an area of vast concern. In this paper, we consider two types of suicide prevention programs aiming to target college students in Florida. The first program, general suicide education, typically used in middle and high schools, is a curriculum based suicide prevention program. The second program, peer support group program, can be conducted in either school or non-school settings, and is designed to foster peer relationships, competency development, and social skills as a method to prevent suicide among high-risk individuals. Our purpose is to estimate whether comprehensive suicide education and peer support programs would have positive social net benefits, and, therefore be beneficial to society, if implemented in colleges and universities. We use cost–benefit analysis on prevention programs with a target population of college students in Florida. Although suicide is the third leading cause of death among youths in Florida, there is no existing prevention program targeting this age group. If the economic evaluation of the programs indicates positive net social benefits for either or both programs, these results could influence policy makers in future use of prevention resources within the area of young adults or college age youth. 2. Suicide theories and their implications for prevention programs Some issues, such as marriage decisions, fertility, crime and punishment, smoking behavior, substance abuse and addiction, although not seemed questions directly regarded as economic issues, have been studied by economists, but suicide and suicidal behavior have received less attention. In contrast to other social scientists, economists stayed away from suicide and suicidal behavior despite its clear economic implications (for few exceptions, see Hamermesh and Soss, 1974; Rosenthal, 1993; Yang et al., 1992; Yaniv, 2001). Our aim in this section is not to provide a comprehensive review of the literature on suicide from economics and other disciplines but just review selected works that shed lights to the prevention programs studied in this paper (for a comprehensive review, see Lester, 1989, 2004). In the Hamermesh and Soss (1974) model, individuals’ decisions toward suicide are modelled under certainty for the outcome of their actions and perfect information for the future streams of income. In this framework, an individual would commit suicide if the present discounted utility from life, plus the individual’s taste for living become lower than zero. The model also depends
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on the assumption that the survival probability after a suicide attempt is zero, implying that there is no uncertainty for the outcome of an attempt. This theory considers the individual’s action as a rational act, suggesting that a cost–benefit comparison would be possible at that stage of life. Hamermesh and Soss do not provide any explanation for the impact of a suicide attempt on future utility since the model does not consider possibility of survival after an attempt. However, if the suicidal individual engages in a gambling type of suicidal behaviour as suggested in Rosenthal (1993), would it be possible to perform a cost–benefit comparison under uncertainty of suicide attempt and the future utility through compensation from other parties based on the outcome of the action? This seems not an easy judgement and hard to believe that someone in that stage of cognitive ability would make a rational calculation. In this model, there is also no explicit explanation for the taste of living. One particular reason would be to avoid the potential pain to third parties after a successful suicide attempt. At that particular time in life, even though an individual may not derive direct positive utility from living, he/she may choose to live in order to prevent possible suffering to others. As an alternative explanation, we offer status quo bias or endowment effect for the source of this type of taste (for an extensive review of this literature see Rabin, 1998). Both imply that once individuals possess a good, they start valuing the good more than before they possess it. Kahneman et al. (1991) suggest that these types of choices are best explained by changes in utility relative to a neutral reference point. This implies that individuals may have different reference points for living, which even may not be stable over time, and use suicidal attempts as signals to reflect their preference for living to others. This last argument is not compatible with the model provided in Hamermesh and Soss (1974). However, it is likely that individuals may use suicide attempt as a signal to others in order to get favourable treatments. This possibility was raised in Rosenthal (1993). Rosenthal (1993) examines suicidal behaviour in a signalling game framework. He develops a game theoretical model to analyze suicide attempts which have chances of either success or failure. In his model, an individual attempting suicide (sender) sends a signal through the severity of suicide attempt to others (receiver) in order to manipulate their behaviour. The sender knows his/her real intention while the receiver gets a signal only. If the signal is credible then the sender is compensated or gets favourable behaviour after the unsuccessful attempt. This implies that after an unsuccessful attempt, an individual’s future utility will be higher than ex ante expected utility, suggested in the Hamermesh and Soss (1974) model. Marcotte (2003) provides an empirical test for this hypothesis. Using survey data from the United States, he concludes that the suicide attempt and future income are closely correlated. Persons who attempted suicide and survived report higher income than persons who seriously considered but never attempted suicide. And an even higher economic improvement after an attempt was observed for those making the most severe suicide attempt. He concludes that resources and any attention due to suicide attempt are reserved for those attempts which present the most credible threat. The sociological theories of suicidal behaviour have been heavily influenced by Durkheim’s concept of social integration (Durkheim, 1951). It has been argued that social processes which decrease social integration results in an increasing suicide rate. Durkheim (1951) classifies this type of action as egoistic suicide. Egoism as stated in Lester (2004) results from excessive individualism and the individual is protected from egoism by family ties and social interactions. These types of theories stress the importance of social interaction and attachment to a group as a way of preventing the suicide. This implies that a social environment conducive to higher interactions would serve as an effective prevention method for suicide [see Lester, 1989 for a detailed discussion on sociological theories influenced by Durkheim, 1951].
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Suicide prevention programs range from antidepressant medication to individuals and group based methods. These can be crisis intervention and hotlines or telephone counseling, general suicide education, peer support groups, and means restriction of lethal methods. Antidepressant medications have been available for decades for individuals suffering with mental illnesses and depression with an assumption that depression may lead to suicide (Wood et al., 1996). However, the effectiveness of antidepressant drug use in suicide prevention varies in subsequent studies (Isacsson, 2000). Crisis intervention and telephone counseling have been widely used in many countries. These are the methods available for individuals seeking help, suggesting that these services may not reach other people, possibly many who are seriously considering committing suicide. It is therefore likely that the success rate of crisis intervention and telephone counseling would be overestimated due to self selection to the prevention methods/centers. Alternative methods are the community or group based programs, which are based on the assumption that among many suicide risk behaviors, the lack of social and family supports are the most important ones. Economic and sociological theories reviewed above lead to interesting conclusions about the nature of suicide, and suicide attempt. These theories also have implications for the suicide prevention programs. For example, Rosenthal’s signaling game has implications for suicide prevention, suggesting that depressed senders are less likely to engage in gambling type suicidal behavior if the receiver is very likely to give a sympathetic response (Yang and Lester, 1996). Thus, friends and relatives of potentially suicidal individuals should be encouraged to give sympathetic responses, and many suicide education programs train the participants to respond in sympathetic ways to their suicidal peers. Sociological theories influenced by Durkheim also have direct implication for prevention programs. Peer support programs, for instance, are designed to create an environment for social interaction among individuals through social gatherings and to create bonding relationship among peers. School-based programs such as general suicide education programs provide students with facts about suicide, alert them to suicide warning signs, and provide them with information about how to seek help for themselves or for others. Burns and Patton (2000) suggest that suicide education programs aim to raise awareness, train participants to identify individuals at risk and provide education regarding community mental health resources. These programs often incorporate a variety of self-esteem or social competency development activities. The idea for the general suicide education programs is that the more students know about suicide warning signs and sources of help, the more likely they will be to ask for help for themselves or refer others for help. The efforts of general suicide education programs to help students discuss feelings and promote interpersonal competence are meant to help increase their use of existing social support networks. If successful, general suicide education programs would presumably result in an increase in calls to hotlines and higher entry rates of suicidal youth into programs that provide mental health services. Implicit in the general suicide education approach is recognition of the difficulty of determining who, among thousands of healthy adolescents, is truly at high risk of suicide. For this reason, programs employing this strategy are given to all students, without efforts to screen and target high-risk youth [see King, 2001 for a review of a comprehensive school based prevention program]. Alternatively, peer support programs are a fairly new development for prevention programs, and a totally new concept for suicide prevention strategies. They can be conducted in either school or non-school settings, and are designed to promote peer relationships, competency development, and social skills as a method to prevent suicide among high-risk youth. Silbert and Berry (1991) point out that educators and peers are the first to detect suicidal behaviors and therefore, these individuals are most likely to be the rescuers for the youth planning and contemplating suicide.
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The goal is to provide a setting in which young people who may be at risk for suicide can receive the support of their peers and develop interpersonal and coping skills. As a result, it allows participants to increase their use of regular social support networks in order to improve their school attendance and performance. They might help to reduce antisocial behavior and substance abuse, factors associated with suicide. The programs also improve the functioning of youths and increase their use of social support networks to reduce the rates of suicide and premature death from other causes such as alcohol-related traffic fatalities and homicide. 3. Suicide deaths and costs of suicide in Florida 3.1. Suicide deaths among college students A suicide death is defined as intentional or deliberate self-harm or self-poisoning leading to or culminating in death. The data on suicide are based on the reported results from Florida Vital Statistics Annual Reports. A total of 189 suicide deaths were reported in Florida between the ages of 15 and 24; with 131 suicide deaths between the ages of 20 and 24, and 58 suicide deaths between the ages of 15 and 19 in 2000 (Florida Department of Health, 2000). The prevention programs being considered here are those which could be implemented in college campuses, targeting youths between 18 and 24. However, the suicide data are aggregated for those aged 15–24, and are not available by education level. Therefore, we make some assumptions to estimate the suicide among college students aged 18–24. We assume that death due to suicide is uniformly distributed among age cohorts. Under this assumption, the number of deaths for 18 and 19 years olds would be 40% of deaths for those aged 15–19. This implies that estimated death due to suicide for 18–24 age groups is 154 in 2000. In order to estimate the total number of deaths due to suicide among college students, we use the college enrollment rate of 42.5% as weights in 2000 for those 18–24 years (US Census Bureau, 2005a). With this adjustment, we estimate the deaths due to suicide among college students, aged 18–24, to be 65 in Florida. 3.2. Costs of suicides Suicide may have direct and indirect costs to the individual and to the society. Direct costs are costs directly traceable to youth suicide deaths, such as ambulance services and autopsy services. Indirect costs, however, are not directly associated with the event, but represent the lost value of a productive member of society, i.e., potential earnings lost due to premature death, and productivity loss of immediate family members. The American Ambulance Association (2002) reports the summary of Medicare Ambulance Fee Schedule, which lists the ground rates for service level Advanced Life Support, Level 2 (ALS2) classified as the administration of at least three different medications and/or the provision of one or more of the Advanced Life Support procedures that include manual defibrillation/cardioversion, endotracheal intubations, central venous line, cardiac pacing, chest decompression, surgical airway, and intraosseous line. The total ground rate for the ALS2 service in 2000 is US$ 468.99 allowable by Medicare. With the inclusion of gas mileage, this rate would be even higher. An average charge for autopsies in Florida within the age group of 18 and 24 years was US$ 3637.50 in 2002 (Agency for Health Care Administration, 2002). This corresponds to US$ 3482 in year 2000 dollars. Autopsies reported in this database were performed as inpatient hospital services. However, the cost of suicide autopsies would be higher since it requires additional services such as transportation of medical examiners to the scene, doctors’ time in collecting
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and reviewing data, investigator and morgue technician expenses and their time. This implies that based on information available from the Agency for Health Care Administration and the American Ambulance Association, we underestimate the actual direct cost associated with suicide. Years of potential life lost is one of the most important costs to the society after a suicide. It is a premature mortality measurement for the population, calculated using the number of deaths for each group multiplied by the years of life lost. We calculate the average number of potential years of life lost per suicide by taking the difference between 65 years and the mean age of suicide deaths, 21. As a result, the total life lost among college students in Florida would be 2860 years. Human capital approach is one of the most common methods used to estimate the value of life. In this method, the monetary value of each life is estimated using the market value of the output produced by an individual during his/her expected lifetime (Mishan, 1971; Giles, 2003). This approach measures the monetary value of life using the discounted value of future earnings resulting from an improvement or extension of life. In our application, average annual earnings by age and educational attainment in Florida are used as a proxy to estimate the contribution of each individual to the production process. The median earnings by age and educational attainment in Florida are available for those who worked full time in 1999 (US Census Bureau, 2005a). In order to obtain the future earnings, we adjusted current earnings using a rate of earning growth, which is a sum of nominal and real growth rates. The nominal rate of change is measured by a 10-year average change in consumer price index from 1990 to 2000 (US Census Bureau, 2005b). The real change is measured by differences in current wages among different age groups with the same level of education. 4. Economic analysis of prevention programs The assessment of suicide prevention programs in economic models requires evaluations of potential costs and benefits from prevention programs. According to Drummond et al. (1997), cost–benefit analysis is suitable when results beyond those of just the person’s or patient’s view need to be calculated. In this analysis, the aim is to calculate the net social benefit associated with a potential health policy decision and to determine the resource allocation so that the net benefit is maximized for the society. Cost–benefit analysis is also a method to take externalities into account in policy decision process. Although costs of the prevention programs are relatively straightforward to calculate, benefits are not easy to measure, especially when externalities play a role. For instance, if the event affects the third parties, i.e., immediate family members or relatives, it is extremely hard to calculate for third parties the value of the potential loss in production saved, or the value of the loss in satisfaction or utility averted due to a continuation of life and/or better health. Although the net benefit estimates will not be accurate when these additional benefits were not taken into account, it may still be sufficient to estimate the lower limits of the net benefits for competing health policy options to deal with this shortcoming. These are discussed in Section 4.4 in detail. The present discounted value of net benefit from each program is calculated using Eq. (1) below: NBi =
T (1 − pt )Bt t=0
(1 + r)t
− C0
(1)
where NBi stands for present value of net benefit from program i, Bt denotes the monetized benefits at time t. C0 is the costs of the program at the present time, and r stands for the rate of interest. The
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denominator captures the time preference of individuals implying that net benefit is worth more if it is experienced sooner. In our application, the costs of the program accrue at the present time, but each program yields a stream of future returns. This implies that we need to discount the future benefits using an appropriate discounting factor to reflect the time value of money (Feldstein, 1964; Sen, 1967). There is a likelihood that an individual may not survive to the next period, and may die due to other reasons with probability pt. To take this into account, benefits from saving an additional life year are weighted with survival probability of (1 − pt ) at time t. The survival rates can be obtained from a life table, which measures the incidence of mortality in a population. Using age-specific death rates, life tables for each year can be constructed to present demographic data including life expectancy at the current age, and survival rates to the next period. 4.1. Total costs General suicide education is typically used in middle and high schools. On occasion, it is a curriculum based suicide prevention program. For example, in California, a large school district similar to the Florida school district, where the population is also composed of a large number of minority groups, the state implemented the California School Suicide Prevention Program. This is a statewide youth suicide prevention program for high schools. The Centers for Disease Control and Prevention (1992) reported that this program consists of five lessons of one class period each and these lessons are to be taught in grade 9 through 12. The program was implemented in 1986, and the amount to fund the development of this suicide curriculum was US$ 300,000 for the first 3 years of development with an additional yearly cost of US$ 1000 for training and materials. The amount of funding varies among states, and it is estimated that Florida, specifically a grant received from Miami-Dade County school district, had a funding of US$ 120,000 per year in 1992. Under the assumption that the cost of the program increases at the same rate as the general increase in price level, the annual cost of implementing the program in Florida is US$ 147,000 per year for each program in year 2000 dollars. Therefore, the total cost of implementing the program in 119 college campuses is US$ 17.49 million. The second program, peer support group program, is an established program by the California Association of Peer Programs (CAPP). The CAPP is a corporation that is dedicated to the establishment and support of youth service through peer support programs. It serves suicidal youths involved in peer programs. The budget needed for peer programs depends on the number of participants, style of training, district, state policies and local resources. Peer led programming allows young people to develop skills in cooperative learning. Through this program youth investigate together issues they feel adults may not relate to, and the program instills leadership skills in the youth. They learn to share with and comfort with each other. Furthermore peer support groups create and help to develop empathy, and empathy is a critical component for social and cognitive development. This program is a prevention program that has proven to be effective in areas such as alcohol and drug abuse (Tobler and Stratton, 1997). The cost savings in peer support programs are substantial since peer services are directed by the peers rather than by paid professionals. The savings apply to the college age population, where friendships and associations during college years have usually long lasting effects. The main program cost is generally housing, chartering a bus or transportation and food for a weekend retreat. According to the CAPP, the approximate total budget needed to implement a peer support group per year is US$ 69,060 in 1992. The CAPP uses the budget in Table 1 as an intensive training program to understand and to develop a quality peer program in schools. Using these values, we estimate that the total annual cost for the program would be US$ 84,760 in year 2000
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Table 1 Peer support program budget in 1992 Categories
Description
Housing and food for retreat Transportation Supplies Postage Trainers’ honorariums Computer cards and time
US$ 40 per person (2 nights and 6 meals) Bus transportation for 120 miles Paper, hand-outs, training materials, etc. Postage expenses Payment for trainers US$ 0.05–0.07 each to purchase cards for needs assessment survey Coordinator stipend If not volunteered for after school sessions Other expenses
In-school coordinator stipend Snacks Miscellaneous Total per month Total per year
Monthly cost (US$) 1600 3000 100 25 200 150 600 30 50 5755 69,060
Source: California Association of Peer Programs (2002).
dollars. This implies that the total cost of statewide implementation of the program is US$ 10.09 million. 4.2. Total benefits The calculation presented in the suicide costs per youth is converted into benefits to society. For example, autopsy charges of US$ 3482 are a part of monetary benefits to the society due to preventing one suicide death, and consequently the same applies for other direct and indirect costs due to suicide. The potential earning lost is calculated under the assumption that the future growth rate of potential earnings would be equivalent to the rate of growth in the Consumer Price Index plus an increase in earnings due to productivity growth. Assuming an average age of 21 at the time of suicide, and average educational level of less than 4 years of college, the lost earnings would have amounted to a present value of US$ 0.96 million when discounted at an interest rate of 6.3%, a rate used by Federal government for the long term projects in 2000 (Office of Management and Budget, 2006). These calculations are based on earnings lost for those aged 21–65, weighted with the survival probabilities (see Arias, 2002 for survival probabilities in 2000). The calculated direct and indirect cost per youth aged 18–24 years amounted to more than US$ 0.96 million in Florida, suggesting that each prevention program increases the social welfare by US$ 0.96 million for each life saved. However, the programs are not 100% effective in preventing suicides. According to de Castro et al. (2004), effect rates of general education and peer support programs are 57% and 60%, respectively. To calculate the total benefit from each program, we use effect rates as weights to estimate the total number of students who would have been saved if the programs were available in 2000. This would suggest that 37 and 39 students would have been saved if the general education and peer support programs were available in each campus. Using these effect rates, we calculated total benefits from each program and reported the results in Table 2. 4.3. Cost–benefit comparisons Table 2 shows the net benefits as well as the benefit cost ratio for both programs. Initially, future returns are discounted at an interest rate of 6.3%. As shown in Table 2, the benefit cost
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Table 2 Cost–benefit analysis Prevention program
Discount rate (%)
Benefit (million US$)
Cost (million US$)
Net Benefit (million US$)
Benefit–cost ratio
General suicide education Peer support program
6.3 6.3
35.56 37.43
17.49 10.09
18.07 27.34
2.03 3.71
Note: Cost of each program is calculated under the assumption that programs are implemented in all university/college campuses.
ratio for the peer support program is 3.71, suggesting that the benefit to the society is US$ 3.71 for each dollar invested. General suicide education program also shows a positive net benefit with benefit–cost ratio of 2.03. The net benefit from the peer support prevention program exceeds that of general suicide education program. These results align favorably with those found for cost–benefit analysis on a drug abuse prevention program conducted by Kim et al. (1995) where the benefit cost ratio is 14.89, indicating that the benefit in drug prevention efforts is of US$ 14.89 for every dollar invested. 4.4. Sensitivity analysis Our results in Table 2 above depend heavily on the choice of discount factor, and the choice of effect rates for prevention programs. As an alternative, we calculate the net benefit for each program at various discount rates and effect rates. Fig. 1 presents the net benefits of each program at a range of discount rates from 4% to 20%. It is shown in Fig. 1 that the net benefits of both programs are positive as long as the discount rate is lower than 11%. For the peer support program, the break-even discount rate is even higher. Although the net benefit of the peer support program is higher at all discount rate, the results imply that implementation of either programs would contribute substantially to the social welfare if the discount rate is not higher than 10%. The Office of Management and Budget mandates a 5.2% discount rate in 2006 for use in all federal policy analysis with durations 30 years or longer (Office of Management and Budget, 2006). This implies that at this mandated discount rate, policy makers could increase the social welfare more than US$ 36 million per year by implementing
Fig. 1. Net benefits of prevention programs.
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Fig. 2. Net benefit in general education program by discount rate.
the peer support program or more than US$ 26 million per year by implementing general suicide education program in Florida. These estimates are based on effect rates of 57% and 60% for general education and peer support programs, respectively. These rates were just 15% and 20% better than the success rates for high-risk adolescents in the control condition who received general health education only. The 95% confidence interval for these two predicted levels of success are plus or minus 5% for the general education program, and plus or minus 12% for the peer support group program. This suggests that lower boundaries for effect rates are 52% for general education program, and 48% for peer support program (Lipsey and Wilson, 2001). We provide estimates for net benefits from both programs by various effect rates and discount factors in Figs. 2 and 3. At 5% discount rate, general education program provides positive net benefit if the effect rate is higher than 22%. For peer support program, net benefit is positive if the effect rate is higher than 14%. At the lower boundaries for effect rates and 5% discount rates, the social welfare increases more than US$ 22
Fig. 3. Net benefit in peer support program by discount rate.
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million per year by implementing the peer support program or more than US$ 23 million per year by implementing general suicide education program in Florida.1 The net benefit estimates above do not take several other monetary and non-monetary benefits into account; therefore, they underestimate the actual benefit from the prevention programs. We identify additional benefits of a successful prevention program not taken into account in our estimations: when a suicide is prevented and the person lives a productive life, then reduction in productivity loss of immediate family members is quite obviously an additional monetary benefit of a prevention program. Other additional benefits, although non-monetary in nature, may include improved social functioning, higher educational achievement, reduced personal and family stress, better household management, improved social support, improved mental health, fewer social and emotional adjustment problems, improved physical health, fewer injuries, and improved social functioning in young adults. Some of the additional benefits presented above would be taken into consideration using alternative methods for measuring the value of life. One of which is the willingness-to-pay approach. In this approach, the estimates represent society’s willingness to pay to avoid the death or injury. Although, the human capital approach depends only on the market value or contributions of each individual to the production process as measured by its market value, the willingness-to-pay approach measures the total value of life by including both the market value, i.e., forgone earnings and the non-market value received from life and good health. Hence, the estimates from the latter approach would be higher than that generated by the human capital approach. Based on numerous studies, Viscusi (1993) reports that the willingness-to-pay estimates for value of life range between US$ 3 and 7 million in year 1990 dollars. In Miller (1990), it is higher than US$ 3.4 million in year 1995 dollars. The lower limits from these studies correspond to US$ 3.95 million and US$ 3.84 million in year 2000 dollars, respectively. This suggests that our estimates from the human capital approach underestimate the benefit from prevention programs since even with the lowest discount rate of 4% the value of life estimate is less than US$ 1.54 million (for a comparison of value of life estimates from different methods, see also Blomquist, 1981; Linnerooth, 1979; Viscusi, 1983). Under the assumption of the lowest value of life estimate of US$ 3.84 million from the willingness-to-pay approach, which may take most of the additional benefits presented above into account, and using the lower boundaries for effect rates, the implied net benefits from the general education and peer support programs would be more than US$ 112 million and US$ 109 million, respectively. The results indicate that the implementation of general suicide education programs and/or peer support group programs provide positive net benefits to the society even with the most conservative value of life estimates. 5. Conclusions Cost–benefit analysis enables researchers to identify effective programs and assist policy makers in evaluating new policies. It is a valuable tool, allowing the researcher to place monetary estimates on life and enabling the calculation of cost and benefits for prevention or intervention programs, particularly for suicide prevention. Our economic evaluation of two specific suicide 1 A critical question here is whether the 57% and 60% of those who participated in their respective programs and whose suicide risk and hopelessness was decreased would necessarily not attempt or would not successfully commit suicide. That would require a very large-scale longitudinal study, one that is yet to be performed. For the ensuing analysis and discussion, we will make the assumption that the answer to the question is yes and the results of the analysis must be limited by this assumption. As an alternative, we also estimate the net benefits for various effect rates in Figs. 2 and 3.
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prevention programs, general suicide education and peer support programs, shows that both programs are cost beneficial interventions. Even with the most conservative estimates, these programs would provide at least US$ 22 million per year. One of the important limitations is the conjecture of the underreporting of suicide. Kleck (1988) argues that the net underreporting is estimated around 10–20%. There are other studies suggesting that there may be correlation between vehicle accidents and suicide deaths (Peck and Warner, 1995). Therefore, if the conjecture of under reporting of suicidal deaths is true; then our net benefit estimates would be even higher for both programs. We make some assumptions with regard to the direct cost of suicide. The ambulance cost calculations, for instance, are based on data reported by the American Ambulance Association, rather than original ambulance invoices. Autopsy services may also vary in cost, especially when dealing with suicide deaths. These assumptions can be addressed by directly working with each suicide case if researchers have a direct access to the suicide database. Several possible strategies and suggestions may guide future cost–benefit analysis on suicide prevention programs. Potential directed research at colleges and universities should focus on data refinement that will support the cost–benefit analysis of suicide prevention programs. Another suggestion is to target the families of those who committed suicide to understand the added cost to family members in terms of their coping strategies, e.g., taking time off from work, or school, which may require additional resources or lost opportunities. Additional costs may be accrued by an increased utilization of health care and mental health resources after the death of a loved one. Future efforts should also attempt to consider the differential costs due to gender, differences in earning and socio-economic status of the person who died, as well as that of those who mourned the death. Additional research may include replicating this study and exploring states where suicide mortality is higher, such as Oregon and Vermont, and specific areas where there is a great concentration of colleges and universities and young adults. Acknowledgements We would like to thank anonymous referees, and the discussant and participants of 2005 Western Economic Association Meeting, San Francisco, for their insightful comments and suggestions. References Agency for Health Care Administration, 2002. Hospital and Outpatient Care Health Data. Florida Health Statistics Online Database at http://www.floridahealthstat.com/hosp amb.shtml. American Ambulance Association, 2002. Summary of Medicare Ambulance Fee Schedule-Final Rule. Retrieved November 15, 2004 from http://www.the-aaa.org/industryissues/reimbursement/medicarefs/feeschedule summary.htm. Arias, E., 2002. United States Life Tables, 2000. National Vital Statistics Reports 51(3). National Center for Health Statistics, Hyattsville, Maryland. Blomquist, G., 1981. The value of human life: an empirical perspective. Economic Inquiry 19, 157–164. Brener, N.D., Hassan, S.S., Barrios, L.C., 1999. Suicidal ideation among college students in the United States. Journal of Consulting and Clinical Psychology 67 (6), 1004–1008. Burns, J.M., Patton, G.C., 2000. Preventive interventions for youth suicide: a risk factor-based approach. Australian and New Zealand Journal of Psychiatry 34 (3), 388–407. Centers for Disease Control and Prevention, 1992. Youth Suicide Prevention Programs: A Resource Guide. Centers for Disease Control and Prevention, Atlanta. Centers for Disease Control and Prevention, 2006. Leading Causes of Death Reports: 1999–2003. National Center for Injury Prevention and Control. Retrieved April 3, 2006 from http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html.
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de Castro, S., Mills, G., Sari, N., Newman, F.L., 2004. Using meta analysis to generate a cost–benefit analysis of two suicide prevention programs for the middle and high school age population in Florida. In: Session on Mental Disorders Among Children: Epidemiology and Prevention. American Public Health Association Meeting, Washington, DC, November 2004. Durkheim, E., 1951. Suicide: A Study of Sociology. The Free Press, New York. Drummond, M.F., O’Brien, C.P., Stoddart, G.L., Torrance, G.W., 1997. Methods for the Economic Evaluation of Health Care Programmes. Oxford University Press, New York. Feldstein, M.S., 1964. The social time preference rate. Economic Journal 74, 360–379. Florida Department of Health, 2000. Florida Vital Statistics Annual Report 2000. Retrieved April 7, 2005 from http://www.doh.state.fl.us/planning eval/vital statistics/00vitals/deaths.pdf. Giles, M., 2003. The cost of road crashes: a comparison of methods and recent Australian estimates. Journal of Transport Economics and Policy 37 (1), 95–110. Gutierrez, P.M., Osman, A., Kopper, B.A., Barrios, F.X., Bagge, C.L., 2000. Suicide risk assessment in a college student population. Journal of Counseling Psychology 47 (4), 403–413. Hamermesh, D.S., Soss, N.M., 1974. An economic theory of suicide. Journal of Political Economy 82 (1), 83–98. Isacsson, G., 2000. Suicide prevention: a medical breakthrough? Acta Psychiatrica Scandinavica 102 (2), 113–115. Kahneman, D., Knetsch, J.L., Thaler, R.H., 1991. Anomalies: endowment effect, loss aversion, and status quo bias. Journal of Economic Perspectives 5 (1), 193–206. Kim, S., Coletti, S.D., Crutchfield, C.C., Williams, C., 1995. Benefit–cost analysis of drug abuse prevention programs: a macroscopic approach. Journal of Drug Education 25 (2), 111–127. King, K.A., 2001. Developing a comprehensive school suicide prevention program. Journal of School Health 71 (4), 132–137. Kleck, G., 1988. Magnitude of underreporting of suicide. Suicide and Life Threatening Behavior 18 (3), 219–236. Lester, D., 1989. Suicide from a Sociological Perspective. Charles Thomas Publisher, Springfield, IL. Lester, D., 2004. Thinking About Suicide: Perspectives on Suicide. Nova Science Publishers, New York. Linnerooth, J., 1979. The value of human life: a review of the models. Economic Inquiry 17, 52–73. Lipsey, M.W., Wilson, D.B., 2001. Practical Meta-Analysis. Sage Publications, Thousand Oaks, CA (Chapter 8). Marcotte, D.E., 2003. The economics of suicide. Revisited. Southern Economic Journal 69 (3), 628–643. Miller, T.R., 1990. The plausible range for the value of life—red herrings among the Mackerel. Journal of Forensic Economics 3, 17–39. Mishan, E.J., 1971. Evaluation of life and limb: a theoretical approach. Journal of Political Economy 79 (4), 687–705. Office of Management and Budget, 2006. Discount Rates for Cost–Effectiveness, Lease Purchase and Related Analyses, Circular No. A-94 Appendix C. Retrieved April 3, 2006, from http://www.whitehouse.gov/omb/circulars/ a094/dischist-2006.pdf. Peck, D.L., Warner, K., 1995. Accident or suicide? Single-vehicle car accidents and the intent hypothesis. Adolescence Sum 30 (118), 463–472. Rabin, M., 1998. Psychology and economics. Journal of Economic Literature 36 (1), 11–46. Rosenthal, R.W., 1993. Suicide attempts and signaling games. Mathematical Social Sciences 26, 25–33. Schwartz, A.J., 1990. The epidemiology of suicide among students at colleges and universities in the United States. Journal of College Student Psychotherapy 4, 25–44. Sen, A.K., 1967. The social time preference rate in relation to the market rate of interest. Quarterly Journal of Economics 81, 112–124. Silbert, K.L., Berry, G.L., 1991. Psychological effects of a suicide prevention unit on adolescents’ levels of stress, anxiety and hopelessness: implications for counseling psychologists. Counseling Psychology Quarterly 4 (1), 45–58. The California Association of Peer Support Programs, 2002. Program Organization Funding-Projecting a Retreat Budget. Tobler, N.S., Stratton, H.H., 1997. Effectiveness of school-based drug prevention programs: a meta-analysis of the research. The Journal of Primary Prevention 18, 71–128. US Census Bureau, 2005a. 2000 Census Summary File 3, Matrices P37 and PCT25, Quick Table-P20 Educational Attainment by Sex 2000. US Census Bureau, 2005b. 2001 Statistical Abstract of the United States. Retrieved November 3, 2005 from http://www.census.gov/prod/2002pubs/01statab/prices.pdf. Viscusi, W.K., 1983. Alternative approaches to valuing the health impacts of accidents: liability law and prospective evaluations. Law and Contemporary Problems 46 (4), 49–68. Viscusi, W.K., 1993. The value of risks to life and health. Journal of Economic Literature 31, 1912–1946. Westefeld, J.S., Furr, S.R., 1987. Suicide and depression among college students. Professional Psychology: Research and Practice 18 (2), 119–123.
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Should we invest in suicide prevention programs? Nazmi Sari a,∗ , Sahily de Castro b , Frederick L. Newman b , Gerry Mills c a
University of Saskatchewan, Department of Economics and SPHERU, Arts 815, Saskatoon SK S7N 5A5, Canada b Florida International University, USA c Mercer University, USA Accepted 1 December 2006
Abstract Suicide is the third leading cause of death among college aged youths in Florida. However, there is no prevention program targeting this population group. This paper examines the potential impact of making two prevention programs, general suicide education and peer support programs, available for college students. The results show that both programs increase social welfare by creating social benefits which exceed the costs of the programs. These results hold true even with conservative estimates for effect rates and benefits of the programs. © 2007 Elsevier Inc. All rights reserved. JEL classification: I18; H43 Keywords: Suicide; Suicide prevention; Cost–benefit analysis; Human capital approach
1. Introduction Suicide is a major cause of death in the world. It is the 13th leading cause of death worldwide and even higher among younger people. In 2000, the global mortality rate due to suicide was 14.5 per 100,000 population, or one death about every 40 s (World Health Organization, 2002). It is also high among youth in the US. For instance; the suicide rate for persons 20–24 years old in 2003 was 68% higher than that of adolescents 15–19 years old (Centers for Disease Control and Prevention, 2006). The National College Health Risk Behavior Survey evaluated the incidence of suicide ideation among college students, aged 18–24 years, and concluded that during the first year preceding the survey, approximately 10% of the students had seriously considered attempting ∗
Corresponding author. Tel.: +1 306 966 5216; fax: +1 306 966 5232. E-mail address: [email protected] (N. Sari).
1053-5357/$ – see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.socec.2006.12.029
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suicide (Brener et al., 1999). As the suicide rate among young adults continues to rise, the economic burden imposed on society due to loss of life increases as well. However, investment decisions for prevention programs should depend on net return, i.e., the impacts of programs in preventing death or suicide attempts compared to the costs of the programs. Suicide prevention programs have been implemented at junior and high schools targeting this age group, but there is no program, to our knowledge, targeting youths between the ages of 18 and 24 in Florida. In this study, we examine the economic implications of suicide prevention programs if implemented at colleges and universities. Colleges and universities are concerned with imparting education, striving to amplify quality, fostering and supporting research and adequately training students. However, in some instances these institutions overlook the implications and demands of higher education on students’ mental health. According to Schwartz (1990), the size and prestige of the campus, and academic disappointment are factors that increase student suicide rates. It is likely that the students confront a variety of potential suicide high-risk situations such as depression, stress, drug/alcohol abuse, and societal/parental pressures. Gutierrez et al. (2000) suggest that suicidal ideation, non-lethal attempts and completed suicide are legitimate areas of concern for the university student population. A survey of 962 college students by Westefeld and Furr (1987) indicate that the incidence and prevalence of depression and suicide in college students is an area of vast concern. In this paper, we consider two types of suicide prevention programs aiming to target college students in Florida. The first program, general suicide education, typically used in middle and high schools, is a curriculum based suicide prevention program. The second program, peer support group program, can be conducted in either school or non-school settings, and is designed to foster peer relationships, competency development, and social skills as a method to prevent suicide among high-risk individuals. Our purpose is to estimate whether comprehensive suicide education and peer support programs would have positive social net benefits, and, therefore be beneficial to society, if implemented in colleges and universities. We use cost–benefit analysis on prevention programs with a target population of college students in Florida. Although suicide is the third leading cause of death among youths in Florida, there is no existing prevention program targeting this age group. If the economic evaluation of the programs indicates positive net social benefits for either or both programs, these results could influence policy makers in future use of prevention resources within the area of young adults or college age youth. 2. Suicide theories and their implications for prevention programs Some issues, such as marriage decisions, fertility, crime and punishment, smoking behavior, substance abuse and addiction, although not seemed questions directly regarded as economic issues, have been studied by economists, but suicide and suicidal behavior have received less attention. In contrast to other social scientists, economists stayed away from suicide and suicidal behavior despite its clear economic implications (for few exceptions, see Hamermesh and Soss, 1974; Rosenthal, 1993; Yang et al., 1992; Yaniv, 2001). Our aim in this section is not to provide a comprehensive review of the literature on suicide from economics and other disciplines but just review selected works that shed lights to the prevention programs studied in this paper (for a comprehensive review, see Lester, 1989, 2004). In the Hamermesh and Soss (1974) model, individuals’ decisions toward suicide are modelled under certainty for the outcome of their actions and perfect information for the future streams of income. In this framework, an individual would commit suicide if the present discounted utility from life, plus the individual’s taste for living become lower than zero. The model also depends
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on the assumption that the survival probability after a suicide attempt is zero, implying that there is no uncertainty for the outcome of an attempt. This theory considers the individual’s action as a rational act, suggesting that a cost–benefit comparison would be possible at that stage of life. Hamermesh and Soss do not provide any explanation for the impact of a suicide attempt on future utility since the model does not consider possibility of survival after an attempt. However, if the suicidal individual engages in a gambling type of suicidal behaviour as suggested in Rosenthal (1993), would it be possible to perform a cost–benefit comparison under uncertainty of suicide attempt and the future utility through compensation from other parties based on the outcome of the action? This seems not an easy judgement and hard to believe that someone in that stage of cognitive ability would make a rational calculation. In this model, there is also no explicit explanation for the taste of living. One particular reason would be to avoid the potential pain to third parties after a successful suicide attempt. At that particular time in life, even though an individual may not derive direct positive utility from living, he/she may choose to live in order to prevent possible suffering to others. As an alternative explanation, we offer status quo bias or endowment effect for the source of this type of taste (for an extensive review of this literature see Rabin, 1998). Both imply that once individuals possess a good, they start valuing the good more than before they possess it. Kahneman et al. (1991) suggest that these types of choices are best explained by changes in utility relative to a neutral reference point. This implies that individuals may have different reference points for living, which even may not be stable over time, and use suicidal attempts as signals to reflect their preference for living to others. This last argument is not compatible with the model provided in Hamermesh and Soss (1974). However, it is likely that individuals may use suicide attempt as a signal to others in order to get favourable treatments. This possibility was raised in Rosenthal (1993). Rosenthal (1993) examines suicidal behaviour in a signalling game framework. He develops a game theoretical model to analyze suicide attempts which have chances of either success or failure. In his model, an individual attempting suicide (sender) sends a signal through the severity of suicide attempt to others (receiver) in order to manipulate their behaviour. The sender knows his/her real intention while the receiver gets a signal only. If the signal is credible then the sender is compensated or gets favourable behaviour after the unsuccessful attempt. This implies that after an unsuccessful attempt, an individual’s future utility will be higher than ex ante expected utility, suggested in the Hamermesh and Soss (1974) model. Marcotte (2003) provides an empirical test for this hypothesis. Using survey data from the United States, he concludes that the suicide attempt and future income are closely correlated. Persons who attempted suicide and survived report higher income than persons who seriously considered but never attempted suicide. And an even higher economic improvement after an attempt was observed for those making the most severe suicide attempt. He concludes that resources and any attention due to suicide attempt are reserved for those attempts which present the most credible threat. The sociological theories of suicidal behaviour have been heavily influenced by Durkheim’s concept of social integration (Durkheim, 1951). It has been argued that social processes which decrease social integration results in an increasing suicide rate. Durkheim (1951) classifies this type of action as egoistic suicide. Egoism as stated in Lester (2004) results from excessive individualism and the individual is protected from egoism by family ties and social interactions. These types of theories stress the importance of social interaction and attachment to a group as a way of preventing the suicide. This implies that a social environment conducive to higher interactions would serve as an effective prevention method for suicide [see Lester, 1989 for a detailed discussion on sociological theories influenced by Durkheim, 1951].
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Suicide prevention programs range from antidepressant medication to individuals and group based methods. These can be crisis intervention and hotlines or telephone counseling, general suicide education, peer support groups, and means restriction of lethal methods. Antidepressant medications have been available for decades for individuals suffering with mental illnesses and depression with an assumption that depression may lead to suicide (Wood et al., 1996). However, the effectiveness of antidepressant drug use in suicide prevention varies in subsequent studies (Isacsson, 2000). Crisis intervention and telephone counseling have been widely used in many countries. These are the methods available for individuals seeking help, suggesting that these services may not reach other people, possibly many who are seriously considering committing suicide. It is therefore likely that the success rate of crisis intervention and telephone counseling would be overestimated due to self selection to the prevention methods/centers. Alternative methods are the community or group based programs, which are based on the assumption that among many suicide risk behaviors, the lack of social and family supports are the most important ones. Economic and sociological theories reviewed above lead to interesting conclusions about the nature of suicide, and suicide attempt. These theories also have implications for the suicide prevention programs. For example, Rosenthal’s signaling game has implications for suicide prevention, suggesting that depressed senders are less likely to engage in gambling type suicidal behavior if the receiver is very likely to give a sympathetic response (Yang and Lester, 1996). Thus, friends and relatives of potentially suicidal individuals should be encouraged to give sympathetic responses, and many suicide education programs train the participants to respond in sympathetic ways to their suicidal peers. Sociological theories influenced by Durkheim also have direct implication for prevention programs. Peer support programs, for instance, are designed to create an environment for social interaction among individuals through social gatherings and to create bonding relationship among peers. School-based programs such as general suicide education programs provide students with facts about suicide, alert them to suicide warning signs, and provide them with information about how to seek help for themselves or for others. Burns and Patton (2000) suggest that suicide education programs aim to raise awareness, train participants to identify individuals at risk and provide education regarding community mental health resources. These programs often incorporate a variety of self-esteem or social competency development activities. The idea for the general suicide education programs is that the more students know about suicide warning signs and sources of help, the more likely they will be to ask for help for themselves or refer others for help. The efforts of general suicide education programs to help students discuss feelings and promote interpersonal competence are meant to help increase their use of existing social support networks. If successful, general suicide education programs would presumably result in an increase in calls to hotlines and higher entry rates of suicidal youth into programs that provide mental health services. Implicit in the general suicide education approach is recognition of the difficulty of determining who, among thousands of healthy adolescents, is truly at high risk of suicide. For this reason, programs employing this strategy are given to all students, without efforts to screen and target high-risk youth [see King, 2001 for a review of a comprehensive school based prevention program]. Alternatively, peer support programs are a fairly new development for prevention programs, and a totally new concept for suicide prevention strategies. They can be conducted in either school or non-school settings, and are designed to promote peer relationships, competency development, and social skills as a method to prevent suicide among high-risk youth. Silbert and Berry (1991) point out that educators and peers are the first to detect suicidal behaviors and therefore, these individuals are most likely to be the rescuers for the youth planning and contemplating suicide.
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The goal is to provide a setting in which young people who may be at risk for suicide can receive the support of their peers and develop interpersonal and coping skills. As a result, it allows participants to increase their use of regular social support networks in order to improve their school attendance and performance. They might help to reduce antisocial behavior and substance abuse, factors associated with suicide. The programs also improve the functioning of youths and increase their use of social support networks to reduce the rates of suicide and premature death from other causes such as alcohol-related traffic fatalities and homicide. 3. Suicide deaths and costs of suicide in Florida 3.1. Suicide deaths among college students A suicide death is defined as intentional or deliberate self-harm or self-poisoning leading to or culminating in death. The data on suicide are based on the reported results from Florida Vital Statistics Annual Reports. A total of 189 suicide deaths were reported in Florida between the ages of 15 and 24; with 131 suicide deaths between the ages of 20 and 24, and 58 suicide deaths between the ages of 15 and 19 in 2000 (Florida Department of Health, 2000). The prevention programs being considered here are those which could be implemented in college campuses, targeting youths between 18 and 24. However, the suicide data are aggregated for those aged 15–24, and are not available by education level. Therefore, we make some assumptions to estimate the suicide among college students aged 18–24. We assume that death due to suicide is uniformly distributed among age cohorts. Under this assumption, the number of deaths for 18 and 19 years olds would be 40% of deaths for those aged 15–19. This implies that estimated death due to suicide for 18–24 age groups is 154 in 2000. In order to estimate the total number of deaths due to suicide among college students, we use the college enrollment rate of 42.5% as weights in 2000 for those 18–24 years (US Census Bureau, 2005a). With this adjustment, we estimate the deaths due to suicide among college students, aged 18–24, to be 65 in Florida. 3.2. Costs of suicides Suicide may have direct and indirect costs to the individual and to the society. Direct costs are costs directly traceable to youth suicide deaths, such as ambulance services and autopsy services. Indirect costs, however, are not directly associated with the event, but represent the lost value of a productive member of society, i.e., potential earnings lost due to premature death, and productivity loss of immediate family members. The American Ambulance Association (2002) reports the summary of Medicare Ambulance Fee Schedule, which lists the ground rates for service level Advanced Life Support, Level 2 (ALS2) classified as the administration of at least three different medications and/or the provision of one or more of the Advanced Life Support procedures that include manual defibrillation/cardioversion, endotracheal intubations, central venous line, cardiac pacing, chest decompression, surgical airway, and intraosseous line. The total ground rate for the ALS2 service in 2000 is US$ 468.99 allowable by Medicare. With the inclusion of gas mileage, this rate would be even higher. An average charge for autopsies in Florida within the age group of 18 and 24 years was US$ 3637.50 in 2002 (Agency for Health Care Administration, 2002). This corresponds to US$ 3482 in year 2000 dollars. Autopsies reported in this database were performed as inpatient hospital services. However, the cost of suicide autopsies would be higher since it requires additional services such as transportation of medical examiners to the scene, doctors’ time in collecting
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and reviewing data, investigator and morgue technician expenses and their time. This implies that based on information available from the Agency for Health Care Administration and the American Ambulance Association, we underestimate the actual direct cost associated with suicide. Years of potential life lost is one of the most important costs to the society after a suicide. It is a premature mortality measurement for the population, calculated using the number of deaths for each group multiplied by the years of life lost. We calculate the average number of potential years of life lost per suicide by taking the difference between 65 years and the mean age of suicide deaths, 21. As a result, the total life lost among college students in Florida would be 2860 years. Human capital approach is one of the most common methods used to estimate the value of life. In this method, the monetary value of each life is estimated using the market value of the output produced by an individual during his/her expected lifetime (Mishan, 1971; Giles, 2003). This approach measures the monetary value of life using the discounted value of future earnings resulting from an improvement or extension of life. In our application, average annual earnings by age and educational attainment in Florida are used as a proxy to estimate the contribution of each individual to the production process. The median earnings by age and educational attainment in Florida are available for those who worked full time in 1999 (US Census Bureau, 2005a). In order to obtain the future earnings, we adjusted current earnings using a rate of earning growth, which is a sum of nominal and real growth rates. The nominal rate of change is measured by a 10-year average change in consumer price index from 1990 to 2000 (US Census Bureau, 2005b). The real change is measured by differences in current wages among different age groups with the same level of education. 4. Economic analysis of prevention programs The assessment of suicide prevention programs in economic models requires evaluations of potential costs and benefits from prevention programs. According to Drummond et al. (1997), cost–benefit analysis is suitable when results beyond those of just the person’s or patient’s view need to be calculated. In this analysis, the aim is to calculate the net social benefit associated with a potential health policy decision and to determine the resource allocation so that the net benefit is maximized for the society. Cost–benefit analysis is also a method to take externalities into account in policy decision process. Although costs of the prevention programs are relatively straightforward to calculate, benefits are not easy to measure, especially when externalities play a role. For instance, if the event affects the third parties, i.e., immediate family members or relatives, it is extremely hard to calculate for third parties the value of the potential loss in production saved, or the value of the loss in satisfaction or utility averted due to a continuation of life and/or better health. Although the net benefit estimates will not be accurate when these additional benefits were not taken into account, it may still be sufficient to estimate the lower limits of the net benefits for competing health policy options to deal with this shortcoming. These are discussed in Section 4.4 in detail. The present discounted value of net benefit from each program is calculated using Eq. (1) below: NBi =
T (1 − pt )Bt t=0
(1 + r)t
− C0
(1)
where NBi stands for present value of net benefit from program i, Bt denotes the monetized benefits at time t. C0 is the costs of the program at the present time, and r stands for the rate of interest. The
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denominator captures the time preference of individuals implying that net benefit is worth more if it is experienced sooner. In our application, the costs of the program accrue at the present time, but each program yields a stream of future returns. This implies that we need to discount the future benefits using an appropriate discounting factor to reflect the time value of money (Feldstein, 1964; Sen, 1967). There is a likelihood that an individual may not survive to the next period, and may die due to other reasons with probability pt. To take this into account, benefits from saving an additional life year are weighted with survival probability of (1 − pt ) at time t. The survival rates can be obtained from a life table, which measures the incidence of mortality in a population. Using age-specific death rates, life tables for each year can be constructed to present demographic data including life expectancy at the current age, and survival rates to the next period. 4.1. Total costs General suicide education is typically used in middle and high schools. On occasion, it is a curriculum based suicide prevention program. For example, in California, a large school district similar to the Florida school district, where the population is also composed of a large number of minority groups, the state implemented the California School Suicide Prevention Program. This is a statewide youth suicide prevention program for high schools. The Centers for Disease Control and Prevention (1992) reported that this program consists of five lessons of one class period each and these lessons are to be taught in grade 9 through 12. The program was implemented in 1986, and the amount to fund the development of this suicide curriculum was US$ 300,000 for the first 3 years of development with an additional yearly cost of US$ 1000 for training and materials. The amount of funding varies among states, and it is estimated that Florida, specifically a grant received from Miami-Dade County school district, had a funding of US$ 120,000 per year in 1992. Under the assumption that the cost of the program increases at the same rate as the general increase in price level, the annual cost of implementing the program in Florida is US$ 147,000 per year for each program in year 2000 dollars. Therefore, the total cost of implementing the program in 119 college campuses is US$ 17.49 million. The second program, peer support group program, is an established program by the California Association of Peer Programs (CAPP). The CAPP is a corporation that is dedicated to the establishment and support of youth service through peer support programs. It serves suicidal youths involved in peer programs. The budget needed for peer programs depends on the number of participants, style of training, district, state policies and local resources. Peer led programming allows young people to develop skills in cooperative learning. Through this program youth investigate together issues they feel adults may not relate to, and the program instills leadership skills in the youth. They learn to share with and comfort with each other. Furthermore peer support groups create and help to develop empathy, and empathy is a critical component for social and cognitive development. This program is a prevention program that has proven to be effective in areas such as alcohol and drug abuse (Tobler and Stratton, 1997). The cost savings in peer support programs are substantial since peer services are directed by the peers rather than by paid professionals. The savings apply to the college age population, where friendships and associations during college years have usually long lasting effects. The main program cost is generally housing, chartering a bus or transportation and food for a weekend retreat. According to the CAPP, the approximate total budget needed to implement a peer support group per year is US$ 69,060 in 1992. The CAPP uses the budget in Table 1 as an intensive training program to understand and to develop a quality peer program in schools. Using these values, we estimate that the total annual cost for the program would be US$ 84,760 in year 2000
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Table 1 Peer support program budget in 1992 Categories
Description
Housing and food for retreat Transportation Supplies Postage Trainers’ honorariums Computer cards and time
US$ 40 per person (2 nights and 6 meals) Bus transportation for 120 miles Paper, hand-outs, training materials, etc. Postage expenses Payment for trainers US$ 0.05–0.07 each to purchase cards for needs assessment survey Coordinator stipend If not volunteered for after school sessions Other expenses
In-school coordinator stipend Snacks Miscellaneous Total per month Total per year
Monthly cost (US$) 1600 3000 100 25 200 150 600 30 50 5755 69,060
Source: California Association of Peer Programs (2002).
dollars. This implies that the total cost of statewide implementation of the program is US$ 10.09 million. 4.2. Total benefits The calculation presented in the suicide costs per youth is converted into benefits to society. For example, autopsy charges of US$ 3482 are a part of monetary benefits to the society due to preventing one suicide death, and consequently the same applies for other direct and indirect costs due to suicide. The potential earning lost is calculated under the assumption that the future growth rate of potential earnings would be equivalent to the rate of growth in the Consumer Price Index plus an increase in earnings due to productivity growth. Assuming an average age of 21 at the time of suicide, and average educational level of less than 4 years of college, the lost earnings would have amounted to a present value of US$ 0.96 million when discounted at an interest rate of 6.3%, a rate used by Federal government for the long term projects in 2000 (Office of Management and Budget, 2006). These calculations are based on earnings lost for those aged 21–65, weighted with the survival probabilities (see Arias, 2002 for survival probabilities in 2000). The calculated direct and indirect cost per youth aged 18–24 years amounted to more than US$ 0.96 million in Florida, suggesting that each prevention program increases the social welfare by US$ 0.96 million for each life saved. However, the programs are not 100% effective in preventing suicides. According to de Castro et al. (2004), effect rates of general education and peer support programs are 57% and 60%, respectively. To calculate the total benefit from each program, we use effect rates as weights to estimate the total number of students who would have been saved if the programs were available in 2000. This would suggest that 37 and 39 students would have been saved if the general education and peer support programs were available in each campus. Using these effect rates, we calculated total benefits from each program and reported the results in Table 2. 4.3. Cost–benefit comparisons Table 2 shows the net benefits as well as the benefit cost ratio for both programs. Initially, future returns are discounted at an interest rate of 6.3%. As shown in Table 2, the benefit cost
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Table 2 Cost–benefit analysis Prevention program
Discount rate (%)
Benefit (million US$)
Cost (million US$)
Net Benefit (million US$)
Benefit–cost ratio
General suicide education Peer support program
6.3 6.3
35.56 37.43
17.49 10.09
18.07 27.34
2.03 3.71
Note: Cost of each program is calculated under the assumption that programs are implemented in all university/college campuses.
ratio for the peer support program is 3.71, suggesting that the benefit to the society is US$ 3.71 for each dollar invested. General suicide education program also shows a positive net benefit with benefit–cost ratio of 2.03. The net benefit from the peer support prevention program exceeds that of general suicide education program. These results align favorably with those found for cost–benefit analysis on a drug abuse prevention program conducted by Kim et al. (1995) where the benefit cost ratio is 14.89, indicating that the benefit in drug prevention efforts is of US$ 14.89 for every dollar invested. 4.4. Sensitivity analysis Our results in Table 2 above depend heavily on the choice of discount factor, and the choice of effect rates for prevention programs. As an alternative, we calculate the net benefit for each program at various discount rates and effect rates. Fig. 1 presents the net benefits of each program at a range of discount rates from 4% to 20%. It is shown in Fig. 1 that the net benefits of both programs are positive as long as the discount rate is lower than 11%. For the peer support program, the break-even discount rate is even higher. Although the net benefit of the peer support program is higher at all discount rate, the results imply that implementation of either programs would contribute substantially to the social welfare if the discount rate is not higher than 10%. The Office of Management and Budget mandates a 5.2% discount rate in 2006 for use in all federal policy analysis with durations 30 years or longer (Office of Management and Budget, 2006). This implies that at this mandated discount rate, policy makers could increase the social welfare more than US$ 36 million per year by implementing
Fig. 1. Net benefits of prevention programs.
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Fig. 2. Net benefit in general education program by discount rate.
the peer support program or more than US$ 26 million per year by implementing general suicide education program in Florida. These estimates are based on effect rates of 57% and 60% for general education and peer support programs, respectively. These rates were just 15% and 20% better than the success rates for high-risk adolescents in the control condition who received general health education only. The 95% confidence interval for these two predicted levels of success are plus or minus 5% for the general education program, and plus or minus 12% for the peer support group program. This suggests that lower boundaries for effect rates are 52% for general education program, and 48% for peer support program (Lipsey and Wilson, 2001). We provide estimates for net benefits from both programs by various effect rates and discount factors in Figs. 2 and 3. At 5% discount rate, general education program provides positive net benefit if the effect rate is higher than 22%. For peer support program, net benefit is positive if the effect rate is higher than 14%. At the lower boundaries for effect rates and 5% discount rates, the social welfare increases more than US$ 22
Fig. 3. Net benefit in peer support program by discount rate.
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million per year by implementing the peer support program or more than US$ 23 million per year by implementing general suicide education program in Florida.1 The net benefit estimates above do not take several other monetary and non-monetary benefits into account; therefore, they underestimate the actual benefit from the prevention programs. We identify additional benefits of a successful prevention program not taken into account in our estimations: when a suicide is prevented and the person lives a productive life, then reduction in productivity loss of immediate family members is quite obviously an additional monetary benefit of a prevention program. Other additional benefits, although non-monetary in nature, may include improved social functioning, higher educational achievement, reduced personal and family stress, better household management, improved social support, improved mental health, fewer social and emotional adjustment problems, improved physical health, fewer injuries, and improved social functioning in young adults. Some of the additional benefits presented above would be taken into consideration using alternative methods for measuring the value of life. One of which is the willingness-to-pay approach. In this approach, the estimates represent society’s willingness to pay to avoid the death or injury. Although, the human capital approach depends only on the market value or contributions of each individual to the production process as measured by its market value, the willingness-to-pay approach measures the total value of life by including both the market value, i.e., forgone earnings and the non-market value received from life and good health. Hence, the estimates from the latter approach would be higher than that generated by the human capital approach. Based on numerous studies, Viscusi (1993) reports that the willingness-to-pay estimates for value of life range between US$ 3 and 7 million in year 1990 dollars. In Miller (1990), it is higher than US$ 3.4 million in year 1995 dollars. The lower limits from these studies correspond to US$ 3.95 million and US$ 3.84 million in year 2000 dollars, respectively. This suggests that our estimates from the human capital approach underestimate the benefit from prevention programs since even with the lowest discount rate of 4% the value of life estimate is less than US$ 1.54 million (for a comparison of value of life estimates from different methods, see also Blomquist, 1981; Linnerooth, 1979; Viscusi, 1983). Under the assumption of the lowest value of life estimate of US$ 3.84 million from the willingness-to-pay approach, which may take most of the additional benefits presented above into account, and using the lower boundaries for effect rates, the implied net benefits from the general education and peer support programs would be more than US$ 112 million and US$ 109 million, respectively. The results indicate that the implementation of general suicide education programs and/or peer support group programs provide positive net benefits to the society even with the most conservative value of life estimates. 5. Conclusions Cost–benefit analysis enables researchers to identify effective programs and assist policy makers in evaluating new policies. It is a valuable tool, allowing the researcher to place monetary estimates on life and enabling the calculation of cost and benefits for prevention or intervention programs, particularly for suicide prevention. Our economic evaluation of two specific suicide 1 A critical question here is whether the 57% and 60% of those who participated in their respective programs and whose suicide risk and hopelessness was decreased would necessarily not attempt or would not successfully commit suicide. That would require a very large-scale longitudinal study, one that is yet to be performed. For the ensuing analysis and discussion, we will make the assumption that the answer to the question is yes and the results of the analysis must be limited by this assumption. As an alternative, we also estimate the net benefits for various effect rates in Figs. 2 and 3.
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prevention programs, general suicide education and peer support programs, shows that both programs are cost beneficial interventions. Even with the most conservative estimates, these programs would provide at least US$ 22 million per year. One of the important limitations is the conjecture of the underreporting of suicide. Kleck (1988) argues that the net underreporting is estimated around 10–20%. There are other studies suggesting that there may be correlation between vehicle accidents and suicide deaths (Peck and Warner, 1995). Therefore, if the conjecture of under reporting of suicidal deaths is true; then our net benefit estimates would be even higher for both programs. We make some assumptions with regard to the direct cost of suicide. The ambulance cost calculations, for instance, are based on data reported by the American Ambulance Association, rather than original ambulance invoices. Autopsy services may also vary in cost, especially when dealing with suicide deaths. These assumptions can be addressed by directly working with each suicide case if researchers have a direct access to the suicide database. Several possible strategies and suggestions may guide future cost–benefit analysis on suicide prevention programs. Potential directed research at colleges and universities should focus on data refinement that will support the cost–benefit analysis of suicide prevention programs. Another suggestion is to target the families of those who committed suicide to understand the added cost to family members in terms of their coping strategies, e.g., taking time off from work, or school, which may require additional resources or lost opportunities. Additional costs may be accrued by an increased utilization of health care and mental health resources after the death of a loved one. Future efforts should also attempt to consider the differential costs due to gender, differences in earning and socio-economic status of the person who died, as well as that of those who mourned the death. Additional research may include replicating this study and exploring states where suicide mortality is higher, such as Oregon and Vermont, and specific areas where there is a great concentration of colleges and universities and young adults. Acknowledgements We would like to thank anonymous referees, and the discussant and participants of 2005 Western Economic Association Meeting, San Francisco, for their insightful comments and suggestions. References Agency for Health Care Administration, 2002. Hospital and Outpatient Care Health Data. Florida Health Statistics Online Database at http://www.floridahealthstat.com/hosp amb.shtml. American Ambulance Association, 2002. Summary of Medicare Ambulance Fee Schedule-Final Rule. Retrieved November 15, 2004 from http://www.the-aaa.org/industryissues/reimbursement/medicarefs/feeschedule summary.htm. Arias, E., 2002. United States Life Tables, 2000. National Vital Statistics Reports 51(3). National Center for Health Statistics, Hyattsville, Maryland. Blomquist, G., 1981. The value of human life: an empirical perspective. Economic Inquiry 19, 157–164. Brener, N.D., Hassan, S.S., Barrios, L.C., 1999. Suicidal ideation among college students in the United States. Journal of Consulting and Clinical Psychology 67 (6), 1004–1008. Burns, J.M., Patton, G.C., 2000. Preventive interventions for youth suicide: a risk factor-based approach. Australian and New Zealand Journal of Psychiatry 34 (3), 388–407. Centers for Disease Control and Prevention, 1992. Youth Suicide Prevention Programs: A Resource Guide. Centers for Disease Control and Prevention, Atlanta. Centers for Disease Control and Prevention, 2006. Leading Causes of Death Reports: 1999–2003. National Center for Injury Prevention and Control. Retrieved April 3, 2006 from http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html.
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