Suicide Prevention
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National Strategy for Suicide Prevention:
Goals and Objectives for Action
Introduction
What is the U.S. National Strategy for Suicide Prevention?
The National Strategy for Suicide Prevention (National Strategy or NSSP) is designed to be a catalyst for social change with the power to transform attitudes, policies, and services. Representing the combined work of advocates, clinicians, researchers and survivors, the National Strategy lays out a framework for action and guides development of an array of services and programs yet to be set in motion. It strives to promote and provide direction to efforts to modify the social infrastructure in ways that will affect the most basic attitudes about suicide and its prevention, and that will also change judicial, educational, and health care systems.
As conceived, the Strategy requires a variety of organizations and individuals to become involved in suicide prevention and emphasizes coordination of resources and culturally appropriate services at all levels of government– Federal, State, tribal and community. The NSSP represents the first attempt in the United States to prevent suicide through a coordinated approach by both the public and private sectors.
This document, Goals and Objectives for Action, is a key element in the National Strategy. Its clear articulation of a set of goals and objectives provides a roadmap for action. The next step will be to develop a detailed plan that includes specific activities corresponding to each objective. The Strategy, as represented here, is highly ambitious because the devastation wrought by suicide demands the strongest possible response.
The NSSP is based on existing knowledge about suicidal behavior and suicide prevention. It employs the public health approach, which has helped the nation effectively address problems as diverse as tuberculosis, heart disease, and unintentional injury. This Introduction to Goals and Objectives for Action outlines the components of a comprehensive suicide prevention plan, describes the public health approach as it relates to suicide, and summarizes the knowledge gained from the experience of suicide prevention initiatives in other nations.
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Aims of the National Strategy
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A Plan for Suicide Prevention: Goals, Objectives and Activities
This document presents the 11 goals and 68 objectives of this component of the National Strategy.
A set of activities will be developed for each objective in the next phase of the NSSP. Goals, objectives and activities are defined as follows:
GOAL: A goal is a broad and high-level statement of general purpose to guide planning around an issue. It is focused on the end result of the work.
OBJECTIVE: An objective narrows the goal by specifying the who, what, when and where associated with obtaining the goal or clarifies by how much, how many, or how often. Ideally, an objective offers measurable milestones or targets and is very specific–it clearly identifies what is to be achieved. The objectives that appear in the Goals and Objectives for Action should be considered "developmental" until all these requisites are established. Until then, the target date of 2005 is used as a place holder on most Objectives to convey a sense of urgency, while considering the time needed for government and private-sector organizations to make progress toward the goal (see also Chapter 12 for the discussion on benchmarks).
ACTIVITIES: Activities specify how objectives will be reached. They are the “things that will be done” to ensure that the goals and objectives are met. A small selection of activities are suggested within “Ideas for Action” boxes that are placed throughout this document. These are designed primarily to be illustrative of the types of activities that will be developed in the next phase of the NSSP, and their presence in the Goals and Objectives for Action is not meant as proof of their effectiveness, but rather as a stimulus to creative thinking in developing suicide prevention activities. The final set of activities for the National Strategy will occur through a national consensus process designed to fully engage the Nation and assure maximum involvement in its implementation.
The Public Health Approach
The public health approach to suicide prevention, reflected in the National Strategy, represents a rational and organized way to marshal prevention efforts and ensure that they are effective. In contrast with the clinical medical approach, which explores the history and health conditions that could lead to suicide in a single individual, the public health approach focuses on identifying patterns of suicide and suicidal behavior throughout a group or population.
These steps may occur sequentially, but they also sometimes overlap. For example, the techniques used to define the problem, such as determining the frequency with which a particular problem arises in a community, may be used in assessing the overall effectiveness of prevention programs. Information gained from evaluations may lead to new and promising interventions.
The Public Health Approach as Applied to Suicide Prevention
Clearly Define the Problem
Collecting information about the rates of suicide and suicidal behavior is known as surveillance. Surveillance may also include collection of information on the characteristics of individuals who die by suicide, the circumstances surrounding these incidents, possible precipitating events, and the adequacy of social support and health services. Sometimes data are collected on the cost of injuries related to suicidal behavior. Surveillance helps to define the problem for a community. It documents the extent to which suicide is a burden to a community and how suicide rates vary by time geographic regions, age groups, or special populations.
While data on suicides are available, data on attempted suicides, particularly among adults, are much less complete. Suicide rates vary by age, gender, and ethnic groups.
It is generally agreed that not all deaths that are suicides are reported as such. Deaths may be misclassified as homicides or accidents where individuals have intended suicide by putting themselves in harm's way and lack of evidence does not allow for classifying the death as suicide. Other suicides may be misclassified as accidental or undetermined deaths in deference to community or family. Many studies suggest that the actual suicide rate is considerably higher than recorded. (Clark et al., 1992; Gibbs et al., 1988; O'Carroll, 1989).
Suicide rates have changed over time, especially among certain subgroups. For example, from 1980 to 1996, the rate of suicide among children aged 10-14 increased by 100 percent, and among African-American males aged 15-19, the rate increased by 105 percent (Peters et al., 1998).
While no national data base of attempted suicide exists, the Youth Risk Behavior Survey, conducted by the CDC biennially, provides important information on young people (CDC, 1999). This survey consistently finds that a large number of youth in grades 9-12 consider or attempt suicide (Brener, Krug, & Simon, 2000).
Suicide is very costly to the Nation. In addition to the emotional suffering experienced by family members of those who have died by suicide and the physical pain endured by those who have attempted suicide, there are financial costs. However, attempts to compute such costs on a national basis are based on incomplete data (e.g., underreporting of suicides and an absence of reliable data on suicide attempts); in addition, such estimates, like economic analyses of other health problems, are of necessity based on certain assumptions, and the accuracy of these cannot always be assured. Consequently, there is no firm consensus on the true dollar costs of suicide. One economic analysis, however, estimated the total economic burden of suicide in the U.S. in 1995 to be $111.3 billion; this includes medical expenses of $3.7 billion, work-related losses of $27.4 billion, and quality of life costs of $80.2 billion (Miller et al., 1999).
While national data provide an overall view of the problem, State and local suicide rates vary considerably from these national rates. Local data are key to effective prevention efforts. It is important to note, however, that local suicide rates, due to the significant fluctuations that occur in small populations, are often not useful in evaluating the effectiveness of suicide prevention programs in the short-run. "Proxy" measures may work better, including changes in risk and protective factors.
Identify Risk and Protective Factors
Risk factors may be thought of as leading to or being associated with suicide; that is, people "possessing" the risk factor are at greater potential for suicidal behavior. Protective factors, on the other hand, reduce the likelihood of suicide. They enhance resilience and may serve to counterbalance risk factors. Risk and protective factors may be biopsychosocial, environmental, or sociocultural in nature. Although this division is somewhat arbitrary, it provides the opportunity to consider these factors from different perspectives.
Understanding the interactive relationship between risk and protective factors in suicidal behavior and how this interaction can be modified are challenges to suicide prevention (Móscicki, 1997). Unfortunately, the scientific studies that demonstrate the suicide prevention effect of altering specific risk or protective factors remain limited in number (see Appendix C).
However, the impact of some risk factors can clearly be reduced by certain interventions such as providing lithium for manic depressive illness or strengthening social support in a community (Baldessarini, Tando, Hennen, 1999). Risk factors that cannot be changed (such as a previous suicide attempt) can alert others to the heightened risk of suicide during periods of the recurrence of a mental or substance abuse disorder or following a significant stressful life event (Oquendo et al., 1999). Protective factors are quite varied and include an individual's attitudinal and behavioral characteristics, as well as attributes of the environment and culture (Plutchik & Van Praag, 1994). Some of the most important risk and protective factors are outlined below.
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Protective Factors for Suicide
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Measures that enhance protective factors play an essential role in preventing suicide. However, positive resistance to suicide is not permanent, so programs that support and maintain protection against suicide should be ongoing.
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Risk Factors for Suicide Biopsychosocial Risk Factors
Environmental Risk Factors
Socialcultural Risk Factors
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Information about risk and protective factors for attempted suicide is more limited than that on suicide. One problem in studying nonlethal suicidal behaviors is a lack of consensus about what actually constitutes suicidal behavior (O'Carroll et al., 1996). Should self-injurious behavior in which there is no intent to die be classified as suicidal behavior? If intent defines suicidal behavior, how is it possible to quantify a person's intent to die? The lack of agreement on such issues makes valid research difficult to conduct. As a result, it is not yet possible to say with certainty that risk and protective factors for suicide and non-lethal forms of self-injury are the same. Some authors argue that they are, whereas others accentuate differences (Duberstein et al., 2000; Linehan, 1986).
Develop and Test Interventions
Suicide prevention interventions reduce risk or enhance protective factors; some address both. Interventions, like risk and protective factors, may be characterized along biopsychosocial, environmental, and sociocultural dimensions. An intervention might attempt to influence some combination of psychological state, physical environment, or the cultural/subcultural conditions. Alternatively, suicide prevention efforts have been classified as either universal, selective, or indicated: a universal approach is designed for everyone in a defined population regardless of their risk for suicide, such as a health care system, or a county, or a school district; a selective approach is for subgroups at increased risk, for example, due to age, gender, ethnicity or family history of suicide; and an indicated approach is designed for individuals who, on examination, have a risk factor or condition that puts them at very high risk, for example, a recent suicide attempt (Gordon, 1983). The intersections of these dimensions in a matrix shows the intended mechanisms of action and the level of population addressed by interventions. The matrix can identify gaps for development of additional suicide prevention approaches and help match intervention evaluations to the intended outcomes and mechanisms of action.
Rigorous scientific testing of interventions, prior to large scale implementation, is important to ensure that interventions are safe, ethical, and feasible. This testing usually undergoes several stages including small scale, or pilot studies, of efficacy and effectiveness. Efficacy studies test whether a preventive or treatment intervention works under ideal conditions. The application of the intervention is monitored closely and the question, "Can it work?" is addressed. Only if the answer is "yes" are effectiveness studies undertaken in real world settings. A different question is answered here: "If you do this in the real world, does it prevent suicide?" When interventions have been documented as safe, ethical and feasible, further testing with larger groups can also lead to refinements and enhancements based on important differences among age, gender, geographic, and cultural groups. It is frequently difficult to conduct efficacy studies, although in the absence of such studies, if an intervention does not work, there is no way to know if that is because the program idea was flawed or because the implementation was flawed.
In actuality, definitive pilot studies are frequently missing for many types of social and mental health interventions, including those designed to prevent suicide. By default, program planners may incorporate "promising" interventions into community suicide prevention plans before the evidence base is fully developed. This makes careful evaluation of local outcomes especially important.
Implement Interventions
State and local organizations will often develop suicide prevention programs that consist of a broad mix of interventions. By selecting interventions from several cells in the "Matrix of Interventions for Suicide Prevention," a more comprehensive program can be developed. Considerations for selecting the elements of a program, i.e., the mix of interventions that will be implemented, include local needs (based on a specific assessment of the problem of suicide in the community) and an analysis of cost vs. potential effectiveness of different interventions. Moreover, program planners will need to consider ways to integrate interventions into existing programs and to strengthen collaboration.
Such comprehensive suicide prevention programs are believed to have a greater likelihood of reducing the suicide rate than are interventions that address only one risk or protective factor, particularly if the program incorporates a range of services and providers within a community. Comprehensive programs engage community leaders through coalitions that cut across traditionally separate sectors, such as health and mental health care, public health, justice and law enforcement, education and social services. The coalitions involve a range of groups, including faith communities, civic groups, and business. Suicide prevention programs need to support and reflect the experience of survivors, build on community values and standards, and integrate local cultural and ethnic perspectives (U.S. Department of Health and Human Services, 1999). For example, cultural prohibitions on talking about suicide may have to be taken into account in the development of certain types of programs. Evaluation can help determine if community interventions are having the desired effect for all groups.
Evaluate Effectiveness
It is important to note that most interventions that are assumed to prevent suicide, including some that have been widely implemented, have yet to be evaluated. An ideal, "evidence-based" intervention is one that has been evaluated and found to be safe, ethical, and feasible, as well as effective. Determination of cost effectiveness is another important aspect of evaluation. Evaluation can help determine for whom a particular suicide prevention strategy is best fitted or how it should be modified in order to be maximally effective. Appendix B provides additional information on evaluation.
The International Experience Building Suicide Prevention Strategies
Through the NSSP, the United States has joined the small number of nations that have created a national strategy for the prevention of suicide that is both comprehensive and multifaceted and in which there is a planned integration among different prevention components (Taylor et al., 1997). The U.S. strategy builds on the experience of other nations and also incorporates the recommendations of the 1996 publication Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies, published by the United Nations/World Health Organization (United Nations, 1996).
The first national suicide prevention strategy was initiated in Finland in 1986; the Finnish initiative has provided tremendous amounts of information that have been helpful in the creation of the national suicide prevention strategies of other countries, including the U.S. The U.S. strategy also benefits from the national suicide prevention efforts of Norway, Sweden, New Zealand, Australia, the United Kingdom, The Netherlands, Estonia, and France.
National strategies for suicide prevention share a number of common elements. These include a focus on educational settings as a site of intervention; attempts to change the portrayal of suicidal behavior and mental illness in the media; efforts to increase the detection and treatment of depression and other mental illnesses, including alcohol and substance use disorders; an emphasis on reducing the stigma associated with being a consumer of mental health or substance abuse services; strategies designed to improve access to services; promotion of effective clinical practices; and efforts to reduce access to lethal means of suicide. Not every country with a national suicide prevention strategy, however, includes all of these elements in its strategy, although all current strategies do include plans for increasing research on suicide and suicide prevention (IASP, 1999).
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Effective Suicide Prevention Programs:
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Even when nations address the same issue in their strategies, they frequently do so in different ways. For instance, interventions after a suicide has occurred (called postvention) aimed at reducing the impact of suicide on surviving friends and relatives have been proposed by all countries. However, approaches to postvention vary across countries. For example, Norway has proposed outreach services to relatives and friends of those who died by suicide in the community, while other countries that have focused on youth suicide prevention, such as New Zealand, suggest specific postvention efforts to minimize suicide contagion in school settings.
One important difference among nations with respect to their national strategies is the extent to which the community is involved in the creation and implementation of the initiative. The UN/WHO guidelines recommend that no single agency, organization, or governmental body have sole responsibility for suicide prevention (Ramsey & Tanney, 1996). In this regard, a particular strength of the Finnish strategy has been strong community involvement in the process of developing and implementing its strategy. Other countries with different resources, have needed to rely heavily on government agencies to implement their strategies. The development of the National Strategy in the U.S. has been led by the Federal government, but in collaboration with numerous non-governmental organizations and with advice from hundreds of interested, individual citizens.
National suicide prevention strategies vary in terms of their target audiences. The National Strategy is aimed at the entire population of the U.S. and in this respect is similar to the strategies of Norway, Sweden, and Finland. In contrast, New Zealand and Australia focus exclusively on youth suicide. Finland has also targeted young men for special attention, given their increasing rate of suicide in that country.
The UN/WHO guidelines recommend that suicide prevention programs be coherent in their approach. Nations take different approaches to ensuring such coherence. For example, the Finnish initiative commenced with a national research study on suicide, using the psychological autopsy method. Data derived from this research were used to help in the development and implementation of suicide prevention programs. In contrast, the New Zealand strategy was guided by a literature review born out of a workshop that included representation from both governmental and non-governmental organizations, including advocacy groups. The development of the U.S. strategy has been based on the public health model, which has proven so effective for approaching other health problems.
The extent to which evaluation is a central component of a nation's suicide prevention strategy varies considerably. The Finnish government commissioned both an internal and external evaluation to assess the outcome of the strategy (Upanne, 1999). Norway has plans for an external evaluation of its strategy, and Australia requires evaluation for all funded demonstration projects. New Zealand agencies are self-monitoring; in addition, a small steering group convenes annually and reports to the Ministers of Health and Youth Affairs on the progress of the strategy. As recommended by the UN/WHO guidelines, the U.S. strategy includes specific objectives with the potential for measurement. Provision is also made for the evaluation of specific preventive interventions.
Summary
Suicide is a major cause of death in the U.S. and also contributes–through suicide attempts–to disability and suffering. Suicide is a serious public health problem. Persons who experience the loss of someone close as a result of suicide experience tremendous emotional trauma. Suicide is a special burden for certain age, gender, and ethnic groups, as well as particular geographic regions. The public health approach provides a framework for a national strategy to address this serious national problem. The Goals and Objectives for Action that follow are designed to provide direction to the Nation on ways to prevent suicide and suicidal behavior.
GOAL 1:
Promote Awareness that Suicide is a Public Health Problem that is Preventable
Why is this Goal Important to the National Strategy?
In a democratic society, the stronger and broader the support for a public health initiative, the greater its chance for success. The social and political will can be mobilized when it is believed that suicide is preventable. If the general public understands that suicide and suicidal behaviors can be prevented, and people are made aware of the roles individuals and groups can play in prevention, many lives can be saved.
In order to mobilize social and political will, it is important to first dispel the myths that surround suicide. Many of these myths relate to the causes of suicide, the reasons for suicide, the types of individuals who contemplate suicide, and the consequences associated with suicidal ideation and attempts. Better awareness that suicide is a serious public health problem results in knowledge change, which then influences beliefs and behaviors (Satcher, 1999). Increased awareness coupled with the dispelling of myths about suicide and suicide prevention will result in a decrease in the stigma associated with suicide and life-threatening behaviors. An informed public awareness coupled with a social strategy and focused public will lead to a change in the public policy about the importance of investing in suicide prevention efforts at the local, State, regional, and national level (Mrazek & Haggerty, 1994).
Background Information and Current Status
The factors that contribute to the development, maintenance, and exacerbation of suicidal behaviors are now better understood from a public health perspective (Silverman & Maris, 1995). A public health approach allows suicide to be seen as a preventable problem, because it offers a way of understanding pathways to self-injury that lend themselves to the development of testable preventive interventions (Gordon, 1983; Potter, Powell & Kachur, 1995). Although some have criticized the public health model of suicide as being too disease-oriented, it does, in fact, take into account psychological, emotional, cognitive, and social factors that have been shown to contribute to suicidal behaviors (Potter, Rosenberg, & Hammond, 1998).
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Did You Know? |
Suicide is a major public health problem. It is one of the top ten leading causes of death in the United States, ranking 8th or 9th for the last few decades. For the approximately 31,000 suicide deaths per year, there are an estimated 200,000 additional individuals who will be affected by the loss of a loved one or acquaintance by suicide. The economic and emotional toll on the Nation is profound (Palmer, Revicki, Halpern, & Hatziandreu, 1995).
How Will the Objective Facilitate Achievement of the Goal?
The objectives established for this goal are focused on increasing the degree of cooperation and collaboration between and among public and private entities that have made a commitment to public awareness of suicide and suicide prevention. To accomplish this goal, support for innovative techniques and approaches is needed to get the message out, as well as support for the organizations and institutions involved.
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Objective 1.1: |
By 2005, increase the number of States in which public information campaigns designed to increase public knowledge of suicide prevention reach at least 50 percent of the State's population. |
Suicide has been designated as a serious public health problem by the U.S. Surgeon General, and the 105th U.S. Congress has recognized that this problem deserves increased attention [U.S. Senate Resolution 84 (5/6/97) and U.S. House Resolution 212 (10/9/98)]. They recognize suicide as a national problem and declare suicide prevention as a national priority, encouraging the development of an effective national strategy for the prevention of suicide. Public and private organizations have developed information campaigns to educate the public that suicide is preventable, as it can be a consequence of other treatable disorders such as depression, schizophrenia, bipolar illness, alcohol and drug abuse, and certain medical conditions. Campaigns alert professional, community, and lay groups about the common signs and symptoms associated with suicidal behavior. Some organizations with existing campaigns include the American Association of Suicidology (AAS), the American Foundation for Suicide Prevention (AFSP), the Suicide Awareness\Voices of Education (SA\VE), the Suicide Prevention Advocacy Network (SPAN USA), and Yellow Ribbon Suicide Prevention Program.
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Ideas for Action |
Public information campaigns can take many forms. No single slogan or message works for everyone. For example, the primary purpose of the annual National Depression Screening Day is to identify, in a variety of settings, individuals with symptoms of depression and refer them for treatment (Jacobs, 1999b). However, such a screening program performed at primary care centers, mental health and substance abuse treatment centers, colleges, universities, and places of employment can play an important role in raising awareness and educating large groups of individuals about this mental disorder and its association with suicidal behaviors. Because no one is immune to suicide the challenge is to develop a variety of messages targeting the young and the old, various racial and ethnic populations, individuals of various faiths, those of different sexual orientations, and people from diverse socioeconomic groups and geographical regions.
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Objective 1.2: |
By 2005, establish regular national congresses on suicide prevention designed to foster collaboration with stakeholders on prevention strategies across disciplines and with the public. |
Broad-based participation and involvement is needed to ensure progress in reducing the toll of suicide. Open discussion and assessment of suicide prevention programs can only lead to their refinement and better chances for success.
The techniques and tools to create and implement prevention initiatives can be taught and demonstrated. Learning how to develop and disseminate public health messages and to mount public health campaigns is critical to implementing suicide prevention efforts.
A number of organizations have convened annual, national meetings devoted to suicide prevention. Currently, such meetings are sponsored by AAS, AFSP, and biennially by the International Association for Suicide Prevention (IASP). The establishment of regular national congresses on suicide prevention, collaboratively sponsored by more than one organization, will maintain interest and focus on this issue. Ideally, these national congresses should be sponsored by public/private partnerships (see Objective 2.2), and focus on needs and plans for coordinating effective suicide prevention efforts.
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Ideas for Action |
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Objective 1.3: |
By 2005, convene national forums to focus on issues likely to strongly influence the effectiveness of suicide prevention messages. |
National forums increase awareness of the problem of suicide and serve to mobilize social will. Such meetings keep the subject in the forefront of attention and raise concerns to the national level. Such activities increase connectedness between and among key stakeholders, and serve to bring support, consensus and collaboration to suicide prevention efforts.
Focusing on factors that influence the effectiveness of suicide prevention initiatives is critical to an overall strategy. National forums are opportunities to focus on specific issues that affect all efforts to mount suicide prevention initiatives. By highlighting specific areas, consensus can be reached on how best to incorporate elements into a suicide prevention plan and how best to evaluate effectiveness.
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Ideas for Action |
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Objective 1.4: |
By 2005, increase the number of both public and private institutions active in suicide prevention that are involved in collaborative, complementary dissemination of information on the World Wide Web. |
The World Wide Web offers an unparalleled opportunity to bring public health information to a much broader audience because it can be accessed at home, at work, at schools, at community centers, at libraries, or at any other location where there is access to the Internet. Not only does the World Wide Web offer exciting possibilities for the delivery of public health messages (including promoting awareness and referral sources for those in need), but it offers an opportunity to develop preventive interventions as well.
For example, the World Wide Web offers the potential for interactive dialogue and exchange of accurate information. Clear, concise, and culturally sensitive public health messages are key to assisting individuals to evaluate their at-risk status accurately and to know where and how to get help. It therefore is important that both public and private institutions committed to suicide prevention activities collaborate and cooperate to deliver information that is consistent, comparable, complementary, and not competitive. In addition to several Federal websites (see Appendix D), some of the key national organizations currently disseminating suicide prevention information on the World Wide Web include AAS, AFSP, IASP, SPAN USA, and the American Academy of Pediatrics.
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Did You Know? |
GOAL 2:
Develop Broad-Based Support for Suicide Prevention
Why is this Goal Important to the National Strategy?
Because there are many paths to suicide, prevention must address psychological, biological, and social factors if it is to be effective. Collaboration across a broad spectrum of agencies, institutions, and groups–from schools to faith-based organizations to health care associations– is a way to ensure that prevention efforts are comprehensive. Such collaboration can also generate greater and more effective attention to suicide prevention than can these groups working alone. Public/private partnerships that evolve from collaboration blend resources and build upon each group's strengths. Broad-based support for suicide prevention may also lead to additional funding, through governmental programs as well as private philanthropy and to the incorporation of suicide prevention activities into the mission of organizations that have not previously addressed it. In 1993, the United Nations/World Health Organization identified broad-based collaborative support as a key element in developing and implementing national suicide prevention strategies (UN/WHO, 1996).
Background Information and Current Status
In the last five years, a new collaborative effort has been forged in the fight against suicide. The 1998 National Suicide Prevention Conference brought several Federal agencies together with private groups to focus attention on suicide prevention. This conference engendered renewed enthusiasm for suicide prevention and increased collaboration among public health and mental health agencies on suicide prevention activities (see Foreword, Public efforts leading to the Goals and Objectives for Action).
An indication that the Nation has begun to recognize the severity of the problem of suicide is an increase in the numbers of Members of Congress who have begun to focus attention on the topic. Another is the expansion or formation of organizations focused solely on suicide prevention. For example, the American Association of Suicidology has broadened its membership considerably and now has approximately 900 members. In 1996, the Suicide Prevention Advocacy Network was formed, a grassroots organization made up of survivors of suicide, attempters of suicide, community activists, and health and mental health clinicians. The American Foundation for Suicide Prevention, established in 1987, is a private organization that supports research on suicide prevention and disseminates information on effective strategies. In 2000, the National Council for Suicide Prevention was formed, representing a total of 12 advocacy, survivor and research organizations, each with a primary focus on suicide prevention. In short, support for suicide prevention is growing, but much work still remains to be done to engage the public fully.
How Will the Objectives Facilitate Achievement of the Goal?
The objectives established for this goal are focused on developing collective leadership and on increasing the number of groups working to prevent suicide. They will help ensure that suicide prevention is better understood and that organizational support exists for implementing prevention activities. The objectives also provide a management structure for the NSSP, a key factor in its success.
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Objective 2.1: |
By 2001, expand the Federal Steering Group to appropriate Federal agencies to improve Federal coordination on suicide prevention, to help implement the National Strategy for Suicide Prevention, and to coordinate future revisions of the National Strategy. |
The Federal government has a major role to play in suicide prevention, and several Federal agencies have responsibilities related to suicide prevention, suicidal behavior, and response to suicide attempts, as described in Appendix D.
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Did You Know? |
While several Federal agencies are active in suicide prevention efforts, improved planning and coordination can ensure that resources are used most effectively. Knowledge and resources can also enhance the prevention efforts of each agency. With Federal agencies working together, the goals of the National Strategy can be embedded in their ongoing work and suicide prevention efforts can become integrated into the spectrum of an agency's mandates and activities. The NSSP Federal Steering Group, established in 2000 by the Secretary of Health and Human Services, is already facilitating such coordination, and thus this objective is to some degree already met. In addition to the Office of the Surgeon General and the U.S. Public Health Service Regional Health Administrators, its membership includes several agencies of the Department of Health and Human Services–the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Indian Health Service, the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration. This membership is augmented by liaisons from eleven other Federal agencies (see Appendix D).
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Objective 2.2: |
By 2002, establish a public/private partnership(s) (e.g., a national coordinating body) with the purpose of advancing and coordinating the implementation of the National Strategy. |
Leadership and collaboration are the keys to success of the National Strategy. The establishment of a public/private coordinating body will stimulate the requisite national attention to the issue. Such a body will help to ensure that suicide prevention is perceived as a national problem and the NSSP as a national plan. The partnership will help establish momentum for the plan and will provide continuity over time and legitimacy through the involvement of key groups. And finally, the coordinating body will oversee the implementation of the National Strategy.
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Objective 2.3: |
By 2005, increase the number of national professional, voluntary, and other groups that integrate suicide prevention activities into their ongoing programs and activities. |
To make suicide prevention efforts more effective and to leverage resources, suicide prevention must be integrated into programs and activities that already exist and included in the agendas of communities and national groups. Some national advocacy groups and some communities attempt to address many problems simultaneously, but have not considered or included suicide among these issues. It is often possible to target several health or social problems with one intervention, particularly since some risk factors put population groups at risk for more than one problem at the same time. Therefore, an intervention that targets one or more risk or protective factors has the potential to effect change in more than one identified problem. For example, the suicide rate has risen steeply over the last two decades for African-American youth, a group with a high risk for other health and social problems. Programs focused on enhancing educational and occupation-al opportunities for African-American youth may contribute to feelings of hope and self-assurance, and as a by-product reduce suicide. However, by consciously integrating program elements that address suicide prevention more directly (for example, encouraging help-seeking for emotional distress), a program may be even more effective overall.
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Ideas for Action |
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Objective 2.4: |
By 2005, increase the number of nationally organized faith communities adopting institutional policies promoting suicide prevention. |
While many faith groups have already taken strong stands on suicide prevention, others have not. And yet the statements and positions of faith groups are often key to influencing public opinion. By adopting institutional policies on suicide, faith groups can help to de-stigmatize mental illness and alcohol and substance use problems and change the perception of suicide from something that is shameful to a problem that can be prevented. Faith groups can also assist in suicide prevention by helping their members identify risk factors, encouraging treatment for depression, sustaining protective factors and offering support and guidance to individuals during stressful times. For instance, faith-based organizations are well positioned to provide community guidance on ways to support family members who survive the loss of a loved one to suicide, while avoiding the excessive memorializing of those who have died by suicide that may lead to suicide contagion. A few faith groups have developed statements or "messages" on suicide prevention, which provide guidance to members on the scope of suicide and on how individuals can help prevent it (Evangelical Lutheran Church in America, 1999).
GOAL 3:
Develop and Implement Strategies to Reduce the Stigma Associated with Being a
Consumer of Mental Health, Substance Abuse, and Suicide
Prevention Services
Why is this Goal Important to the National Strategy?
Suicide is closely linked to mental illness and substance abuse and effective treatments exist for both. In fact, 60 to 90 percent of all suicidal behaviors are associated with some form of mental illness and/or substance use disorder (Harris & Barraclough, 1997). Despite the fact that effective treatments exist for these disorders and conditions, the stigma of mental illness and substance abuse prevents many persons from seeking assistance; they fear prejudice and discrimination. About two thirds of people with mental disorders do not seek treatment (Kessler et al.,1996). The stigma of suicide, while deterring some from attempting suicide, is also a barrier to treatment for many persons who have suicidal thoughts or who have attempted suicide.
People who have a substance use disorder also face stigma, because many people believe that abuse and addiction are moral failings and that individuals are fully capable of controlling these behaviors (Murphy, 1992). Rather, many mental health professionals, consider mental disorders, alcohol abuse, and drug abuse disorders not as signs of weakness, but as disorders that require professional assessment and clinically appropriate treatment (U.S. Department of Health and Human Services, 1999).
While the stigma attached to mental illness and addiction prevents persons at risk of suicide from seeking help for treatable problems, the stigma of suicide itself may also reduce the number of people who seek help, while adding to emotional burdens. Family members of suicide attempters often hide the behavior from friends and relatives, since they may believe that it reflects badly on their own relationship with the suicide attempter or that suicidal behavior itself is shameful or sinful. Persons who attempt suicide may have many of these same feelings. Those who have survived the suicide of a loved one suffer not only the grief of loss, but the pain of isolation from a community that may be perplexed and uninformed about suicide and its risk factors.
Historically, the stigma associated with mental illness, substance use disorders and suicide has contributed to the inadequate funding available for preventive services and to low insurance reimbursements for treatments. Until the stigma is reduced, treatable substance use and mental health problems–including those strongly correlated with suicide– will continue to go untreated, and services tailored to persons in crisis will continue to be limited. As a result, the number of individuals at risk for suicide and suicidal behavior will remain unnecessarily high.
Background Information and Current Status
Stigma has been identified as the most formidable obstacle to future progress in the arena of mental health (U.S. Dept. of Health and Human Services, 1999). It is a key reason that certain ethnic groups are particularly disinclined to seek treatment for mental illness or substance abuse (Sussman et al., 1987; Uba, 1994). Stigma is intense in rural areas (Hoyt et al., 1997) and it is implicated in the low percentages of youth and the elderly with mental disorders–both groups at high risk for suicidal behavior– who receive mental health services (Kazdin et al., 1997; U.S. Department of Health and Human Services, 1999).
Over the past 25 years, a principal goal shared by mental health consumer and family advocacy groups is to overcome the stigma of mental illness. These groups include the National Alliance for the Mentally Ill and the National Mental Health Association. Other mental health advocates, such as the American Psychological Association and the American Psychiatric Association, have also worked to reduce stigma. The publication of Mental Health: A Report of the Surgeon General represents a milestone in the Federal government's effort to reduce stigma by dispelling myths about mental illness and by providing accurate knowledge.
How Will the Objectives Facilitate Achievement of the Goal?
The objectives established for this goal are designed to create the conditions that enable persons in need of mental health and substance abuse services to receive them. There are many reasons why individuals may not receive such services, but stigma is an important factor. Stigma dissuades people from seeking mental health or substance abuse services. It is both a contributing cause and a result of society's collective devaluation of mental and substance abuse illness as compared to physical illness, such as heart disease or diabetes. The stigma of mental illness and substance abuse has resulted in the establishment of separate systems for physical health and mental health care; one consequence is that preventive services and treatment for mental illness and substance abuse are much less available than for other health problems. Moreover, this separation has led to bureaucratic and institutional barriers between the two systems that complicate the provision of services and further impede access to care. Destigmatizing mental illness and substance abuse could increase access to treatment by reducing financial barriers, integrating care, and increasing the willingness of individuals to seek treatment.
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Did You Know? |
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Objective 3.1: |
By 2005, increase the proportion of the public that views mental and physical health as equal and inseparable components of overall health. |
Due to the historic bias and prejudice against those with mental illnesses, health care, mental health care, and substance abuse treatment have traditionally been viewed as separate types of treatment; persons who need mental health care or substance abuse treatment avoid seeking it, and insurance companies often do not pay for it. As our Nation moves towards viewing mental illness and substance abuse disorders with the same concern and understanding as it views other illnesses, there will be a concomitant change in the importance attached to effective and available care, along with increased political support for "parity" (the financing of mental health care and substance abuse treatment on the same basis as that of other health services).
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Ideas for Action |
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Objective 3.2: |
By 2005, increase the proportion of the public that views mental disorders as real illnesses that respond to specific treatments. |
Behavior associated with mental disorders is still viewed by many persons as evidence of a character flaw rather than an illness. Consequently, disease that is treatable remains untreated because it is not perceived as disease. When people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, much of the negative stereotyping may dissipate; more persons will seek treatment and the suicide rate will be reduced.
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Ideas for Action |
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Objective 3.3: |
By 2005, increase the proportion of the public that views consumers of mental health, substance abuse, and suicide prevention services as pursuing fundamental care and treatment for overall health. |
When the act of seeking services for mental health concerns is normalized, and when such care is reimbursed, a larger number of persons at risk for suicide will receive treatment. Such a change in perspective might also lead to a better integration of the separate systems of care that now exist–one for mental health, one for substance abuse, the other for primary and specialty health care.
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Objective 3.4: |
By 2005, increase the proportion of those suicidal persons with underlying disorders who receive appropriate mental health treatment. |
Research indicates that suicides are more likely early in the course of certain severe mental illnesses and that persons who have required hospitalization for severe mood disorders have a substantially increased lifetime risk of suicide compared to individuals with less severe illnesses. Yet, only a minority of persons with those mental or substance use disorders seek professional help. The literature suggests that up to two-thirds of those who die by suicide are not receiving mental health or substance abuse treatment at the time of their death and that half had never seen a mental health professional (Jamison & Baldessarini, 1999; U.S. Department of Health and Human Services, 1999). Older people, for whom depression is quite prevalent and who have the highest rates of suicide in the U.S., are especially unlikely to utilize mental health services (Conwell, 1996; Hoyert et al., 1999). They tend to seek and receive health care in primary care settings, where it has been found that depression is frequently undiagnosed and untreated (Caine et al., 1996).
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Ideas for Action |
Members of some ethnic groups may also be reluctant to seek professional mental health care. Few treatment providers in the U.S. are knowledgeable about effective combinations of Western health care and culture- specific remedies that may enhance utilization of mental health services. Moreover, mental health services may not be available from persons who speak the language of individuals from particular ethnic groups or who understand the meaning of mental illness in the culture. Persons from many ethnic and cultural groups encounter additional barriers to access, such as lack of health insurance. Since effective treatments now exist for the major depressive disorders, and since these disorders are implicated in such a high proportion of suicides, ensuring treatment for these illnesses should reduce the suicide rate. Mood disorders are very prevalent among individuals who complete suicide, with 36-70 percent of individuals having a mood disorder at the time of death (Barraclough, Bunch, Nelson, & Sainsbury, 1974; Henriksson et al., 1993; Foster, Gillespie, McClelland, & Patterson, 1999; Rich, Young, & Fowler, 1986). Schizophrenia, certain personality disorders, and anxiety disorders in combination with other illnesses carry increased risk for suicide (Harris & Barraclough, 1997). An individual who suffers from one of these mental illnesses–especially if he or she has severe symptoms or a co-existing addictive disorder–is at increased risk of suicide (Angst et al., 1999).
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Did You Know? |
Reducing stigma related to mental illness and substance abuse will increase the number of persons from all groups who receive appropriate treatment for mental disorders associated with suicide.
GOAL 4:
Develop and Implement Community-Based Suicide Prevention Programs
Why is this Goal Important to the National Strategy?
Research has shown that many suicides are preventable; however, effective suicide prevention programs require commitment and resources. The public health approach, as described in the Introduction, provides a framework for developing preventive intervention programs: clearly define the problem, identify risk and protective factors, develop and test interventions, implement programs that are based on local needs, and evaluate effectiveness. Programs may be specific to one particular organization, such as a university or a community health center, or they may encompass an entire State. While other goals in the National Strategy address interventions to prevent suicide, a special emphasis of this goal is that of ensuring a range of interventions that in concert represent a comprehensive and coordinated program and of fostering planning and program development work.
Background Information and Current Status
The methodological problems inherent in conducting suicide prevention research have led to the current situation, in which considerably less is known about effective programs than is desirable; nevertheless, some interventions have proven effective and others appear promising but, are in need of evaluation (Silverman & Felner, 1995). The term "evidence-based" is often used to suggest the importance of implementing those interventions that have scientific evidence of effectiveness. The Introduction presents a matrix that can assist in program planning by clarifying the group(s) targeted for intervention and the focus of interventions– biopsychosocial, environmental, or sociocultural. Appendix C includes information on some interventions currently in progress that are, or could be evaluated.
How Will the Objectives Facilitate Achievement of the Goal?
The objectives established for this goal are designed to foster the implementation of suicide prevention interventions, especially through organizations and agencies that have access to groups of individuals for other purposes. The objectives also address the need for systematic planning at both the State and local levels, the need for technical assistance in the development of suicide prevention programs, and the need for ongoing evaluation.
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Objective 4.1: |
By 2005, increase the proportion of States with comprehensive suicide prevention plans that a) coordinate across government agencies, b) involve the private sector, and c) support plan development, implementation, and evaluation in its communities |
Suicide prevention is a complex problem. It intersects public health (especially injury prevention), mental health, and substance abuse; it requires commitment from education, justice, and social services; and it requires the commitment of various private sector groups, including business and labor. Effective programming requires collaboration and coordination of the State and local agencies that deliver services in these three arenas, as well as mobilization of the private sector. The planning process itself can help States and local jurisdictions accomplish a variety of activities that will help to prevent suicide: bring together partners who each play a role in solving the problem; raise awareness of suicide; develop a comprehensive approach to suicide prevention; and ensure that the most current research is employed in developing strategies. At a minimum, the plan should include an assessment of the problem, including a statistical analysis of suicide in the State and its communities; goals, objectives, and timetable; and actions to be taken. State plans may include resources for local communities, such as task force recommendations and screening tools (Children's Safety Network, 2000). It may help communities address the local issues important in suicide prevention; for example, the suicide rate is affected by community norms and cultural values, and suicide rates vary with such factors as percent of the population residing in rural areas and the ethnic composition of the population. A plan implies a locus of responsibility and appropriate resources to carry it out. Both State and local leadership are needed for suicide prevention planning and implementation.
Considerable attention has been devoted to youth suicide prevention. In 1985, a bill was introduced into the House of Representatives to provide funding to States to address youth suicide. Though the bill was not enacted into law, many States did engage in suicide prevention planning. However, during the early 1990s, suicide prevention programs and plans in some States were discontinued and allowed to lapse (Metha et al., 1998). Regional conferences for States were sponsored by the Health Resources and Services Administration in the mid-1990s to encourage renewed State planning for youth suicide prevention, and the National Suicide Prevention Conference held in Reno, Nevada, in 1998 also spurred interest in State-level planning for suicide prevention across the life span. While a number of States currently have suicide prevention plans, few are comprehensive and the plans do not uniformly link public health, mental health and substance abuse programs (Metha et al., 1998; West, 1998). Moreover, not all address the entire life span and few involve all key stakeholders, such as education, justice, social services, and the private sector.
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Objective 4.2: |
By 2005, increase the proportion of school districts and private school associations with evidence-based programs designed to address serious childhood and adolescent distress and prevent suicide. |
Most school-based suicide prevention efforts are curriculum-based, with a focus on increasing awareness of the problem of adolescent suicide, identifying adolescents at risk, and teaching referral techniques and resources. In 1996, the New Zealand Department of Education developed and published a guide for schools that summarizes the literature on school-based programs and recommends improving the awareness of teachers and other adults about issues related to youth suicide and suggests a tiered structure of counseling for students identified by these adults as at risk of suicide (Beautrais et al., 1997; Ministry of Education, 1998). Limited evaluation of curriculum-based programs has found minimal increases in knowledge, that attitudes towards suicide remain unchanged, or that attitudes have changed in negative ways (Garland & Ziegler, 1993; Hazell & King, 1996). Yet, given the nature of our current knowledge, it is premature to dismiss curriculum-based efforts in suicide prevention, though prudence is clearly indicated.
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Ideas for Action |
Efforts concentrating on teaching youth to identify the warning signs of suicide in themselves and their peers may not be effective, since prior research has found that suicidal youth are not likely to self-refer or seek help from school staff, nor do knowledgeable peers request adult help (Kalafat & Elias, 1995). This suggests that schools should screen for youth at risk and that school staff need to be trained and aware of the warning signs for suicidal youth and have a plan of action for helping those at risk.
An alternative approach to school-based efforts that focus on suicide prevention is to target risk and protective factors that occur earlier in the pathways to suicide, and to also consider specific needs and subcultures of the school population (e.g., gay and lesbian youth) (McDaniel et al., 2001). For example, there are many proven prevention programs that reduce substance use and aggressive behavior by teaching techniques in problem solving and building positive peer relations (see Appendix C). When implemented effectively, these programs have the potential for reducing risk for suicide simultaneous with other negative outcomes, in this case substance use and aggressive behavior.
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Objective 4.3: |
By 2005, increase the proportion of colleges and universities with evidence-based programs designed to address serious young adult distress and prevent suicide. |
Suicide is the third leading cause of death among the U.S. college-aged population. Among adults, those aged 18-24 have the highest incidence of reported suicide ideation (Crosby et al., 1999). One fourth of all persons aged 18-24 years in the U.S. are either full- or part-time college students, suggesting that a large proportion of young adults could be reached through college-based suicide prevention efforts. Colleges and universities are increasingly challenged to identify and manage mental health and substance use problems in students. In part this is because more youth with disorders are able to attend college thanks to effective treatments that improve symptoms of their illness, and the age of onset of a number of psychiatric disorders is in young adulthood (Barrios et al., 2000; Brener et al., 1999; Silverman et al., 1997). Because many of the risk and protective factors for suicide among young adults are similar to those for mental disorders and other problem behaviors, including alcohol, drug abuse and interpersonal violence (Brent et al., 1994; Henriksson et al., 1993), suicide prevention may be best integrated within broad prevention efforts.
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Ideas for Action |
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Objective 4.4: |
By 2005, increase the proportion of employers that ensure the availability of evidence-based prevention strategies for suicide. |
Because so many teens and adults are in the workforce, employers have an important role to play in suicide prevention. It is in the interests of employers to prevent suicide and suicidal behaviors; for example, providing mental health treatment, or reducing maladaptive substance use, can improve an employee's functioning. A suicide in the family of an employee may result in such grief that the employee becomes incapacitated.
Employers are a very important player in health insurance in the United States since so many people obtain coverage through their work; employers are the payors of health care and therefore help determine the coverage that workers can obtain. Employers who insist on mental health and substance abuse parity in the insurance policies they offer to workers assure that their workers can obtain treatment for depression and other mental illnesses and substance abuse disorders.
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Ideas for Action |
Employee Assistance Programs (EAP) are one example of worksite-based programs that employers may use to help prevent suicide. EAPs help employees identify and resolve personal concerns, including mental or physical health, marital, family, financial, alcohol, drug, or other personal issues, that may affect job performance. Some employers provide family services for their workers, and others engage in a variety of activities and programs in their communities designed to foster a higher quality of life for their workers; it is possible to integrate suicide prevention into such programs.
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Objective 4.5: |
By 2005, increase the proportion of employers that ensure the availability of evidence-based prevention strategies for suicide. |
Jails and juvenile justice facilities have exceptionally high suicide rates, although rates in Federal prisons are relatively low. Suicide rates in jails have been estimated to be approximately nine times higher than that of the general population (Hayes & Rowan, 1988), while suicide rates in some State prisons are at least one and a half times higher (Hayes, 1995). Jail rates are especially high because arrestees may be under the influence of or in withdrawal from alcohol and/or drugs within the first twenty- four hours of arrest (Hayes, 1995).
The suicide rate in the Federal prison system is lower than the rate for the general population of males, and there have been no reported suicides of a female offender in the Federal system since the 1960's. These facts suggest that the experience of the Federal prison system, strategies are available to prevent suicide in correctional settings (Condelli et al., 1997; Cox & Morschauser, 1997). Jail or "lock up" suicides most often occur within 24-48 hours after arrest, suggesting an important role for appropriate medical assessment of substance abuse and administration of standardized suicide assessments. Comprehensive programs include training, screening, effective communication methods, intervention, use of reporting protocols, and mortality review (Hayes, 1997).
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Ideas for Action |
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Objective 4.6: |
By 2005, increase the proportion of State Aging Networks that have evidence-based suicide prevention programs designed to identify and refer for treatment of elderly people at risk for suicidal behavior. strategies for suicide. |
Since the elderly have the highest overall suicide rate of all age groups, organizations that have special access to older persons have an important role in suicide prevention. State Aging Networks exist in every State and Territory. They plan, develop and fund a variety of in-home and community- based services for older people. States organize the provision of such services through area agencies on aging, which coordinate a broad range of services for older people in a designated geographic area. In addition, State aging networks or the hundreds of tribal and native organizations that provide services to older American Indians, Alaskan Natives, and Native Hawaiians may also help to maintain protective factors among those elderly at somewhat lower risk for suicide.
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Ideas for Action |
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Objective 4.7: |
By 2005, increase the proportion of family, youth and community service providers and organizations with evidence-based suicide prevention programs. strategies for suicide. |
The integration of suicide prevention into existing service-based organizations provides opportunities to expand the numbers of individuals who may be reached by preventive interventions. For example, county extension and 4-H programs have unique access to rural populations, and tribal service organizations may be best positioned to reach Native American youth. Homeless youth and young people who have dropped out of school require special attention by these organizations since school-based programs will not reach them. Faith-based organizations have a special role to play, as do natural community helpers.
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Ideas for Action |
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Objective 4.8: |
By 2005, develop one or more training and technical resource centers to build capacity for States and communities to implement and evaluate suicide prevention programs. |
Resource centers can serve a number of important functions, such as disseminating information on evidence-based interventions and serving as an information repository; convening meetings; coordinating regional activities; providing technical assistance in planning and program design; and monitoring regional changes in the suicide rate.
While there is now considerable understanding of risk factors for suicide, less progress has been made in the design and evaluation of programs to prevent suicide (Bonnie et al., 1999). A key function of suicide prevention resource centers is evaluation. Useful evaluation is an enormous undertaking for local programs, and measurement at the local level is difficult. Given the need for evaluation of preventive interventions, technical assistance in evaluation is particularly important. Evaluations promoted by the centers can be structured to involve practitioners in evaluations to ensure that the evaluations address questions of particular interest to practitioners and are sensitive to local issues. They may also include a feed-back loop to project staff in programs being evaluated to document findings as they are generated. Moreover, the centers can be given the task of interpreting evaluation findings more widely to the practitioner community. Finally, the resource centers may help to further specify ethnic and culturally-specific risk and protective factors in the implementation of interventions.
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Did You Know? |
GOAL 5:
Promote Efforts to Reduce Access to Lethal Means and Methods to Self-Harm
Why is the Goal Important to the National Strategy?
Evidence from many countries and cultures shows that limiting access to lethal means and methods of self-harm is an effective strategy to prevent self-destructive behaviors in certain individuals (Brent et al., 1987; Kellerman et al., 1992; Kreitman, 1976). Often referred to as "means restriction," this preventive intervention approach is based on the belief that a small but significant number of suicidal acts are, in fact, impulsive and of the moment (Mann, 1998). A number of suicidal behaviors result from a combination of psychological pain or despair coupled with the availability of the means by which to inflict self-injury (Shneidman, 1999). If intervention is not possible when an individual is in a state of psychological pain, a self-destructive act may be prevented by limiting the individual's access to the means or methods of self-harm. Evidence suggests that there may be a limited time effect for decreasing suicide, as over time, individuals with ongoing suicide intent may substitute a more available for the restricted, less available methods (Marzuk, 1992).
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Did You Know? |
Controversy exists about how to accomplish this goal because restricting means can take many forms and signifies different things to different people. Different types of means restrictions may be effective in different settings and for different populations. For some, it may connote redesigning or altering the existing lethal means of self-harm currently available, and to others eliminating or limiting their availability to those at risk for self-harm.
This goal is important and necessary to contribute to an overall effort to reduce the rates of suicide and suicidal behaviors in our population. Means restriction is a key activity in a broader public health approach to reducing intentional injuries.
Background Information and Current Status
In the United States, the focus has been on protecting individuals from access to loaded firearms, lethal doses of prescription medications or illegal substances, illegal access to alcohol by underage youth, and danger-ous settings (such as bridges and rooftops of high buildings) (Birckmayer & Hemenway, 1999; Brent et al., 1993b; ; Marzuk et al., 1992; O'Carroll, Silverman & Berman, 1994).
The majority of suicides and homicides in the U.S. are firearm-related (NCHS, 1997). Between 40-50 percent of all U.S. households have a firearm inside the home. Much focus has been placed on firearm restrictions and safety measures including education, improved storage, and the technology of ensuring that a firearm will not fire unintentionally or be used by those for whom it was not intended. According to recent research (Brent et al., 1988, 1991, 1993a; Kellerman et al., 1992), those who use firearms for suicidal behaviors in the home are not necessarily those who purchase the weapons. Firearms must be safely stored so they are not misappropriated and improperly used.
In 1996, the Youth Suicide by Firearms Task Force met to endorse a consensus statement on youth suicide by firearms (Berman, 1998). They concluded that there is clear evidence that intervening in or preventing the immediate accessibility of a lethal weapon can save lives. They identified the safe storage of guns as one preventive intervention approach that would result in the decrease in the number of youth suicides. Close to 40 national organizations endorsed a combination of indicated, selective, and universal preventive interventions addressing this objective.
In addition to efforts related to firearms, activities have been devoted to educating physicians and other prescribing and dispensing professionals about limiting prescriptions of potentially lethal medications to amounts that are non-lethal. Issues of training related to prescribing and dispensing medications are covered in Goal 6.
Improvements and changes in car exhaust emissions have resulted in a decrease in carbon monoxide poisoning and death by this means. The objectives point to the necessity of collaborating with all stakeholders including, but not limited to, the auto industry, the pharmaceutical industry, gun proponent groups, and gun manufacturers.
How Will the Objectives Facilitate Achievement of the Goal?
Much more needs to be done to reduce the likelihood of the use of lethal means during an impulsive act of self-injury or self-destruction. By eliminating or restricting the easy availability of one particular means of suicide, impulsive individuals often do not substitute another method in the immediate time frame. Current forms of means restriction have meaning over the short-term, but may not over the long-term (Marzuk et al., 1992). Thus, separating in time and space the suicidal impulse from access to lethal means and methods of self-harm has great potential for saving lives.
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Objective 5.1: |
By 2005, increase the proportion of primary care clinicians, other health care providers, and health and safety officials who routinely assess the presence of lethal means (including firearms, drugs, and poisons) in the home and educate about actions to reduce associated risks. |
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Ideas for Action |
It has been shown that the presence of a lethal means of self-destruction in the home (particularly a firearm) is associated with increased rates of suicide (Brent et al., 1993, Kellerman et al., 1992). Because of their positions, primary care clinicians, other health care providers, and health and safety officials ordinarily inquire about an individual's overall health, safety, and welfare, including their mental health (Goldman, Wise & Brody, 1998). It is incumbent upon them to ask patients, families, and care givers routinely about the presence of lethal means of self harm and to evaluate the risk for their use. This is especially important when talking with individuals who are in crisis, or who have mental disorders, substance abuse problems, or suicidal thoughts (Goldman, Silverman & Albert, 1998; WHO, 2000c).
Safety officials and health care providers are also in a unique position to educate about firearm storage and access, and about appropriate storage of alcoholic beverages, prescription drugs, over-the-counter medications, and poisons used for household purposes (bleaches, disinfectants, herbicides). To aid in this effort, for example, the American Academy of Pediatrics has developed guidelines on how to talk to parents about the presence of guns in the home (AAP, 1992). Such actions may reduce the likelihood that these lethal means will be used for self-destructive outcomes.
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Objective 5.2: |
By 2005, expose a proportion of households to public information campaign(s) designed to reduce the accessibility of lethal means, including firearms, in the home. |
Public information campaigns have been shown to be of great value in changing health behavior and improving public health. Successful campaigns have decreased tobacco use, increased seat belt use, decreased the number of drunk drivers through designated driver campaigns, decreased alcohol use during pregnancy, increased early detection of cancer symptoms, decreased use of illicit drugs (particularly among adolescents and young adults), and increased installation of smoke alarms in homes. The success of these campaigns provides hope that similar efforts will be successful in educating the public about reducing access and availability to lethal means, including firearms, in the home.
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Objective 5.3: |
By 2005, develop and implement improved firearm safety design using technology where appropriate. |
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Ideas for Action |
Efforts are underway to explore the use of technology to improve the safety of firearms. Activities include development of removable firearm pins, computer chips to ensure that only the owner can activate the weapon ("smart guns"), and devices to indicate whether a gun's chamber is loaded. These and other efforts need to be completed so that firearms can be made safer for their intended uses and prevented from being used for self-destructive purposes.
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Objective 5.4: |
By 2005, develop guidelines for safer dispensing of medications for individuals at heightened risk of suicide. |
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Ideas for Action |
There has been a significant improvement in limiting the potential for lethal overdose with the newer generation of antidepressants currently available (i.e., selective serotonin reuptake inhibitors and other related compounds are less lethal in overdose). Still, some individuals benefit from the use of older antidepressants and there are many other medications that are dangerous in relatively small overdoses. Processes that ensure flexibility in the frequency of prescription refills and regular contact with patients who use these medications need to be developed and supported.
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Objective 5.5: |
By 2005, improve automobile design to impede carbon monoxide-mediated suicide. |
Carbon monoxide poisoning and death occurs with prolonged exposure to car exhaust fumes. The redesign of automobile monitoring and exhaust systems would make carbon monoxide poisoning more difficult to accomplish, especially for someone who may be impulsive. Such efforts would also reduce the likelihood of accidental deaths. Cost analyses are needed to determine best approaches.
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Ideas for Action |
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Objective 5.6: |
By 2005, institute incentives for the discovery of new technologies to prevent suicide. |
The development of safer drugs and better medical emergency technologies and techniques to intervene in the treatment of overdoses and self-poisonings will result in saving more lives. Better computer technologies will improve the means of educating and communicating messages faster and more precisely. Engineering advances have the potential to influence the design and construction of safer bridges and roof barriers, the design and operation of firearms that function solely for the purposes for which they are intended, and the development of more fuel-efficient and cleaner engines for automobiles. New medical technologies may include the use of blood tests to determine who may be at increased risk for suicide and who might benefit from the use of a particular medication.
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Ideas for Action |
GOAL 6:
Implement Training for Recognition of At-Risk Behavior and Delivery of Effective
Treatment
Why is this Goal Important to the National Strategy?
Key gatekeepers, those people who regularly come into contact with individuals or families in distress, must be trained to recognize behavioral patterns and other factors that place individuals at risk for suicide and be equipped with effective strategies to intervene before the behaviors and early signs of risk evolve further. Key gatekeepers interact with people in environments of work, play, and natural community settings, and have the opportunity to interact in other than medical settings.
Although many textbooks, manuals, handbooks, multimedia presentations, journals, and brochures discuss the assessment and management of suicidal risk, as well as the identification and promotion of protective factors (Hawton & von Herringen, 2000; Jacobs, 1999a; Maris, Berman & Silverman, 2000), there is a need to define minimum course objectives in educating each type of key gatekeeper about his or her special role and perspective. Each has a unique relationship to individuals at risk and a responsibility to intervene in a timely and effective manner.
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Key Gatekeepers
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Background Information and Current Status
With the advent of safer and/or very effective psychotropic medications, many conditions associated with suicidal behaviors can be treated effectively (Montgomery 1997; Tondo, Jamison & Baldessarini, 1997). Furthermore, advances in family, group, and individual therapies (especially cognitive behavioral therapy, dialectical behavioral therapy, and interpersonal psychotherapies) have led to better treatment of at-risk individuals (Linehan, 1997; Linehan, Heard & Armstrong, 1993; Rudd, Joiner & Rajab, 2000; Zimmerman & Asnis, 1995).
About 45 percent of individuals who die by suicide have had some contact with a mental health professional within the year of their death (Pirkis & Burgess, 1998) and as many as 90 percent carry a psychiatric diagnosis at the time of death (Conwell & Brench, 2000). However, only 18 percent of suicide decedents reported suicidal ideation to a health professional prior to their death (Robins, 1981). Thus, at-risk individuals often seek professional help, but may not have their condition adequately recognized and are not likely to report the true severity of their condition.
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Studies indicate that many health professionals are not adequately trained to provide proper assessment, treatment, and management of suicidal patients and clients, or know how to refer them properly for specialized assessment and treatment (Bongar, Lomax & Harmatz, 1992; Ellis and Dickey, 1998; Ellis, Dickey & Jones, 1998; Kleespies, 1998). Despite the increased awareness of suicide as a major public health problem, gaps remain in training programs for health professionals and others who often come into contact with patients in need of these specialized assessment techniques and treatment approaches. In addition, many health professionals lack training in the recognition of risk factors often found in grieving family members of loved ones who have died by suicide (suicide survivors).
How Will the Objective Facilitate Achievement of the Goal?
Much needs to be done to ensure that all key gatekeepers are adequately trained to identify individuals at risk for suicidal behaviors, as well as respond to those expressing self-destructive behaviors. Key gatekeepers also need to identify opportunities for reinforcing protective factors that do exist and help foster protective factors when indicated. Furthermore, gatekeepers need to be educated about the availability and use of effective treatment interventions and when and how to refer to formal treatment settings those identified as being at risk (Hawton, Arensman, Townsend et al., 1998; Rudd, Joiner, Jobes et al., 1998).
As part of the process for designing and implementing training, it would be useful to develop a baseline of professionals' awareness, attitudes and knowledge of risk and protective factors related to suicide. For instance, awareness of the suicide protective effects of lithium for individuals with bipolar disorder is estimated to be low among certain health care personnel. Knowledge of which health care personnel and the extent of their awareness would permit more targeted training efforts.
Consensus about what needs to be taught and how to ensure appropriate training has not been reached; however, with the provision of appropriate and targeted education and training to each key gatekeeper group, it is likely that many suicide attempts and suicides can be prevented.