Safe and Effective Messaging for Suicide Prevention
This document offers evidence-based recommendations for creating safe and effective messages
to raise public awareness that suicide is a serious and preventable public health problem. The following
list of “Do’s” and “Don’ts” should be used to assess the appropriateness and safety of message content insuicide awareness campaigns. Recommendations are based upon the best available knowledge about
messaging.1,2,3 They apply not only to awareness campaigns, such as those conducted through PublicService Announcements (PSAs), but to most types of educational and training efforts intended for thegeneral public.
These recommendations address message content, but not the equally important aspects ofplanning, developing, testing, and disseminating messages. While engaged in these processes, one
should seek to tailor messages to address the specific needs and help-seeking patterns of the target
audience. For example, since youth are likely to seek help for emotional problems from the Internet, apublic awareness campaign for youth might include Internet-based resources.4

The Do’s—Practices that may be helpful in public awareness campaigns:•Do emphasize help-seeking and provide information on finding help. When recommending
mental health treatment, provide concrete steps for finding help. Inform people that help isavailable through the National Suicide Prevention Lifeline (1-800-273-TALK [8255]) and throughestablished local service providers and crisis centers.

•Do emphasize prevention. Reinforce the fact that there are preventative actions individuals cantake if they are having thoughts of suicide or know others who are or might be. Emphasize that5suicides are preventable and should be prevented to the extent possible.

•Do list the warning signs, as well as risk and protective factors of suicide. Teach people
how to tell if they or someone they know may be thinking of harming themselves. Include lists ofwarning signs, such as those developed through a consensus process led by the American
Association of Suicidology (AAS).6 Messages should also identify protective factors that reduce
the likelihood of suicide and risk factors that heighten risk of suicide. Risk and protective factors
are listed on pages 35-36 of the National Strategy for Suicide Prevention.

•Do highlight effective treatments for underlying mental health problems. Over 90 percent of
those who die by suicide suffer from a significant psychiatric illness, substance abuse disorder orboth at the time of their death.7-8 The impact of mental illness and substance abuse as risk
factors for suicide can be reduced by access to effective treatments and strengthened social
support in an understanding community.9

The Don’ts—Practices that may be problematic in public awareness campaigns:•Don’t glorify or romanticize suicide or people who have died by suicide. Vulnerable people,
especially young people, may identify with the attention and sympathy garnered by someone whohas died by suicide.10 They should not be held up as role models.

•Don’t normalize suicide by presenting it as a common event. Although significant numbersof people attempt suicide, it is important not to present the data in a way that makes suicide seem
common, normal or acceptable. Most people do not seriously consider suicide an option;
therefore, suicidal ideation is not normal. Most individuals, and most youth, who seriously
Continued > >Suicide Prevention Resource Center  www.sprc.org  877-GET-SPRC (877-438-7772)
Education Development Center, Inc.  55 Chapel Street, Newton, MA 02458-1060

Safe and Effective Messaging for Suicide Prevention•

consider suicide do not overtly act on those thoughts, but find more constructive ways to resolvehem. Presenting suicide as common may unintentionally remove a protective bias against
suicide in a community.11•Don’t present suicide as an inexplicable act or explain it as a result of stress only.
Presenting suicide as the inexplicable act of an otherwise healthy or high-achieving person may
encourage identification with the victim.12 Additionally, it misses the opportunity to informaudiences of both the complexity and preventability of suicide. The same applies to any
explanation of suicide as the understandable response to an individual’s stressful situation or to
an individual’s membership in a group encountering discrimination. Oversimplification of suicide
in any of these ways can mislead people to believe that it is a normal response to fairly common
life circumstances.13•Don’t focus on personal details of people who have died by suicide. Vulnerable individuals
may identify with the personal details of someone who died by suicide, leading them to consider
ending their lives in the same way.14•

Don’t present overly detailed descriptions of suicide victims or methods of suicide.
Research shows that pictures or detailed descriptions of how or where a person died by suicide
can be a factor in vulnerable individuals imitating the act. Clinicians believe the danger is evengreater if there is a detailed description of the method.15

Acknowledgment
SPRC thanks Madelyn Gould, PhD, MPH [Professor at Columbia University in the Division of Child andAdolescent Psychiatry (College of Physicians & Surgeons) and Department of Epidemiology (School ofPublic Health), and a Research Scientist at the New York State Psychiatric Institute] for her extensive
contributions and guidance in drafting and editing this document.

1

Gould, M. S., Jamieson, P. & Romer, D. (2003). Media contagion and suicide among the young. American Behavioral Scientist,
46(9), 1269-1284.
2Gould, M.S. (1990). Suicide clusters and media exposure. In S. J. Blumenthal & D. J. Kupfer (Eds.), Suicide over the life cycle(pp.517-532). Washington, DC: American Psychiatric Press.
3Chambers, D. A., Pearson, J. L., Lubell, K., Brandon, S., O’Brien, K., & Zinn, J. (2005). The science of public messages for suicide
prevention: A workshop summary. Suicide and Life-Threatening Behavior, 35(2), 134-145.
4Gould, M. S., Velting, D., Kleinman, M., Lucas, C., Thomas, J. G., & Chung, M. (2004). Teenagers' attitudes about coping
strategies and help seeking behavior for suicidality. Journal of the American Academy of Child and Adolescent Psychiatry, 43(9),1124-1133.
5U.S. Department of Health and Human Services. (2001). National strategy for suicide prevention: Goals and objectives for action.

Rockville, MD: Author.
6Rudd, M. D., Berman, A. L., Joiner, T. E., Nock, M. K., Silverman, M. M., Mandrusiak, M., Van Orden, K., and Witte, T. (2006).
Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior, 36(3), 255-262.
7Shaffer, D., Gould, M. S., Fisher, P., Trautman, P., Moreau, D., Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child andadolescent suicide. Archives of General Psychiatry, 53 (4), 339-348.
8Conwell Y., Duberstein P. R., Cox C., Herrmann J.H., Forbes N. T., & Caine E. D. (1996). Relationships of age and axis I
diagnoses in victims of completed suicide: a psychological autopsy study. American Journal of Psychiatry, 153, 1001-1008.
9Baldessarini, R., Tondo, L, & Hennen, J. (1999). Effects of lithium treatment and its discontinuation on suicidal behavior in bipolar
manic-depressive disorders. Journal of Clinical Psychiatry, 60 (Suppl. 2), 77-84.
10Fekete, S., & A. Schmidtke. (1995) The impact of mass media reports on suicide and attitudes toward self-destruction: Previousstudies and some new data from Hungary and Germany. In B. L. Mishara (Ed.), The impact of suicide. (pp. 142-155). New York:Springer.
11Cialdini, R. B. (2003). Crafting normative messages to protect the environment. Current Directions in Psychological Science,12(4), 105-109.
12Fekete, S., & A. Schmidtke. op. cit.
13Moscicki, E.K. (1999). Epidemiology of suicide. In D. G. Jacobs (Ed.), The Harvard Medical School Guide to suicide assessment
and intervention (pp. 40-51). San Francisco: Jossey-Bass.
14Fekete, S., & E. Macsai, (1990). Hungarian suicide models, past and present. In G. Ferrari (Ed.), Suicidal behavior and riskfactors (pp.149-156). Bologna: Monduzzi Editore.
15Sonneck, G., Etzersdorfer, E., & Nagel-Kuess, S. (1994). Imitative suicide on the Viennese subway. Social Science and Medicine,38(3), 453-457.

Suicide Prevention Resource Center  www.sprc.org  877-GET-SPRC (877-438-7772)
Education Development Center, Inc.  55 Chapel Street, Newton, MA 02458-1060

“Talking About Ethnicity & Inequality in
Public Education”

Youth, Ethnicity, &Public Health Outcomes in Hawai‘i
Earl S. Hishinuma, Ph.D. (hishinumae@dop.hawaii.edu)
Professor & Associate Chair of Research
Department of Psychiatry, University of Hawai‘i at Mānoa
November 7, 2015; Hawai‘i State Teachers Association (HSTA)
Campus Center, University of Hawai‘i at Mānoa, Honolulu, Hawai‘iObjectives
1. Health & Psycho-Social Disparities
a. less on education achievement

2. Special Education Disparities
3. Student-Teacher Ethnicity Incongruence
4. Life Expectancy as a Primary Health Outcome
5. Summary of Trends
6. Implications

Preface
1. Will mostly present on risk factors
a. Important to also emphasize protective factors

2. Careful not to stereotypea. We are more similar than different

3. Important to examine trends in the results so that healthdisparities are appropriately addressed
1. Will be presenting a lot of numbers
2. Will summarize results/trends

Youth Risk Behavior Survey (YRBS)• Centers for Disease Control & Prevention (CDC)• National and local survey administered every odd-numberedyear to high school and middle school students• Health-related questions in several domains• Hawai‘i results• Confidence intervals not included (somewhat large)• Race/ethnicity*:• Native Hawaiians – includes part-Native Hawaiians• Other = mixed/non-Native Hawaiians, Hispanics, African Americans*Hawai‘i Health Data Warehouse. (2011, August). Race-ethnicity documentation. Honolulu, HI: Hawai‘i Health Data Warehouse.

YRBS Hawai‘i % (2013):ItemEuroHawaiian

Filipino

Japanese

OtherAsian

Other
Pac Is.

Other

Overweight or obese(based on body-massindex [BMI])

16.8

34.4

30.2

24.3

17.8

51.9

26.2

Fruit/vegetable 5 or moretimes/day – past week

14.0

18.5

13.4

12.0

14.2

26.1

13.8

Non-school-work-related
screen time of not morethan 2 hours/school day

38.5

44.6

28.5

36.4

26.4

48.5

35.9

From: Hawai‘i Health Data Warehouse, State of Hawai‘i. (2015, November 5). Hawai‘i School Health Survey: Youth Risk Behavior Survey
Module, (report title and years), Report Created: 5/30/14. http://hhdw.org/health-reports-data/data-source/yrbs-reports/

YRBS Hawai‘i % (2013):
ItemEuroHawaiian

FilipinoJapanese

OtherAsian

Other
Pac Is.

Other

Alcohol binge drinking –past 30 days

17.1

18.4

7.6

5.1

4.9

16.6

13.7

Methamphetamine –lifetime

6.4

4.8

2.2

3.5

2.6

2.4

4.2

Prescription drugs
without M.D. - lifetime

19.0

16.5

7.2

11.1

2.4

7.5

15.7

Electronically bullied –lifetime

28.5

22.8

27.9

19.4

22.7

9.9

26.3

Forced by date to do
unwanted sexual things –past year

13.7

14.1

11.4

11.0

-16.2

20.0

Adult to talk to

81.6

77.6

73.9

76.5

78.1

76.8

76.5

YRBS Hawai‘i % (2013):
Item – School-Related

EuroHawaiian

Filipino

Japanese

Other
Asian

Other
Pac Is.

Other

Attend at least 1 physicaleducation class – pastweek

33.8

44.3

37.1

33.5

28.6

46.4

40.6

Teacher/adult at school
to talk to

62.0

72.4

70.3

62.9

68.5

66.8

69.7

YRBS Hawai‘i % (2013):
Item – School-Related

EuroHawaiian

Filipino

Japanese

Other
Asian

Other
Pac Is.

Other

Alcohol – past 30 days

5.9

8.4

2.6

3.7

2.1

5.5

7.5

Marijuana – past 30 days

6.5

11.4

3.9

4.7

0.7

13.7

7.1

Offered, sold, or given
illegal drugs – past year

37.6

33.3

24.0

29.9

26.5

34.8

34.9

Bullied – past year

22.1

18.6

17.2

8.9

12.3

18.7

24.4

Physical fight – past year

9.7

12.3

5.1

3.0

2.5

14.4

7.4

Threatened/injured withweapon – past year (2011)

6.7

4.4

8.0

3.5

2.3

8.3

6.1

Did not go to school
because felt unsafe –past 30 days

6.0

10.2

6.6

5.8

5.016.1

9.4(2011)

Leading Causes of Death in Hawai‘i:
2007-2011
Suicide = 2nd leading cause of death for 10-19 year olds
Suicide = 1st leading cause of fatal injuries for 15-24 year olds

From: Department of Health, State of Hawai‘i. (2012, September). Injuries in Hawai‘i, 2007-2011. Honolulu, HI: Department of Health,State of Hawai‘i.

Suicide Rates by Ethnicity & Age:
2007-2011

YRBS Hawai‘i % (2013): Suicidality
ItemEuro

Hawaiian

FilipinoJapanese

OtherAsian

Other
Pac Is.

Other

Sad/hopeless – past 2weeks

26.4

32.2

28.9

21.921.6

37.7

35.4

Made plan to kill self –past year

9.8

17.1

12.0

16.2

11.5

18.1

21.0

Seriously considered
attempting suicide – pastyear

12.6

19.7

13.4

17.3

9.9

21.5

22.3

Tried to kill self – pastyear

7.0

15.8

8.3

8.6

3.9

19.3

10.7

Suicide attempt resulted
in injury that had to betreated by doctor/nurse –past year

3.6

4.3

2.4

3.0

1.1

6.3

2.4

YRBS: Limitations• Only Hawai‘i public school students• Approximately 15% of Hawai‘i’s youth are in private schools• Surveyed only those with parent permission, youth assent, &present on the day of administration (i.e. not absent,suspended, dropped out of school)• Therefore, probably under-estimations of risk

• Youth self-report• Survey data are anonymous; therefore, cannot link data
across the years for longitudinal analysis• Some of the lower-proportion ethnicities were notdisaggregatedYouth Incarceration
Over-representation at Hawai‘i Youth Correctional Facility:• Native Hawaiians (approx. 50%-55%, expected 25%-30%)• Samoans• African Americans

Under-representation:• European Americans• Filipino Americans• Japanese, Chinese Americans
From: Kassebaum, 1995a/b.

Hawai‘i DoE Special Education %:K-12 By Ethnicity (1997-1998)
Disability

AsianEuropean

Hawaiian

HispanicPortu.

Other

Overall

All Disabilities

7.1

10.9

15.5

15.7

17.2

11.8

11.1

Hearing-Vision

0.2

0.2

0.4

0.3

0.1

0.3

0.3

Intellectual Disability

1.1

0.8

2.1

2.1

2.2

2.2

1.5

Severe Emotional
Disturbance

0.7

1.9

2.0

2.1

2.9

1.4

1.4

Speech-Language

1.2

1.9

1.5

1.3

1.2

1.4

1.4

Learning Disability*2.94.7

8.0

8.3

9.3

5.1

5.1

Other

1.0

1.5

1.5

1.6

1.6

1.5

1.3

*Learning disability not primarily the result of visual, hearing, or motor disabilities, of mental retardation, of emotional disturbance, orof environmental, cultural, or economic disadvantage.
Note: Data from Department of Education, State of Hawai‘i.

Hawai‘i DoE Special Education %:Ages 6-21 By Ethnicity (2011)
Disability

European

Asian

NHOPI*Mixed

All Students (public school)

14.2

35.8

34.1

8.4

All Disabilities

14.4

22.4

46.1

6.8

Autism

25.735.2

21.0

9.0

Emotional Disturbance

17.4

14.1

51.5

6.5

Hearing Impairment

-

29.5

49.0

6.8

Intellectual Disability

10.0

28.1

46.5

6.4

Multiple Disabilities

13.9

33.6

39.4

7.0

Orthopedic Impairment

-

26.6

48.1

-

Other Health Impairment

20.6

17.1

44.1

7.5

Specific Learning Disabilities

11.2

21.5

50.3

6.5

Speech or Language Impairment

25.7

20.0

33.5

6.1

Traumatic Brain Injury

21.3

24.6

45.9

-

Visual Impairment

17.2

-

--

NHOPI = Native Hawaiian and Other Pacific Islander (likely includes part-Native Hawaiians)
From: Individuals with Disabilities Education Act (IDEA) 2011 Child Count and 2010-2011 CCD. https://www2.ed.gov/fund/data/report/idea/partbspap/2013/hi-acc-stateprofile-11-12.pdf

Hawai‘i DoE Student vs. Teacher Ethnicity(2013-2014)
EthnicityStudents Teachers%%

Native Hawaiian

26.4

9.2

Filipino

22.2

6.0

European (+ Portuguese)

18.2

23.4

Japanese

9.2

26.0

Hispanic

3.8

0.3

Samoan3.5

0.4

Chinese3.2

3.7

African American

2.9

0.7

Other Pacific Islanders

5.5?

?

29.3

Other

From: Department of Education, State of Hawai‘i. (2014). Superintendent’s annual report, 2014. Honolulu, HI: Department ofEducation, State of Hawai‘i.

Life Expectancy (Hawai‘i, 2000)
90.0
86.1

Years

85.0
79.0

80.0
75.0

72.8

80.9

81.4

82.8

74.3

70.0
65.0

Park, C. B., Braun, K. L., Horiuchi, B. Y., Tottori, C., & Onaka, A. T. (2009). Longevity disparities in multiethnic Hawai‘i: An analysis of 2000
life tables. Public Health Records, 124, 579-584. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693172/

Summary
Native Hawaiians– life expectancy– Special education, substance use, suicidality, incarceration– + less screen time, adults to talk to at school

Other Pacific Islanders– Overweight, life expectancy– Marijuana (school)?
– Physical fights, threatened with weapon, not go to school
because felt unsafe, incarceration, suicidality– + physically active, fruits/vegetables, less screen timeSummary
European Americans (Caucasians)– Substance use, electronically bullied– Autism, speech-language impairment– + adult to talk toPortuguese– Special education

Other (mostly Mixed/non-Hawaiian)– Dating violence victimization, bullied (school), suicidality– AutismImplications• Important to disaggregate data by ethnicity• But careful not to stereotype by ethnicity• Ethnicity typically accounts for only a small amount the effect• What are other factors?

• Are the measures valid?
• If so, what do we need to do to reduce & eliminate healthdisparities• What is the role of culture?
• Additional emphasis on PREVENTION• Development of innovative programs that tap into strengths &positive youth-family development• Systems approach for positive, sustained changedImplications
Possible Roles of the Hawai‘i Department of Education• Educate the next generation (K-12) in PREVENTION & healthybehaviors• Have youth teach their parents/families• Incorporate culturally appropriate prevention & intervention
strategies• Partner with other agencies/entities outside of the DoE (e.g.,Department of Health, health insurance companies, media)

THANK YOU!
Earl S. Hishinuma, Ph.D.
Professor & Associate Chair of Research
Department of Psychiatry
University of Hawai‘i at Mānoa
hishinumae@dop.hawaii.edu