NATIONAL STRATEGY FOR SUICIDE PREVENTION:

GOALS AND OBJECTIVES FOR ACTION

______________________________________________________________________________

2001

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Rockville, MD
National Library of Medicine Cataloging in Publication

National strategy for suicide prevention : Goals and objectives for action.

Rockville, MD : U.S. Dept. of Health and Human Services, 

Public Health Service, 2001. Includes index.

1. Suicide - prevention & control - United States. 2. Health Planning - United States. I. United States.

Public Health Service.

02NLM:HV 6548.A1 2001.

Copies of this document are available from the Center for Mental Health Services' Knowledge Exchange

Network by calling 1-800-789-2647, reference document number SMA 3517; and on the World Wide

Web at www.mentalhealth.org/suicideprevention, or at http://www.surgeongeneral.gov/library
GOALS AND OBJECTIVES FOR ACTION 1

NATIONAL STRATEGY FOR SUICIDE PREVENTION

PREFACE FROM THE SURGEON GENERAL:

Suicide exacts an enormous toll from the American people. Our Nation

loses 30,000 lives to this tragedy each year, another 650,000 receive

emergency care after attempting to take their own lives. The devastating

trauma, loss, and suffering is multiplied in the lives of family members

and friends. This document, National Strategy for Suicide Prevention

– Goals and Objectives for Action, lays the foundation of our Nation's

strategy to confront this serious public health problem.

At this document's source are countless dedicated individuals representing every facet of our Nation's communities. They include representatives to a 1993 United Nations/World Health Organization Conference

who played key roles in establishing guidelines for national suicide prevention strategies. They include the passionate grassroots activists whose

work stimulated Congressional Resolutions declaring suicide prevention

a national priority and calling for our own national strategy. They include

dedicated public servants and private individuals who jointly organized

and participated in the first National Suicide Prevention Conference in

1998 to consolidate a scientific base for this critical endeavor. These people and their efforts led directly to publication of the Surgeon General's

Call to Action to Prevent Suicide - 1999 with its most important recommendation, the completion of the National Strategy for Suicide

Prevention.

After listening to the concerns of the American people, Government

leaders helped bring stakeholders together in a shining example of public-private collaboration to achieve this major milestone in public health.

Those who have invested their hearts and minds in this effort believe it

effectively points the way for organizations and individuals to curtail the

tragedy of suicide and suicidal behavior. Though it does not specify all

the details, it provides essential guidance and suggests the fundamental

activities that must follow–activities based on the best available science.

Nearly half of the States are engaged in suicide prevention and many

have already committed significant resources to implement programs.

Their leadership in evaluating the effectiveness of these programs will
2 GOALS AND OBJECTIVES FOR ACTION PREFACE

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help guide the efforts of States that follow in their paths. Most of these

plans recognize that much of the work of suicide prevention must occur

at the community level, where human relationships breathe life into public policy. American communities are also home to scores of faith-based

and secular initiatives that help reduce risk factors and promote protective factors associated with many of our most pressing social problems,

including suicide.

As you read further, keep in mind that the National Strategy for

Suicide Prevention is not the Surgeon General's strategy or the Federal

government's strategy; rather, it is the strategy of the American people

for improving their health and well-being through the prevention of suicide. I congratulate each person who played a role in bringing it to completion. You have served your fellow Americans well.

Sincerely yours,

David Satcher, M.D., Ph.D.

Surgeon General
GOALS AND OBJECTIVES FOR ACTION 3

NATIONAL STRATEGY FOR SUICIDE PREVENTION

FROM THE NATIONAL COUNCIL FOR SUICIDE PREVENTION

Dear Surgeon General Satcher:

The members of the National Council for Suicide Prevention are writing to express strong support for this landmark document -- the first ever

National Strategy for Suicide Prevention (National Strategy).

We are particularly grateful to you for bringing needed attention to

the problem of suicide in our country, and for your role in the public/private effort that has led to the National Strategy. Further, we applaud

the fact that this strategy has been created from the expertise and experience of mental health clinicians, research scientists, suicide survivors,

persons who have attempted suicide, prevention advocates and other

concerned individuals.

The enormous amount of time and effort that went into the development of the National Strategy is reflected in its clarity of purpose and

its comprehensiveness. From our perspective, the goals and objectives, as

articulated and well documented in the strategy, provide a focus for the

suicide prevention work of all groups at national, State and local levels.

With this broad agreement on what must be done to prevent suicide,

we now face a new challenge, which is how to achieve, to the fullest

extent possible, the goals and objectives presented in the strategy and to

ensure that it reaches all Americans.

As a council of national not-for-profit organizations whose primary

focus is the prevention of suicide, we are dedicated to working with each

other and with our colleagues in government and the private sector to

do what we can to ensure the timely implementation of the National

Strategy. Together, we can and will do more to prevent loss of life from

suicide.
4 GOALS AND OBJECTIVES FOR ACTION FROM THE NCSP

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Respectfully submitted,

Alan L. Berman, Ph.D.

American Association of Suicidology

Clark Flatt

The Jason Foundation 

Iris Bolton

The Link Counseling Center's National Resource Center for Suicide

Prevention and Aftercare 

James Clemons

Organization for Attempters and Survivors of Suicide in Interfaith

Services 

Jackie Casey

Suicide Awareness\Voices of Education 

Robert Gebbia

American Foundation for Suicide Prevention 

Reese Butler

Kristin Brooks Hope Center

Donna Holland Barnes

National Organization for People of Color Against Suicide

Mary Jean Coleman

Samaritans, Inc.

Jerry Weyrauch

Suicide Prevention Advocacy Network 

Dale Emme

Yellow Ribbon Suicide Prevention Program
GOALS AND OBJECTIVES FOR ACTION 5

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ACKNOWLEDGMENTS

This document was prepared by the Department of Health and Human

Services under the direction of the Substance Abuse and Mental Health

Services Administration, Center for Mental Health Services, and the Office

of the Surgeon General; and through the partnership and collaboration

of stakeholders in the public and private sectors. At the request of the

Secretary, the Surgeon General provided essential leadership to coordinate the related efforts of the following agencies: The Substance Abuse

and Mental Health Services Administration, Center for Mental Health

Services; Centers for Disease Control and Prevention, National Center for

Injury Prevention and Control; The National Institutes of Health, National

Institute of Mental Health; the Health Resources and Services

Administration, Maternal and Child Health Bureau; the Indian Health

Service and the Public Health Service Regional Health Administrators.

Public and private sector contributors are listed individually below.

OFFICE OF THE SECRETARY

VADM David Satcher, M.D., Ph.D., Surgeon General, Office of Public

Health and Science, Washington, DC

RADM Arthur Lawrence, Ph.D., R.Ph., Assistant Surgeon General, USPHS,

Deputy Assistant Secretary for Health (Operations), Office of Public

Health and Science, Washington, DC

RADM Kenneth Moritsugu, M.D., M.P.H., Deputy Surgeon General,

USPHS, Office of the Surgeon General, Washington, DC

Nicole Lurie, M.D., M.S.P.H., (Former) Principal Deputy Assistant Secretary

for Health, Office of Public Health and Science, Office of the Secretary,

Washington, DC

Beverly Malone, Ph.D., R.N., F.A.A.N., (Former) Deputy Assistant Secretary

for Health, Office of Public Health and Science
6 GOALS AND OBJECTIVES FOR ACTION ACKNOWLEDGMENTS

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Damon Thompson, Director of Communications, Office of Public Health

and Science, Office of the Assistant Secretary for Health, Washington, DC

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

Joseph H. Autry III, M.D., Acting Administrator, Substance Abuse and

Mental Health Services Administration, Rockville, Maryland

Bernard S. Arons, M.D., Director, Center for Mental Health Services,

Rockville, Maryland

RADM Brian Flynn, Ed.D., Assistant Surgeon General, Director, Division of

Program Development, Special Populations and Projects, Center for

Mental Health Services, Rockville, Maryland

CAPT Norma J. Hatot, Senior Nurse Consultant, Center for Mental Health

Services, Rockville, Maryland

Charlotte Gordon, Center for Mental Health Services, Rockville, Maryland

CENTERS FOR DISEASE CONTROL AND PREVENTION

Jeffrey P. Koplan, M.D., M.P.H., Director, Centers for Disease Control and

Prevention, Atlanta, Georgia

Rodney Hammond, Ph.D., Director, Division of Violence Prevention,

National Center for Injury Prevention and Control, Atlanta, Georgia

NATIONAL INSTITUTES OF HEALTH

Ruth L. Kirschstein, M.D., Acting Director, National Institutes of Health,

Bethesda, Maryland.
ACKNOWLEDGMENTS GOALS AND OBJECTIVES FOR ACTION 7

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Steven E. Hyman, M.D., Director, National Institute of Mental Health,

Bethesda, Maryland.

Richard Nakamura, Ph.D., Deputy Director, National Institutes of Mental

Health, Bethesda, Maryland

HEALTH RESOURCES AND SERVICES ADMINISTRATION

Claude Earl Fox, M.D., M.P.H., (Former) Administrator, Health Resources

and Services Administration, Rockville, Maryland

INDIAN HEALTH SERVICE

Michael H. Trujillo, M.D., Ph.D., Assistant Surgeon General, Director,

Indian Health Service, Rockville, Maryland

NATIONAL STRATEGY FOR SUICIDE PREVENTION FEDERAL STEERING GROUP

CDR Alex E. Crosby, M.D., M.P.H., (Contributing Writer) Medical

Epidemiologist, Division of Violence Prevention, National Center for

Injury Prevention and Control, Centers for Disease Control and

Prevention, Atlanta, Georgia

CDR Robert E. DeMartino, M.D., (Managing Editor and Science Writer)

Program in Trauma and Terrorism, Center for Mental Health Services,

Substance Abuse and Mental Health Services Administration, Rockville,

Maryland.

Marlene EchoHawk, Ph.D., (Science Reviewer) Health Science

Administrator, Alcoholism and Substance Abuse Program, Indian Health

Service, Rockville, Maryland.
8 GOALS AND OBJECTIVES FOR ACTION ACKNOWLEDGMENTS

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Col David A. Litts, O.D., (Assistant Managing Editor and Contributing

Writer), United States Air Force, Special Advisor, Office of the Surgeon

General, Office of the Secretary, Washington, DC

CAPT Richard Lyons, M.D., (Science Reviewer) MS, Regional Health

Administrator, Public Health Service, Region X, Seattle, Washington.

Jane Pearson, Ph.D., (Contributing Writer) Chair, NIMH Suicide Research

Consortium, National Institute of Mental Health, Rockville, Maryland.

Margaret West, M.S.W., Ph.D., (Science Reviewer) Regional Program

Consultant, Region X, Maternal and Child Health Bureau, Health

Resources and Services Administration, Seattle, Washington.

EDITORS

Morton M. Silverman, M.D., Senior Scientific Editor and Writer, Associate

Professor of Psychiatry, University of Chicago, Chicago, Illinois

Martin J. Frankel, Copy Editor, Columbia, Maryland

A. Cate Miller, Copy Editor, Washington, D.C.

CONTRIBUTING WRITERS AND SPECIAL CONSULTANTS

Lucy Davidson, M.D., Ed.S., Associate Director of Science, Center for Child

Well-being, Atlanta, Georgia

Jean L. Athey, Ph.D., President, Health Policy Resources Group,

Brookeville, Maryland
ACKNOWLEDGMENTS GOALS AND OBJECTIVES FOR ACTION 9

NATIONAL STRATEGY FOR SUICIDE PREVENTION

CONTRIBUTING WRITER

Jason Luoma, M.A., Graduate Student, The Catholic University of

America, Washington, DC

LEADERSHIP CONSULTANTS

Alan Berman, Ph.D., Executive Director, American Association of

Suicidology, Washington DC 

Mary Chung, B.S., CEO/President, National Asian Women's Health

Organization, San Francisco, California

Bob Glover, Ph.D., Executive Director, National Association of State

Mental Health Program Directors, Alexandria, Virginia

Veronica Vaccaro Goff, M.S., Vice President, Washington Business Group

on Health, Washington, DC

Madelyn Gould, Ph.D., M.P.H., Professor, Psychiatry and Public Health

(Epidemiology), Columbia University, New York Psychiatric Institute, New

York, New York

Michael F. Hogan, Ph.D., Director, Ohio Department of Mental Health,

Upper Arlington, Ohio

Thomas E. Lengyel, Ph.D., Director of Research & Evaluation Services,

Alliance for Children & Families, Milwaukee, Wisconsin

Ian A. Shaffer, M.D., M.M.M., Chief Operating Officer, University Alliance

for Behavioral Care, Inc., Reston, Virginia

Margaret Beale Spencer, Ph.D., Professor, Department of Psychology,

University of Pennsylvania, Graduate School of Education, Philadelphia,

Pennsylvania
10 GOALS AND OBJECTIVES FOR ACTION ACKNOWLEDGMENTS

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Jerry Weyrauch, M.B.A., Founder, Suicide Prevention Advocacy Network

(SPAN USA), Marietta, Georgia

Harvey Whiteford, M.D., University of Queensland, Twoowong, Brisbane,

Australia

Glorisa Canino, Ph.D., Director, Behavioral Sciences Research Institute,

University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto

Rico

Felton Earls, M.D., Project on Human Development in Chicago

Neighborhoods, Harvard University, Cambridge, Massachusetts

Spero M. Manson, Ph.D., Director, Division of American Indian and Alaska

Native Programs, University of Colorado Health Sciences Center, Denver,

Colorado

John Gates, Ph.D. (Facilitator), Director of Programs, Collaborative Center

for Child Well-Being, Decatur, Georgia

PARTICIPANTS IN DEVELOPING THE REPORT

Administration on Aging

American Psychiatric Nurses Association, Washington, DC

Karen Abrams, Guidance Counselor, American School Counselors

Association, Concord, New Hampshire

Maria T. Baldi, Public Health Advisor, Center for Mental Health Services,

Substance Abuse and Mental Health Services Administration, Rockville,

Maryland

Nancy Bateman, LCSW-C, CAC, Senior Staff Associate, National

Association of Social Workers, Washington, DC
ACKNOWLEDGMENTS GOALS AND OBJECTIVES FOR ACTION 11

NATIONAL STRATEGY FOR SUICIDE PREVENTION

David Cordts, Associate Director of Student Activities, National

Association of Secondary School Principals, Reston, Virginia

Patricia Dunn, J.D., M.S.W., Director of Public Policy, Gay and Lesbian

Medical Association, San Francisco, California

Arthur Elster, M.D., Director, Medicine and Public Health, American

Medical Association, Chicago, Illinois

Stuart C. Hales, Director of Communications, Employee Assistance

Professionals Association, Arlington, Virginia

Lindsay M. Hayes, Assistant Director, National Center on Institutions and

Alternatives, Mansfield, Maine

Kathy Hogan-Bruen, Director of Prevention, National Mental Health

Association, Alexandria, Virginia

Douglas Jacobs, M.D., Harvard University Medical School, Cambridge,

Massachusetts

Kay Redfield Jamison, Ph.D., Professor of Psychiatry, The Johns Hopkins

University, Baltimore, Maryland

Larry Lehmann, M.D., Chief Consultant for Mental Health, Department of

Veterans Affairs, Washington, DC

Robert J. McNellis, M.P.H., PA-C, Director Clinical Affairs and Education,

American Academy of Physician Assistants, Alexandria, Virginia

William Modzeleski, Director, Safe and Drug-Free Schools Program,

Department of Education, Washington, DC

Denis Nissim-Sabat, Ph.D., Senior Policy Analyst, American Psychological

Association, Washington, DC

Judy Robinson, Ph.D. R.N., Executive Director, National Association of

School Nurses, Castle Rock, Colorado
12 GOALS AND OBJECTIVES FOR ACTION ACKNOWLEDGMENTS

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Holly Schumann, M.S.W., Presidential Management Intern,

Administration on Aging, Office of the Secretary, Department of Health

and Human Services, Washington, DC

Catherine Sutter, J.D., L.L.M., Senior Policy Analyst, Occupational Safety

and Health Administration, Department of Labor, Washington, DC 

Vicki Verdeyen, Ph.D., Psychology Administrator, Federal Bureau of

Prisons, Department of Justice, Washington, DC

MEMBERS OF THE NATIONAL COUNCIL FOR SUICIDE PREVENTION

American Association for Suicidology, Washington, DC (www.suicidology.org)

American Foundation For Suicide Prevention, New York, New York

(www.afsp.org)

Jason Foundation, (www.jasonfoundation.com)

Kristin Brooks Hope Center and the National Hopeline Network (1-800-

SUICIDE), Purcellville, Virginia (www.hopeline.com or www.livewithdepression.org)

The Link's National Resource Center for Suicide Prevention, Atlanta,

Georgia (www.thelink.org)

Million Mom March, San Francisco, California (www.millionmommarch.org)

National Organization of People for Color Against Suicide, San Marcos,

Texas (http://www.nopcas.com/home.html)

Organization of Attempters and Survivors of Suicide in Interfaith Service

(OASSIS), Washington, DC (www.oassis.org)
ACKNOWLEDGMENTS GOALS AND OBJECTIVES FOR ACTION 13

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The Samaritans, Albany, New York

Suicide Awareness\Voices of Education, Minneapolis, Minnesota

(www.save.org)

Suicide Prevention Advocacy Network, Marietta, Georgia

(www.spanusa.org)

Yellow Ribbon Suicide Prevention Campaign, Westminster, Colorado

(www.yellowribbon.org)

OTHER PARTICIPANTS

American Academy of Child and Adolescent Psychiatry, Washington, DC

American College of Emergency Physicians, Dallas, Texas

Ross J. Baldessarini, M.D., Professor of Psychiatry (Neuroscience), Harvard

Medical School, Cambridge, Massachusetts

Virginia Trotter Betts, M.S.N., J.D., R.N. F.A.A.N.

Frederick K. Goodwin, M.D.

Lloyd Potter, Ph.D., Program Manager, Educational Development Center,

Newton, Massachusetts

E. Cameron Ritchie, M.D., Program Director, Mental Health Policy and

Women's Issues, Office of the Assistant Secretary of Defense (Health

Affairs), Washington DC

CONTRACTOR SUPPORT

Educational Services, Inc., Washington, DC
14 GOALS AND OBJECTIVES FOR ACTION ACKNOWLEDGMENTS

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SPECIAL THANKS TO:

Those who participated in the four public hearings on the Goals and

Objectives

Those who provided comments through the Surgeon General's Web Site

The Air Force Medical Service
GOALS AND OBJECTIVES FOR ACTION 15

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GOALS AND OBJECTIVES FOR ACTION

TABLE OF CONTENTS

FOREWORD:

Public efforts leading to the Goals and Objectives for Action

The National Strategy concept

Benefits of a National Strategy

About the Goals and Objectives for Action

INTRODUCTION:

What is the U.S. National Strategy for Suicide Prevention?

A Plan for Suicide Prevention: Goals, Objectives and Activities

The public health approach as applied to suicide prevention 

The international experience building suicide prevention strategies

CHAPTERS 1-11, GOALS AND OBJECTIVES FOR ACTION:

Why this goal is important to the National Strategy

Background information and current status

How will the objectives facilitate achievement of the goal?

Discussion of individual objectives

1. Promote awareness that suicide is a public health problem that is

preventable

2. Develop broad-based support for suicide prevention

3. Develop and implement strategies to reduce the stigma associated with being a consumer of mental health, substance abuse and

suicide prevention services

4. Develop and implement community-based suicide prevention

programs

5. Promote efforts to reduce access to lethal means and methods of

self-harm
16 GOALS AND OBJECTIVES FOR ACTION TABLE OF CONTENTS

NATIONAL STRATEGY FOR SUICIDE PREVENTION

6. Implement training for recognition of at-risk behavior and delivery of effective treatment

7. Develop and promote effective clinical and professional practices

8. Increase access to and community linkages with mental health

and substance abuse services

9. Improve reporting and portrayals of suicidal behavior, mental illness and substance abuse in the entertainment and news media

10. Promote and support research on suicide and suicide prevention

11. Improve and expand surveillance systems

CHAPTER 12: LOOKING AHEAD

Investment and collaboration

Challenges to overcome

Next steps

REFERENCES

APPENDICES:

A:NSSP Goals and Objectives for Action: Summary list

B. Evaluation of suicide prevention programs 

C. Suicide prevention efforts in process of evaluation

D.NSSP Federal Steering Group Agency descriptions

E. Glossary
GOALS AND OBJECTIVES FOR ACTION 17

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FOREWORD

PUBLIC EFFORTS LEADING TO THE GOALS AND OBJECTIVES FOR ACTION

Suicide has stolen lives around the world and across the centuries.

Meanings attributed to suicide and notions of what to do about it have

varied with time and place, but suicide has continued to exact a relentless toll. Only recently have the knowledge and tools become available to

approach suicide as a preventable problem with realistic opportunities to

save many lives. The goals and objectives presented here, a cornerstone

of our Nation's strategy to prevent suicide, are framed upon these

To most of those who have experienced it, the horror of depression

is so overwhelming as to be quite beyond expression, hence the frustrated sense of inadequacy found in the work of even the greatest

artists....If our lives had no other configuration but this, we should

want, and perhaps deserve, to perish; if depression had no termination, then suicide would, indeed, be the only remedy. But one need

not sound the false or inspirational note to stress the truth that

depression is not the soul’s annihilation; men and women who have

recovered from the disease – and they are countless – bear witness

to what is probably its only saving grace: it is conquerable.

William Styron

Suicide is a particularly awful way to die: the mental suffering leading up to it is usually prolonged, intense, and unpalliated. There is no

morphine equivalent to ease the acute pain, and death not uncommonly is violent and grisly. The suffering of the suicidal is private and

inexpressible, leaving family members, friends, and colleagues to

deal with an almost unfathomable kind of loss, as well as guilt.

Suicide carries in its aftermath a level of confusion and devastation

that is, for the most part, beyond description.

Kay Redfield Jamison
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advances in science and public health. Suicide is a serious public health

problem.

The French social scientist, Emile Durkheim (1858-1917) developed a

method of study that became the foundation for scientific inquiry about

suicide. Instead of basing his conclusions only upon commonalities

among people known to have died by suicide, Durkheim originated the

scientific exploration of risk factors for suicide by comparing one group

with another (Durkheim, 1897/1951). To Durkheim, the differences in

rates of suicide could be attributed to distinguishing sociological characteristics among those population groups. Comparing those who are suicidal with those who are not, or groups having high rates of suicide with

those having low rates is the incremental process by which risk and protective factors for suicide have been unveiled.

In the United States, large-scale efforts to prevent suicide began in

1958 through funds from the U.S. Public Health Service to establish the

first suicide prevention center. Based in Los Angeles, Edwin Shneidman,

Norman Farberow, and Robert Litman studied suicide in the context of

providing community service and crisis intervention (Shneidman and

Farberow, 1965). Other crisis intervention centers were founded across

the country to replicate the Los Angeles Suicide Prevention Center's service component.

A more direct Federal role in suicide prevention began in 1966 when the

Center for Studies of Suicide Prevention was established at the National

Institute of Mental Health (NIMH). In time, this unit became the Suicide

Research Unit (no longer existing) that championed the risk factor

approach to suicide prevention, a central tenet in the public health model

of prevention embodied in this National Strategy for Suicide Prevention

(National Strategy or NSSP). During the next two decades, the American

Association of Suicidology and then the American Foundation for Suicide

Prevention were established. Among their activities these professional and

private voluntary organizations worked to increase the scientific understanding of suicide as a base for effective prevention activities.
FOREWORD GOALS AND OBJECTIVES FOR ACTION 19

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In 1983, the Centers for Disease Control and Prevention (CDC) established a violence prevention unit that brought to public attention a disturbing increase in youth suicide rates. In response, the Secretary of

Health and Human Services established the multi-year public/private

Secretary's Task Force on Youth Suicide to review what was known about

risk factors for youth suicide and promising interventions. These reviews

and the Task Force's prevention recommendations were published in

1989 (ADAMHA, 1989).

Shortly thereafter an international effort culminated in the United

Nations/World Health Organization's 1996 summary, Prevention of

Suicide: Guidelines for the Formulation and Implementation of National

Strategies (UN/WHO, 1996). In the U.S., the Suicide Prevention Advocacy

Network (SPAN USA), a grassroots advocacy organization including suicide survivors (persons close to someone who completed suicide), suicide

attempt survivors, and community activists championed these guidelines

as a way to encourage development of a national suicide prevention

strategy for the United States. Their work to marshal social will for suicide prevention generated Congressional Resolutions recognizing suicide

as a national problem and suicide prevention as a national priority. These

resolutions provided further impetus to develop a national suicide prevention strategy.

SPAN propelled the creation of an innovative public/private partnership to jointly sponsor a National Suicide Prevention Conference convened in Reno, Nevada, in October 1998 (Reno Conference). Participating

agencies within the U.S. Department of Health and Human Services were

the Centers for Disease Control and Prevention, the National Institutes of

Health, the Office of the Surgeon General, the Substance Abuse and

Mental Health Services Administration, the Health Resources and Services

Administration, the Indian Health Service and the Public Health Service

Regional Health Administrators. Conference participants, including

researchers, health, mental health and substance abuse clinicians, policy

makers, suicide survivors, consumers of mental health services, and community activists and leaders discussed eight background papers that

were commissioned to summarize the evidence base for suicide prevention (Silverman, Davidson, and Potter, 2001). Working in regional, multi-
20 GOALS AND OBJECTIVES FOR ACTION FOREWORD

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disciplinary groups, participants at the Reno Conference offered many

recommendations for action that were shaped into a list of 81 by an

expert panel.

Moving forward with the work of the Reno Conference, the Surgeon

General issued his Call to Action to Prevent Suicide in July 1999,

emphasizing suicide as a serious public health problem. (USPHS, 1999)

The Surgeon General's Call introduced a blueprint for addressing suicide

prevention through Awareness, Intervention, and Methodology (AIM),

which describes 15 broad recommendations, containing goal statements, broad objectives, and recommendations for implementation,

consistent with a public health approach to suicide prevention. AIM represents a consolidation of the highest-ranked of the 81 Reno Conference

recommendations according to their scientific evidence, feasibility, and

community support.

Continuing attention to suicide prevention issues and the significant

role of mental health and substance abuse services in suicide prevention

is reflected in the landmark Mental Health: A Report of the Surgeon

General (DHHS, 1999) and in the nation's public health agenda, Healthy

People 2010, (see Objectives 18-1 and 18-2)(DHHS, 2000). The effective

implementation of the National Strategy will play a critical role in reaching the suicide prevention goals outlined in Healthy People 2010. In

early 2000, the Secretary of Health and Human Services officially established the National Strategy Federal Steering Group (FSG) to, "...ensure

resources identified...for the purpose of completing the National

[Suicide Prevention] Strategy are coordinated to speed its progress." The

FSG carefully reviewed the recommendations of both the Reno meeting

and the Call to Action with a view to developing a comprehensive plan

outlining national goals and objectives that would stimulate the subsequent development of defined activities for local, State and Federal partners.

The National Strategy Leadership Consultants (see

Acknowledgments) met to identify the scope and priorities for these

Goals and Objectives for Action. The Leadership Consultants have continued to refine the goals and objectives as part of a broadly inclusive
FOREWORD GOALS AND OBJECTIVES FOR ACTION 21

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process which has invited critical examination by scientific, clinical, and

government leaders; other professionals; and the general public. Revised

draft goals and objectives were also posted on the World Wide Web inviting comment. During 2000, public hearings on Goals and Objectives

for Action were held in Atlanta, Boston, Kansas City, and Portland to

provide a face-to-face forum for additional input and clarification.

Working in collaboration to develop the National Strategy has been

a process that has promoted investment in the goal of suicide prevention

and promoted broad collaboration in prevention activities. This volume,

the National Strategy for Suicide Prevention: Goals and Objectives

for Action, represents a significant milestone and continuing progress

towards all of the elements in a planned national strategy.

THE NATIONAL STRATEGY CONCEPT

A national strategy to prevent suicide is a comprehensive and integrated approach to reducing the loss and suffering from suicide and suicidal behaviors across the life course. It encompasses the promotion,

coordination, and support of activities that will be implemented across

the country as culturally appropriate, integrated programs for suicide

prevention among Americans at national, regional, tribal, and community levels.

A broad public/private partnership is essential for developing and

implementing a national strategy. Interwoven within a national strategy

are three key ingredients for action to improve suicide prevention: a

knowledge base, the public will to support change and generate

resources, and a social strategy to accomplish change. Developing a

national strategy provides an opportunity to convene public and private

partners across many sectors of society – government, public health,

education, human services, religion, voluntary organizations, advocacy,

and business – to sustain a true, national effort.
22 GOALS AND OBJECTIVES FOR ACTION FOREWORD

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BENEFITS OF A NATIONAL STRATEGY

A national strategy for suicide prevention can raise awareness and help

make suicide prevention a national priority. This can help direct resources

of all kinds to the issue.

A national strategy provides an opportunity to use public-private partnerships and the energy of survivors to engage those who may not have

considered suicide prevention within their purview. It supports collaboration across a broad spectrum of agencies, institutions, groups, and

community leaders as implementation partners.

A national strategy can link information from many prevention programs to avoid unintentional duplication and disseminate information

about successful prevention interventions.

A national strategy can direct attention to measures that benefit the

whole population and, by that means, reduce the likelihood of suicide

before vulnerable individuals reach the point of danger.

Suicide is an outcome of complex interactions among neurobiological,

genetic, psychological, social, cultural, and environmental risk and protective factors. Multiple risk and protective factors interact in suicide prevention. Development of a national strategy can bring together multiple

disciplines and perspectives to create an integrated system of interventions across multiple levels, such as the family, the individual, schools, the

community, and the health care system.

Collaborating in a national strategy can help develop priorities in an

equitable way. Resources are always finite and priorities direct resources

to projects that are likely to address the greatest needs and achieve the

greatest benefits. Some types of expertise are not available across all

communities. A national strategy can provide technical assistance with

valuable types of expertise to strengthen community programs.

An evidence-based national strategy can maximize success when recommendations are implemented locally. Sound evaluation of community

programs, in turn, builds the evidence base.
FOREWORD GOALS AND OBJECTIVES FOR ACTION 23

NATIONAL STRATEGY FOR SUICIDE PREVENTION

KEY ELEMENTS OF A PLANNED NATIONAL STRATEGY

A national strategy for the prevention of suicide has many interrelated elements contributing to success in reducing the toll from suicide.

n A means of engaging a broad and diverse group of partners to

develop and implement the national strategy with the support of

public and private social policies

n A sustainable and functional operating structure for partners

with authority, funding, responsibility, and accountability for

national strategy development and implementation

n Agreements among Federal agencies and institutions outlining

and coordinating their appropriate segments of the national

strategy

n A summary of the scope of the problem and consensus on prevention priorities; for example, The Surgeon General's Call to

Action to Prevent Suicide 1999 (USPHS, 1999).

n Specified national strategy aims, goals, and measurable objectives integrated into a conceptual framework for suicide prevention

n Appropriate and evaluable activities for practitioners, policy makers, service providers, communities, families, agencies, and other

partners 

n A data collection and evaluation system to track information on

suicide prevention and benchmarks for national strategy progress
24 GOALS AND OBJECTIVES FOR ACTION FOREWORD

NATIONAL STRATEGY FOR SUICIDE PREVENTION

ABOUT THE GOALS AND OBJECTIVES FOR ACTION

The Goals and Objectives for Action represents a synthesis of perspectives from researchers and scientists, practitioners, leaders of nongovernmental organizations and groups, Federal agencies, survivors, and

community leaders. Because Goals and Objectives for Action is meant to

be useful for applications outside the tightly controlled research environment, it builds on and extrapolates from the limited realm of scientific evidence in suicide prevention. While goals and objectives must be

consistent with available scientific evidence and support the expansion of

the scientific knowledge base, they are also intended for use in other

environments: public policy and community action.

Goals and objectives are among many elements needed for a national

strategy, not the entire strategy. The blend of evidence represented in the

Goals and Objectives for Action helps guide an informed selection of

activities for suicide prevention across the spectrum of the nation. The

national dialogue to determine specific activities to accomplish each

objective will be an extension of the consensus reached on these higher

order goals and objectives. In that subsequent step, responsibility and

accountability for carrying out activities will be accorded in the details of

how each activity should be accomplished, by whom, and with what

resources.

Development of specific activities provides the opportunity to address

the particular needs of subgroups at high risk for suicide and particular

cultural/ethnic/social contexts for implementation. For instance, the

objective to "increase the proportion of family, youth, and community

service organizations and providers with evidence based suicide prevention programs" can be achieved by different prevention activities appropriate for younger African-American males, the elderly, gay and lesbian

youth, persons with major mental illnesses, or American Indians and

Alaskan Natives.

Several broad themes for the National Strategy for Suicide

Prevention are interwoven throughout the specific goals and objectives

in this volume. These themes are valuable considerations as groups and
FOREWORD GOALS AND OBJECTIVES FOR ACTION 25

NATIONAL STRATEGY FOR SUICIDE PREVENTION

individuals across the country move forward in designing and strengthening suicide prevention activities. The major themes are:

l Draw attention to a wide range of actions so that specific activities can be developed to fit the resources and areas of interest

of people in everyday community life as well as professionals,

groups, and public agencies. As the eighth leading cause (see

Figure 1) of death among Americans, suicide affects families

and communities everywhere across the Nation. Suicide prevention is everyone's business.

l Seek to integrate suicide prevention into existing health, mental

health, substance abuse, education, and human services activities. Settings that provide related services, such as schools,

workplaces, clinics, medical offices, correctional and detention

centers, eldercare facilities, faith-based institutions, and community centers are all important venues for seamless suicide prevention activities.

l Guide the development of activities that will be tailored to the

cultural contexts in which they are offered. While universal interventions are applicable without regard to risk status, universal

does not mean that one size fits all. The cultural and developmental appropriateness of suicide prevention activities derived

from these goals and objectives is a vital design and implementation criteria.

l Seek to eliminate disparities that erode suicide prevention activities. This is an important commitment in the National Strategy.

Health care disparities are attributable to differences such as

race or ethnicity, gender, education or income, disability, age,

stigma, sexual orientation, or geographic location.

l Emphasize early interventions to reduce risk factors for suicide

and promote protective factors. As important as it is to recognize and help suicidal individuals, progress depends on measures that address problems early and promote strengths so that

fewer people become suicidal.
26 GOALS AND OBJECTIVES FOR ACTION FOREWORD

NATIONAL STRATEGY FOR SUICIDE PREVENTION

l Seek to build the Nation's capacity to conduct integrated activities to reduce suicidal behaviors and prevent suicide. Capacity

building will ensure the availability of the resources, experience,

skills, training, collaboration, evaluation, and monitoring necessary for success.

Moving forward with these Goals and Objectives for Action can

bring suicide prevention into the forefront of the Nation's public commitment to health and well-being. Working together in a coordinated

and systematic way towards appropriate activities for each objective will

lead to measurable progress.

FIGURE 1:

SUICIDE AMONG LEADING CAUSES OF DEATHS BY AGE GROUP - 1998
GOALS AND OBJECTIVES FOR ACTION 27

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.
28 GOALS AND OBJECTIVES FOR ACTION INTRODUCTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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).

AIMS OF THE NATIONAL STRATEGY

n Prevent premature deaths due to suicide across the life span

n Reduce the rates of other suicidal behaviors

n Reduce the harmful after-effects associated with suicidal behaviors and the traumatic impact of suicide on family and friends

n Promote opportunities and settings to enhance resiliency,

resourcefulness, respect, and interconnectedness for individuals,

families, and communities
INTRODUCTION GOALS AND OBJECTIVES FOR ACTION 29

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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. Its

five basic steps are shown

in (Figure 2): 

FIGURE 2:

THE PUBLIC HEALTH APPROACH TO PREVENTION
30 GOALS AND OBJECTIVES FOR ACTION INTRODUCTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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

FIGURE 3:

UNITED STATES SUICIDE RATES, 1933–1998

YEAR

Source: National Center for Health Statistics

Age-adjusted to 1940 U.S. Population
INTRODUCTION GOALS AND OBJECTIVES FOR ACTION 31

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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 (see Figure 3) geographic regions, age groups, or special populations (see Figure 4).

FIGURE 4:

SUICIDE RATES VARY BY GEOGRAPHIC REGION

AGE-ADJUSTED SUICIDE RATES BY STATE

UNITED STATES, 1998

RATE PER

100,000 POP.

Source: National Center for Health Statistics

Age-adjusted to 1940 U.S. Population
32 GOALS AND OBJECTIVES FOR ACTION INTRODUCTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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, as shown in the accompanying charts (see

Figures 5 and 6).

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).

FIGURE 5:

SUICIDE RATES BY AGE GROUP AND SEX

UNITED STATES, 1998

AGE GROUP IN YEARS

Source: National Center for Health Statistics

Males

Females
INTRODUCTION GOALS AND OBJECTIVES FOR ACTION 33

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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

FIGURE 6:

SUICIDE RATES BY RACE, ETHNICITY AND AGE

UNITED STATES, 1995–1998

AGE GROUP IN YEARS

Source: National Center for Health Statistics

Afr-Amer NL

Eur-Amer NL

Amer Ind /

AK Nat NL

Asian / PI NL

Latino

NL = Non-Latino
34 GOALS AND OBJECTIVES FOR ACTION INTRODUCTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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).
INTRODUCTION GOALS AND OBJECTIVES FOR ACTION 35

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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.

PROTECTIVE FACTORS FOR SUICIDE

n Effective clinical care for mental, physical, and substance use 

disorders 

n Easy access to a variety of clinical interventions and support for

help-seeking 

n Restricted access to highly lethal means of suicide

n Strong connections to family and community support

n Support through ongoing medical and mental health care 

relationships

n Skills in problem solving, conflict resolution, and nonviolent 

handling of disputes

n Cultural and religious beliefs that discourage suicide and support

self-preservation
36 GOALS AND OBJECTIVES FOR ACTION INTRODUCTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

RISK FACTORS FOR SUICIDE

BIOPSYCHOSOCIAL RISK FACTORS

n Mental disorders, particularly mood disorders, schizophrenia,

anxiety disorders and certain personality disorders

n Alcohol and other substance use disorders

n Hopelessness

n Impulsive and/or aggressive tendencies

n History of trauma or abuse

n Some major physical illnesses

n Previous suicide attempt

n Family history of suicide

ENVIRONMENTAL RISK FACTORS

n Job or financial loss

n Relational or social loss

n Easy access to lethal means 

n Local clusters of suicide that have a contagious influence

SOCIOCULTURAL RISK FACTORS

n Lack of social support and sense of isolation

n Stigma associated with help-seeking behavior

n Barriers to accessing health care, especially mental health and

substance abuse treatment

n Certain cultural and religious beliefs (for instance, the belief that

suicide is a noble resolution of a personal dilemma)

n Exposure to, including through the media, and influence of 

others who have died by suicide
INTRODUCTION GOALS AND OBJECTIVES FOR ACTION 37

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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
38 GOALS AND OBJECTIVES FOR ACTION INTRODUCTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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
INTRODUCTION GOALS AND OBJECTIVES FOR ACTION 39

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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
40 GOALS AND OBJECTIVES FOR ACTION INTRODUCTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.
INTRODUCTION GOALS AND OBJECTIVES FOR ACTION 41

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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).

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.

EFFECTIVE SUICIDE 

PREVENTION PROGRAMS:

n Clearly identify the population

that will benefit from each intervention and from the program as

a whole;

n Specify the outcomes to be

achieved;

n Are comprised of interventions

known to effect a particular outcome;

n Coordinate and organize the

community to focus on the issue;

and

n Are based on a clear plan with

goals, objectives and implementation steps.
42 GOALS AND OBJECTIVES FOR ACTION INTRODUCTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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 out-
INTRODUCTION GOALS AND OBJECTIVES FOR ACTION 43

NATIONAL STRATEGY FOR SUICIDE PREVENTION

come 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.
44 GOALS AND OBJECTIVES FOR ACTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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 them-
GOAL 1 GOALS AND OBJECTIVES FOR ACTION 45

NATIONAL STRATEGY FOR SUICIDE PREVENTION

selves 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).

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 OBJECTIVES 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.

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)

DID YOU KNOW?

In the 10 years 1989-1998, 307,973

people died as a result of suicide.
46 GOALS AND OBJECTIVES FOR ACTION GOAL 1

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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.

IDEAS FOR ACTION

Work with local media to develop and

disseminate public service announcements describing a safe and effective

message about suicide and its prevention.
GOAL 1 GOALS AND OBJECTIVES FOR ACTION 47

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

IDEAS FOR ACTION

Identify foundations and other

stakeholders to contribute to the

support of national congresses

on suicide prevention. 
48 GOALS AND OBJECTIVES FOR ACTION GOAL 1

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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

IDEAS FOR ACTION

Incorporate suicide awareness and

prevention messages into employee

assistance program activities in businesses with greater than 500 employees. 
GOAL 1 GOALS AND OBJECTIVES FOR ACTION 49

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

DID YOU KNOW?

Suicide is the eighth leading cause of

death for all Americans.
50 GOALS AND OBJECTIVES FOR ACTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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
GOAL 2 GOALS AND OBJECTIVES FOR ACTION 51

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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.
52 GOALS AND OBJECTIVES FOR ACTION GOAL 2

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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).

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.

DID YOU KNOW?

There are now twice as many deaths due

to suicide than due to HIV/AIDS
GOAL 2 GOALS AND OBJECTIVES FOR ACTION 53

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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 AfricanAmerican youth, a group with a high risk for other health and social

problems. Programs focused on enhancing educational and occupational 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.

IDEAS FOR ACTION

Encourage organizations to consider

ways that they could integrate suicide

prevention into their ongoing work.
54 GOALS AND OBJECTIVES FOR ACTION GOAL 2

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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).

IDEAS FOR ACTION

Encourage local faith-based groups to include suicide prevention

as a topic of analysis and discussion.
GOALS AND OBJECTIVES FOR ACTION 55

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.
56 GOALS AND OBJECTIVES FOR ACTION GOAL 3

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.
GOAL 3 GOALS AND OBJECTIVES FOR ACTION 57

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

DID YOU KNOW?

Suicide has ranked among the 10 leading causes of death since 1975.
58 GOALS AND OBJECTIVES FOR ACTION GOAL 3

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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).

IDEAS FOR ACTION

Review (and modify, where indicated) school health curricula to

ensure that mental health and substance abuse is appropriately

addressed.
GOAL 3 GOALS AND OBJECTIVES FOR ACTION 59

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

IDEAS FOR ACTION

Develop public service announcements in which well-known individuals convincingly portray the effectiveness of treatment for mental illnesses and substance use disorders.

Support an educational campaign designed to help the public

understand the implications of the brain research conducted over

the past decade, with special emphasis on mental illness.
60 GOALS AND OBJECTIVES FOR ACTION GOAL 3

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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

IDEAS FOR ACTION

Develop a public information campaign describing the role of lithium in

the treatment of persons with bipolar

disorder.

IDEAS FOR ACTION

Develop public service announcements depicting consumers of mental

health and substance abuse services

as exhibiting responsible and appropriate health care behavior.
GOAL 3 GOALS AND OBJECTIVES FOR ACTION 61

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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).

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).

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.

DID YOU KNOW?

Many who make suicide attempts never

seek professional care immediately

after the attempt.
62 GOALS AND OBJECTIVES FOR ACTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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 "evidencebased" 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.
GOAL 4 GOALS AND OBJECTIVES FOR ACTION 63

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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 pop-
64 GOALS AND OBJECTIVES FOR ACTION GOAL 4

NATIONAL STRATEGY FOR SUICIDE PREVENTION

ulation. 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.

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 min-
GOAL 4 GOALS AND OBJECTIVES FOR ACTION 65

NATIONAL STRATEGY FOR SUICIDE PREVENTION

imal 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.

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.

IDEAS FOR ACTION

Develop criteria by which a State's

suicide prevention plan can be

described and evaluated.
66 GOALS AND OBJECTIVES FOR ACTION GOAL 4

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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. collegeaged 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.

IDEAS FOR ACTION

Develop and test "natural- or peerhelper" programs for use with Native

Americans attending boarding schools.

Implement and evaluate a program

that trains college resident advisors in

principles of suicide risk identification,

crisis intervention, and referral.
GOAL 4 GOALS AND OBJECTIVES FOR ACTION 67

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

Employee Assistance Programs (EAP) are one example of worksitebased 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.

IDEAS FOR ACTION

Work with business associations to provide financial information about the

costs and benefits of mental health and

substance abuse parity.

Foster cultural changes in organizations

that strengthen social support among

workers and encourage help-seeking

for emotional and health concerns.
68 GOALS AND OBJECTIVES FOR ACTION GOAL 4

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Objective 4.5: By 2005, increase the proportion of correctional institutions, jails and detention centers housing either

adult or juvenile offenders, with evidence-based suicide prevention programs.

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).

IDEAS FOR ACTION

Develop monitoring protocols for

alcohol and drug detoxification in jail

and detention settings.
GOAL 4 GOALS AND OBJECTIVES FOR ACTION 69

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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.

Objective 4.7: By 2005, increase the proportion of family, youth and

community service providers and organizations with

evidence-based suicide prevention programs.

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 organizaIDEAS FOR ACTION

Develop and implement a training program for employees of local aging programs to assist these workers and volunteers in identifying persons at risk of

suicide.

IDEAS FOR ACTION

Develop resource kits for service organizations that include suggestions for

activities designed to strengthen connectedness.
70 GOALS AND OBJECTIVES FOR ACTION GOAL 4

NATIONAL STRATEGY FOR SUICIDE PREVENTION

tions 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.

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.

DID YOU KNOW?

Suicide takes the lives of more than

30,000 Americans every year
GOALS AND OBJECTIVES FOR ACTION 71

NATIONAL STRATEGY FOR SUICIDE PREVENTION

GOAL 5

PROMOTE EFFORTS TO REDUCE ACCESS TO

LETHAL MEANS AND METHODS OF SELF-HARM

WHY IS THIS 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).

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.

DID YOU KNOW?

For every two victims of homicide in

the U.S. there are three deaths from

suicide.
72 GOALS AND OBJECTIVES FOR ACTION GOAL 5

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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 dangerous settings (such as bridges and rooftops of high buildings) (see Figure

7) (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
GOAL 5 GOALS AND OBJECTIVES FOR ACTION 73

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

FIGURE 7:

SUICIDE BY METHOD

UNITED STATES, 1998

Source: National Center for Health Statistics
74 GOALS AND OBJECTIVES FOR ACTION GOAL 5

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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.

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

IDEAS FOR ACTION

Develop an emergency department

screening tool to assess the presence of

lethal means in the home.

Develop standardized practices for law

enforcement response to domestic

emergencies that assess for the presence of lethal means and advocate

their removal or safe storage.
GOAL 5 GOALS AND OBJECTIVES FOR ACTION 75

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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 selfdestructive outcomes.

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.

IDEAS FOR ACTION

Incorporate discussions of firearm risks

and safe storage practices as a standard

element of well-child care encounters.
76 GOALS AND OBJECTIVES FOR ACTION GOAL 5

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Objective 5.3: By 2005, develop and implement improved firearm

safety design using technology where appropriate.

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.

Objective 5.4: By 2005, develop guidelines for safer dispensing of

medications for individuals at heightened risk of

suicide.

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.

IDEAS FOR ACTION

Educate parents about how to appropriately store and secure lethal means

of self-harm.

IDEAS FOR ACTION

Develop educational materials to

make parents aware of safe ways of

storing and dispensing common pediatric medications.
GOAL 5 GOALS AND OBJECTIVES FOR ACTION 77

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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.

IDEAS FOR ACTION

Design reliable ignition shut-off sensors

that respond to potentially lethal levels

of carbon monoxide.

IDEAS FOR ACTION

Provide incentives for the discovery of

new technologies such as annual

awards and recognition by professional

organizations.
78 GOALS AND OBJECTIVES FOR ACTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

KEY GATEKEEPERS

n Teachers and school staff

n School health personnel

n Clergy

n Police officers

n Correctional personnel

n Supervisors in occupational 

settings

n Natural community helpers

n Hospice and nursing home 

volunteers

n Primary health care providers

n Mental health care and substance

abuse treatment providers

n Emergency health care personnel
GOAL 6 GOALS AND OBJECTIVES FOR ACTION 79

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

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).

DID YOU KNOW?

Firearms are by far the most common

method of suicide, they are used in

about 6 of every 10 suicides.
80 GOALS AND OBJECTIVES FOR ACTION GOAL 6

NATIONAL STRATEGY FOR SUICIDE PREVENTION

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.

DID YOU KNOW?

In the month prior to their suicide, 75% of elderly persons had visited a physician.
GOAL 6 GOALS AND OBJECTIVES FOR ACTION 81

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Objective 6.1: By 2005, define minimum course objectives for

providers of nursing care in assessment and management of suicide risk, and identification and promotion

of protective factors. Incorporate this material into

curricula for nursing care providers at all professional

levels.

Nurses deliver health care education and interventions in many different settings, from community health

clinics to school settings to private

practice offices to occupational settings and hospital settings. They are

often the first to see and hear about

signs and symptoms of at-risk behavior, and are often in a unique position to intervene effectively when such behaviors are identified. As

important members of the health care delivery team their education and

training in this subject is critical (WHO, 2000a).

Objective 6.2: By 2005, increase the proportion of physician assistant educational programs and medical residency programs that include training in the assessment and

management of suicide risk and identification and

promotion of protective factors.

Physicians and physician assistants

can benefit from training in the assessment of at-risk behaviors for suicide

and in effective treatment interventions (WHO 2000a, WHO 2000c). They

should be skilled in talking with

patients about the risk for suicide, in

providing crisis intervention for those

at imminent risk for the expression of

suicidal behaviors (Kleespies, 1998),

and in referring their patients for

expert assessment and treatment.

DID YOU KNOW?

Suicide rates remain highest among

Americans aged 65 and older.

IDEAS FOR ACTION

Improve marketing of existing effective community-level educational and

support programs through collaboration with faith communities, mental

health clinics, public health announcement providers, mass transit advertisers, and community service organizations.
82 GOALS AND OBJECTIVES FOR ACTION GOAL 6

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Many suicidal individuals make contact with their physicians within a

few weeks prior to their death (Beautrais et al., 1998; Pirkis & Burgess,

1998). Their imminent risk for suicide may have gone undetected or

unappreciated because, in part, the physicians were not appropriately

trained to assess and manage suicide. With such training, fewer suicidal

patients will go unrecognized and untreated (Shea, 1999).

Objective 6.3: By 2005, increase the proportion of clinical social

work, counseling, and psychology graduate programs

that include training in the assessment and management of suicide risk, and the identification and promotion of protective factors.

Counselors, clinical psychologists, and clinical social workers are often

on the "front line" in assessing and treating individuals who are at

increased risk for suicidal behaviors. It is important that these mental

health personnel receive appropriate graduate school training on the

subject of suicide while preparing for their professions (Neimeyer, 2000).

Surveys of clinical psychology training programs (Bongar & Harmatz,

1991) and social work training programs (King et al., 1999), reveal that

an insufficient number of training programs provide adequate preparation for the recognition of at-risk suicidal behavior and the delivery of

effective treatment.

IDEAS FOR ACTION

Develop and disseminate training

modules for all mental health personnel on the subject of suicide.
GOAL 6 GOALS AND OBJECTIVES FOR ACTION 83

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Objective 6.4: By 2005, increase the proportion of clergy who have

received training in identification of and response to

suicide risk and behaviors and the differentiation of

mental disorders and faith crises.

Clergy often provide counseling and interventions for those in distress,

and for some, they may be the first or only professionals to be in a position to provide emotional support. Individuals who are adjusting to and

recovering from personal losses may

be at increased risk for the expression of self-destructive behaviors

(Bailley, Kral & Dunham, 1999).

Clergy should be trained to identify

and respond to suicidal risk as well

as to encourage and support appropriate protective factors to lessen

the likelihood of suicidal behaviors.

Objective 6.5: By 2005, increase the proportion of educational faculty and staff who have received training on identifying

and responding to children and adolescents at risk for

suicide.

Surveys by the Centers for Disease Control (Brener, Krug, & Simon, 2000)

indicate that suicidal thoughts and self-reported suicide attempts are

prevalent among high school students. It is well known that adolescents

and young adults will not seek out interventions or counseling by adults

unless they feel that they can trust the adult to maintain respect, confidentiality, and provide knowledge and appropriate information (Eggert et

al., 1990; Kalafat & Elias, 1994). Therefore, it makes sense to train those

school personnel who are most likely to come in contact with students at

risk (see also Objective 4.2). In addition to educational faculty, bus drivers,

custodians, and playground supervisors are among those school staff with

frequent contact with students. Although efforts have been taken to develop training manuals and handbooks for educators, many school personnel

lack the tools and training to intervene effectively on behalf of students at

risk (Zenere & Lazarus, 1997).

IDEAS FOR ACTION

Provide seminars at educational conferences for clergy that focus on the interface between faith and mental health.
84 GOALS AND OBJECTIVES FOR ACTION GOAL 6

NATIONAL STRATEGY FOR SUICIDE PREVENTION

The staff and teachers in these systems need to be better equipped to

identify and communicate with students about suicidal behaviors, as well

as to communicate among themselves

about these issues. School staff and

faculty are not expected to make clinical diagnoses, but rather to be able to

recognize developing signs and symptoms associated with mental disorders, substance abuse, or suicidal risk.

Providing them with the vocabulary,

techniques, and skills to be comfortable with these issues will enhance

their ability to intervene effectively

and make appropriate referrals

(Grossman et al., 1995).

Objective 6.6: By 2005, increase the proportion of correctional workers who have received training on identifying and

responding to persons at risk for suicide.

Although the Federal prison system has a lower suicide rate than the

general population, there is an alarmingly high rate of suicide attempts

and suicides in jails and correctional institutions in the United States.

Given the often volatile nature of the circumstances that result in someone being placed in a jail or a correctional facility, suicide and suicidal

behaviors are much more common than in the general population. The

training of correctional workers is an important step to reduce the likelihood of individuals engaging in self-destructive behaviors when placed

in correctional settings (Bonner, 2000) (see also Objective 4.5).

IDEAS FOR ACTION

Identify which school, teacher and student characteristics predict successful

involvement of school staff members

in long-term mentoring programs

with students at risk.

Implement training for school nurses

to identify mental health conditions

that contribute to a risk for suicide.
GOAL 6 GOALS AND OBJECTIVES FOR ACTION 85

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Objective 6.7:By 2005, increase the proportion of divorce and family law and criminal defense attorneys who have

received training in identifying and responding to persons at risk for suicide.

Attorneys involved in divorce proceedings, custody cases, family law

cases, and criminal defense cases,

often work with clients who are in

heightened emotional states,

depressed, hopeless, and who may

have lost important social support.

Such individuals may be at increased

risk for violence and suicide, and

attorneys are in a position to identify

the increased risk and to refer them

for specialized interventions.

Objective 6.8: By 2005, increase the proportion of counties (or comparable jurisdictions such as cities or tribes) in which

education programs are available to family members

and others in close relationships with those at risk for

suicide.

It has been shown that educating family members about how to

understand, monitor, and intervene with family members at risk for suicide results in better management and treatment of those identified individuals (Richman, 1986).

Organizations such as the National Alliance for the Mentally Ill have

conclusively demonstrated the value of family education and support

network education to improve the care of individuals who are at risk.

Because the exact timing of suicidal behaviors is very difficult to predict,

it is important that key members of the family unit and social support

network are knowledgeable about potential risks for suicide and about

how to protect an individual from self-harm.

IDEAS FOR ACTION

Develop and test training modules to

help attorneys identify clientele who

are at high risk for self-destructive

behaviors.
86 GOALS AND OBJECTIVES FOR ACTION GOAL 6

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Objective 6.9: By 2005, increase the number of recertification or

licensing programs in relevant professions that

require or promote competencies in depression

assessment and management and suicide prevention.

The close association between mental disorders, especially depression,

and suicidal behaviors warrants ensuring that professionals are competent in applying the tools and techniques of diagnosis, treatment, management, and prevention to those mental disorders associated with suicidal behaviors. In most States, physicians, psychologists, social workers,

nurses, and other health professionals must complete licensing examinations or recertification programs in order to maintain active licenses and

to ensure ongoing professional certifications. One mechanism to ensure

that professionals remain competent to deal with suicidal behaviors is to

include the subject area in recertification or licensing programs.

IDEAS FOR ACTION

Incorporate questions on depression and

suicide risk assessment on professional recertification examinations.

Encourage private organizations in your

community with the capability to provide

suicide awareness and prevention education

to form community partnerships in suicide

prevention training.
GOALS AND OBJECTIVES FOR ACTION 87

NATIONAL STRATEGY FOR SUICIDE PREVENTION

GOAL 7

DEVELOP AND PROMOTE EFFECTIVE CLINICAL AND

PROFESSIONAL PRACTICES

WHY IS THIS GOAL IMPORTANT TO THE NATIONAL STRATEGY?

As defined by the public health approach, one way to prevent suicide is

to identify individuals at risk and to engage them in early and aggressive

treatments that are effective in reducing the personal and situational factors associated with suicidal behaviors (e.g., depressed mood, hopelessness, helplessness, agitation, severe anxiety, pervasive insomnia, alcohol

and drug abuse, among others). Another way to prevent suicide is to promote and support the presence of protective factors such as skills in problem solving, conflict resolution, and nonviolent handling of disputes.

By promoting effective clinical practices in the assessment, treatment,

and referral for individuals at risk for

suicide, the chances are greatly

improved for preventing those individuals from acting on their despair and

distress in self-destructive ways.

Moreover, the development and

implementation of protective factors

for these individuals can contribute

importantly to reducing their risk.

BACKGROUND INFORMATION AND CURRENT STATUS

As in illnesses of all types, individuals who are receiving appropriate

treatment for mental disorders have the best likelihood of recovery

(Jamison & Baldessarini, 1999; Kleespies, 1998; Rudd, 2000; Rudd & Joiner,

1998). It is critical that individuals with psychiatric disorders or otherwise

at increased suicidal risk receive adequate assessment, treatment, and follow-up care.

DID YOU KNOW?

For every suicide death there are 5

hospitalizations and 22 Emergency

Department visits for suicidal behaviors - over 670,000 visits in a year.
88 GOALS AND OBJECTIVES FOR ACTION GOAL 7

NATIONAL STRATEGY FOR SUICIDE PREVENTION

The nature of being in a suicidal crisis can sometimes impede an individual's ability to obtain appropriate medical care for themselves. Some

individuals with psychiatric disorders may at times be unable to serve as

their own best advocates when their illnesses involve impaired cognitions, emotions or interpersonal skills. Patients with suicidal thoughts

report fear of being stigmatized or rejected if they reveal these thoughts

to others (see Objective 8.1). Family members and significant others of

those who have died by suicide may, as well, be at increased risk for suicide. Appropriate attention and sensitivity to their unique situation is

often lacking.

Currently, there are only two psychopharmacological treatments that

have been associated with reduced suicide– lithium and clozapine

(Baldessarini, Tondo, & Hennen, 1999; Meltzer & Okayli, 1995). The data

regarding lithium is extensive—stretching over 28 studies around the

world. The 6-8 fold reduction in the suicide rate associated with this particular treatment is dramatic and needs to be more widely publicized.

New interventions are being developed and tested for the treatment of

disorders associated with suicidal behaviors. Because few studies of

treatments for mental disorders have included suicidal individuals (most

are excluded from clinical trials), new treatments need to be assessed for

their potential to reduce suicide and suicidal behaviors as well as reduce

symptoms of the disorder.

HOW WILL THE OBJECTIVES FACILITATE ACHIEVEMENT OF THE GOAL?

A heightened awareness of the presence or absence of risk and protective conditions associated with suicide will result in better triage systems and better allocation of resources for those in need of specialized

treatment. Accurate assessment of how individuals respond to significant

life events, transitions, and challenges to their mental and physical wellbeing can lead to appropriate and timely interventions. Health care

providers and clergy are often called upon to attend to end of life care

issues, including spiritual, religious, and familial reconciliation. Taken

together, goals 7 and 8 will ensure that key service personnel are trained
GOAL 7 GOALS AND OBJECTIVES FOR ACTION 89

NATIONAL STRATEGY FOR SUICIDE PREVENTION

to conduct thorough suicide assessments, deliver appropriate interventions, make appropriate referrals when indicated, and that health systems are appropriately organized to provide patients with needed and

effective clinical care.

Objective 7.1: By 2005, increase the proportion of patients treated

for self-destructive behavior in hospital emergency

departments that pursue the proposed mental health

follow-up plan.

Suicide attempts are a significant public health problem, particularly

among adolescents and young adults (see Figure 8). Without adequate

intervention, this population is at increased risk for repeat attempts and

death by suicide. Studies have found that fewer than 50 percent of adolescent attempters are referred for treatment following an emergency

department (ED) visit (Piacentini et al.; 1995; Spirito et al., 1989), and a

large proportion of those fail to attend their initial appointment.

Clinical studies have shown the

efficacy of training ED staff to treat

suicide attempts with due seriousness, and to emphasize to adolescents' family members the dangers

of ignoring suicide attempts and

the benefits of follow-up treatment to reduce the reoccurrence

of attempted suicide. Such staff

training has been associated with

greater completion of treatment

on the part of persons having

sought care in emergency departments (Rotheram-Borus et al.,

2000). From a health care perspective, both the patient and the

health care delivery system benefit

from better linkages between

emergency and appropriate followup care.

IDEAS FOR ACTION

Develop guidelines for hospitals and

health delivery systems that ensure adequate resources to implement confirmation of mental health follow-up appointments.

Collaborate locally to establish processes

that increase the proportion of patients

who keep follow-up mental health

appointments after discharge from the

emergency department.
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Case management is not the usual role of emergency departments,

but in facilitating continuity of care they can champion processes that

provide the missing link between an emergency evaluation and appropriate mental health treatment. Hospitals should confirm that patients

receive appropriate referral and follow-up information through ongoing

quality assessment programs while emergency departments identify and

develop linkages with mental health and substance abuse follow-up

resources for referral and treatment of patients with self-destructive

behaviors (see Objective 8.1).

FIGURE 8:

SUICIDAL IDEATION AND BEHAVIOR AMONG HIGH SCHOOL STUDENTS

BY CATEGORY AND SEX*

UNITED STATES, 1999

* During the 12 months preceding the survey

^ One or more times

CONSIDER SUICIDE

n Males

n Females

MADE SUICIDE

PLAN

SUICIDE ATTEMPT^ SUICIDE ATTEMPT

& TREAT

CATEGORY
GOAL 7 GOALS AND OBJECTIVES FOR ACTION 91

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Objective 7.2: By 2005, develop guidelines for assessment of suicidal

risk among persons receiving care in primary health

care settings, emergency departments, and specialty

mental health and substance abuse treatment centers. Implement these guidelines in a proportion of

these settings.

Persons at risk for suicide arrive

in emergency departments and

primary health care settings in a

variety of circumstances, with a

variety of concerns, such as mental and substance use disorders,

physical abuse, recent losses, and

painful physical illnesses, that can

place persons at increased risk for

suicide (Harris & Barraclough, 1997; WHO, 2000a, 2000c). Currently,

there are no universally accepted guidelines for the assessment of suicidal risk in these patients (Shea, 1999). Such guidelines would assure that

these assessments become part of the routine protocol for providing clinical care to all individuals seen in these health care settings and assist in

the process of making clinically appropriate referrals for mental health

and substance abuse treatment.

Objective 7.3: By 2005, increase the proportion of specialty mental

health and substance abuse treatment centers that

have policies, procedures, and evaluation programs

designed to assess suicide risk and intervene to

reduce suicidal behaviors among their patients.

Studies indicate that there is a very high association between some

mental (particularly schizophrenia and mood disorders) and substance

use (alcohol) disorders and increased risk for suicide (Harris &

Barraclough, 1997; Inskip, Harris & Barraclough, 1998; Tanney, 2000).

Many patients with such diagnoses are seen in specialty mental health

and substance abuse treatment centers, where they receive treatment for

their primary psychiatric diagnosis. To provide good clinical care, these

IDEAS FOR ACTION

Develop standardized suicide assessment

guidelines for primary care physicians

when assessing elderly patients.
92 GOALS AND OBJECTIVES FOR ACTION GOAL 7

NATIONAL STRATEGY FOR SUICIDE PREVENTION

centers must have in place policies, procedures, and evaluation programs

designed to identify the level of suicide risk and interventions to reduce

suicidal behaviors. Such

approaches will likely lead to

ensuring that more patients

receive the appropriate assessment for suicidal risk and protective factors. Evaluation of these

policies and procedures over time

will result in more effective and

efficient delivery of health care to

those at risk.

Objective 7.4: By 2005, develop guidelines for aftercare treatment

programs for individuals exhibiting suicidal behavior

(including those discharged from inpatient facilities).

Implement these guidelines in a proportion of these

settings.

It is well known that one of the highest risk periods for suicide is

immediately following discharge from institutional settings (Morgan &

Stanton, 1997). Often the investigations of such deaths identify problems in assessing a patient's readiness for discharge or transition to a less

restrictive level of care, or with post-discharge planning and communications. The transition from mental health and substance abuse institutional treatment settings to community life can be difficult and challenging for individuals at high risk for suicide. All too often the assumption is that individuals are no longer at risk for suicide once they are discharged from inpatient hospital or institutional settings and placed in

after-care treatment programs. Unfortunately, this is not always the case.

Thus, it is critical that after-care treatment programs develop guidelines

for the appropriate assessment, management, and treatment of individuals exhibiting suicidal behaviors following treatment in emergency settings or in inpatient hospital settings (Bongar et al., 1998). Such programs often incorporate some of the following elements: telephone contact, transportation arrangements to ensure attendance at clinical

appointments, appropriate housing arrangements, resources to guaranIDEAS FOR ACTION

Sponsor the development of standardized

policy and procedures for assessing suicidal risk in male alcoholics.
GOAL 7 GOALS AND OBJECTIVES FOR ACTION 93

NATIONAL STRATEGY FOR SUICIDE PREVENTION

tee purchasing of medications, and family or support group education.

It is important to provide education and psychological support to families and significant others of those who have exhibited suicidal behavior.

Objective 7.5: By 2005, increase the proportion of those who provide key services to suicide survivors (e.g., emergency

medical technicians, firefighters, law enforcement

officers, funeral directors, clergy) who have received

training that addresses their own exposure to suicide

and the unique needs of suicide survivors.

When suicide occurs it results in shock and disruption for those who

may have witnessed the event or arrived on the scene soon thereafter, as

well as responding emergency personnel. Often emergency medical technicians and first responders (including law enforcement officers and firefighters) are the individuals to have first contact with suicide survivors.

These are emotionally charged situations that leave indelible memories

for all those involved. First responders have the opportunity to set the

tone for being respectful and sensitive to the needs of survivors and the

need to be prepared themselves

for the impact such events may

have on their own thoughts and

emotions.

These personnel are also often

the first on the scene when called

to assist with a suicide attempt.

Here, too, the situation is often

emotionally charged, volatile, and

unpredictable. The judicial use of

tact, patience, sensitivity, authority,

judgment, and professional skills can result in a successful assessment

and management of the situation. In a similar fashion, other service-oriented professionals (clergy, funeral directors) can provide information

about local support services when appropriate.

IDEAS FOR ACTION

Organize suicide survivors in your community to provide seminars on recognizing

and managing the personal impact of suicide to first responders.
94 GOALS AND OBJECTIVES FOR ACTION GOAL 7

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Objective 7.6: By 2005, increase the proportion of patients with

mood disorders who complete a course of treatment

or continue maintenance treatment as recommended.

A mood disorder is an alteration in an individual's ability to regulate

emotions or feelings. Episodes of depression often recur. A large number

of suicidal patients suffer from mood disorders alone or in combination

with other mental, substance use or physical disorders (co-morbidity)

(Henriksson et al., 1993). Often patients with mood disorders are reluctant

to seek treatment because of the stigma associated with having a mental

disorder.

The effective treatment of patients with mood disorders (which are

often recurrent illnesses, necessitating close monitoring and regular evaluations) may last many months and sometimes even years. For those

patients receiving medications, it may take weeks before they are effective

and symptoms are significantly

reduced. Once symptom relief

occurs it is recommended that

individuals remain on medication

for a minimum of 6-9 additional

months and sometimes even

longer (Stahl, 2000). Remaining on

a therapeutic regimen of medications is an important element in

preventing a relapse or recurrence

of the illness.

Courses of psychotherapy for mood disorders also are important and

curative. Psychotherapy has been found to be as effective as some pharmacologic treatments and some combinations of these two are superior

to either alone. Once individuals begin to feel better and their mood disorder is improved, some tend to discontinue regular treatment and do

not complete a full course of medication management or psychotherapy.

Premature termination of treatment can increase the risk of relapse and

return of symptoms, including suicidal behaviors. The available treatment

modalities for mood disorder are effective when administered over time

IDEAS FOR ACTION

Improve and disseminate easy to use,

web-based tools to aid patients and caregivers in treatment adherence and relapse

prevention.
GOAL 7 GOALS AND OBJECTIVES FOR ACTION 95

NATIONAL STRATEGY FOR SUICIDE PREVENTION

and monitored appropriately. Patients must be educated to understand

the need to complete the full course of recommended treatment, continue maintenance treatment as recommended, and learn to recognize

and manage risk for relapse.

Objective 7.7: By 2005, increase the proportion of hospital emergency departments that routinely provide immediate

post-trauma psychological support and mental health

education for all victims of sexual assault and/or physical abuse.

Clinical studies suggest that a high proportion of victims of sexual

assault and/or physical abuse are at increased risk for psychiatric disturbances associated with suicidal behavior, and at increased risk for selfdestructive behaviors without necessarily developing a psychological disorder (Herman, 1997). It is important for hospital emergency departments to provide immediate post-trauma psychological support and

mental health education for victims of violence, recognizing the traumatic nature of their experience and the risk for self-destructive behaviors they may face in the future. Protocols must be developed to assist

these patients and to ensure proper follow-up and after-care treatment.

Objective 7.8: By 2005, develop guidelines for providing education

to family members and significant others of persons

receiving care for the treatment of mental health and

substance abuse disorders with risk of suicide.

Implement the guidelines in facilities (including general and mental hospitals, mental health clinics, and

substance abuse treatment centers).

This objective is related to Objective 6.8 to increase the availability of

programs to educate family members and significant others about

understanding, monitoring, and intervening with persons who are at risk

of suicide. In combination, these two objectives are intended to ensure

that the educational material is available, and that it is appropriately

delivered to those who can benefit from the information.
96 GOALS AND OBJECTIVES FOR ACTION GOAL 7

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Family members, significant others, and support networks play very

important roles in the care of individuals at increased risk for suicide.

Personal knowledge and daily proximity means that family members are

in the best position to quickly note changes in demeanor and behavior

that may signal a deterioration in thier loved one’s condition. Educating

family members and significant others about how to watch for changes

in mood and behavior, and how to access help when needed are important to ensure that a person at risk does not become self-destructive. 

Objective 7.9: By 2005, incorporate screening for depression, substance abuse and suicide risk as a minimum standard

of care for assessment in primary care settings, hospice, and skilled nursing facilities for all Federally-supported healthcare programs (e.g., Medicaid, CHAMPUS/TRICARE, CHIP, Medicare).

Millions of individuals are treated through Federally-supported health

care programs, including military personnel and their dependents and

elderly, physically and mentally challenged, and indigent persons.

Opportunities exist for these programs to become models for incorporating screening tools and techniques for depression, substance abuse,

and suicide risk.

Mental and substance use disorders,

as well as suicide risk, are often not

assessed in primary care settings

because of the time constraints

involved and because the staff is not

appropriately trained to recognize

the presence of these conditions.

Incorporating targeted screening

tools and techniques into Federally-supported primary care settings, hospices, and skilled nursing facilities is expected to increase the number of

individuals identified with symptoms of depression, substance abuse,

and suicide risk. Appropriate treatment and follow-up care for these

problems, over time, would be expected to prevent suicides.

DID YOU KNOW?

Males are four times more likely to die

from suicide than are females.
GOAL 7 GOALS AND OBJECTIVES FOR ACTION 97

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Objective 7.10: By 2005, include screening for depression, substance

abuse and suicide risk as measurable performance

items in the Health Plan Employer Data and

Information Set (HEDIS).

The Health Plan Employer Data and Information Set (HEDIS) is a set of

standardized performance measures designed to ensure that purchasers

and consumers have the information they need to reliably compare the

performance of managed health care plans. HEDIS is sponsored, supported and maintained by the National Committee for Quality Assurance

(NCQA), a private, not-for-profit organization dedicated to improving the

quality of health care.

The performance measures in HEDIS are related to many significant

public health issues such as cancer, heart disease, smoking, asthma and

diabetes. Screening for depression, substance abuse and suicide should

be added to its performance measures for the same reasons outlined in

objective 7.9, and would provide similar, expected results contributing to

the prevention of suicide.
98 GOALS AND OBJECTIVES FOR ACTION

NATIONAL STRATEGY FOR SUICIDE PREVENTION

GOAL 8

IMPROVE ACCESS TO AND COMMUNITY LINKAGES WITH

MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

WHY IS THIS GOAL IMPORTANT TO THE NATIONAL STRATEGY?

This goal is designed to prevent suicide by ensuring that individuals who

are at high risk due to mental health and substance use problems can

receive prevention and treatment services. Barriers to access need to be

eliminated and linkages between various community agencies and mental

health and substance abuse treatment programs need to be established.

The elimination of health disparities and the improvement of the quality of life for all Americans are central goals for Healthy People 2010 (DHHS,

2000). Some of these health disparities are associated with differences of

gender, race or ethnicity, education, income, disability, geographic location, or sexual orientation. Many of these factors place individuals at

increased risk for suicidal behaviors, because they limit access to mental

health and substance abuse services.

Barriers to equal access and affordability of health care may be influenced by financial, structural, and personal factors. Financial barriers

include not having enough health insurance or not having the ability to pay

for services outside a health plan or insurance program. Structural barriers

include the lack of primary care providers, medical specialists, or other

health care professionals to meet special needs or the unavailability of

health care facilities. Personal barriers include cultural or spiritual differences, language, not knowing when or how to seek care, or concerns

about confidentiality or discrimination (Healthy People 2010). Reducing

disparities is a necessary step in ensuring that all Americans receive appropriate physical health, mental health, and substance abuse services.

Improving access will help ensure that at-risk populations receive the

services they need, and that all community members receive regular preventive health services. Communities need to take responsibility for preventing suicide and promoting health, but must remain sensitive to the
GOAL 8 GOALS AND OBJECTIVES FOR ACTION 99

NATIONAL STRATEGY FOR SUICIDE PREVENTION

balance between preserving individual civil liberties and imposing mandatory treatment in those instances where it may be indicated. Developing

partnerships with mental health and substance abuse services will enable

all components of the community to work together to ensure the overall

health and vitality of its members.

BACKGROUND INFORMATION AND CURRENT STATUS

In the last decade, much effort has been put forth to improve community health service delivery systems. It is believed that providing better

access and linkages has resulted in a decrease in unnecessary illness and

death due to health problems such as unintentional injury, heart attacks,

and chronic illnesses. Most communities

are proud of their emergency medical

services, police and fire emergency

services, emergency departments, and

available health services.

Society's view of suicide and suicidal

behaviors is evolving from seeing such

behavior as an individual act directly

affecting a single person, to a societal

event in which the suicide of one individual affects many facets of a community — a community that must then accept a leading role in preventing

its occurrence. The extent of suicidal behavior is now seen as a reflection

of the overall health and welfare of the community, and many communities have made it a priority concern.

As society shifts its attention to addressing public health concerns such

as violence, suicide, and other intentional injuries, the courts, schools,

churches, social service agencies, correctional institutions, and other community institutions must work with mental health and substance abuse

service systems to forge better relationships.

DID YOU KNOW?

Over half of all suicides occur in adult

men, aged 25-65.
100 GOALS AND OBJECTIVES FOR ACTION GOAL 8

NATIONAL STRATEGY FOR SUICIDE PREVENTION

HOW WILL THE OBJECTIVES FACILITATE ACHIEVEMENT OF THE GOAL?

Achieving this goal is dependent on the extent to which community

organizations and service delivery systems communicate with each other to

facilitate the provision of health services to those in need, and on the

extent to which individuals at risk use these services. As activities to achieve

objectives are implemented, one outcome will be an initial increase in the

number of individuals identified to be in need of mental health and substance abuse services and preventive interventions. This is often the initial

result of improved risk identification and referral systems. However, the

long-term benefit to identifying those in need of services is that the overall health and well-being of the community is better served by addressing

the range of these health problems in the community at an earlier and less

debilitating stage. This benefit extends to suicide survivors who are among

those for whom linkages with mental health services may be indicated. Not

only would there be a long-term reduction in the rate of suicidal behaviors,

but also in the morbidity associated with many other disorders (depression, bipolar illness, schizophrenia, alcohol and drug abuse).

Objective 8.1: By 2005, increase the number of States that require

health insurance plans to cover mental health and substance abuse services on par with coverage for physical

health.

One reason that many mental health problems go untreated in America

is that employee benefit plans tend to provide more liberal coverage for

physical illness (general medical and surgical services) than for mental illness or substance abuse treatment. This disparity has worsened in recent

years due to changes in the

nation's health care delivery systems. Without parity, those in need

of specialty mental health and substance abuse treatment will be

denied adequate access. States

and the Federal government have

begun to require that mental

IDEAS FOR ACTION

Complete and/or disseminate cost-benefit

studies conducted in States that have

implemented parity laws.
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NATIONAL STRATEGY FOR SUICIDE PREVENTION

health and/or substance abuse treatment be covered in the same way as

other medical care (parity). Following the passage of the 1996 Mental

Health Parity Act, some States have passed mandatory parity laws that to

varying degrees require parity in mental health and/or substance abuse

benefits. Others have enacted legislation conforming to the Federal mandate. Most State parity laws are limited in scope or application. Few

address substance abuse treatment, and many are limited only to treatment for serious mental illnesses. Many parity laws exempt small businesses or only apply to plans for government employees. A necessary first step

for States is to require coverage for mental health and substance abuse

care on par with coverage for physical health care.

Objective 8.2: By 2005, increase the proportion of counties (or comparable jurisdictions) with health and/or social services

outreach programs for at-risk populations that incorporate mental health services and suicide prevention.

It is important to help populations at risk receive needed services.

National voluntary organizations such as the American Lung Association,

the American Heart Association, and the American Cancer Society have

been successful in their outreach efforts. They excel in providing timely and

targeted public information, public

health messages, and referral recommendations. It is also critical

that the services themselves are

available in the community, and

are able and willing to reach out to

populations at risk to offer appropriate health and/or social services

that address their needs. At risk

populations are not always able to

access health services easily or to do

it on their own. Often the mental health and substance abuse service

provider systems need to provide ways to help individuals access care and

to follow up with care over time. Such programs, which include outreach

programs for the homeless and street health programs for runaway youth,

reach out by contacting these individuals where they congregate.

IDEAS FOR ACTION

Make available more mobile health and

mental health clinics (clinics on wheels)

for the chronically ill.
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Objective 8.3: By 2005, define guidelines for mental health (including

substance abuse) screening and referral of students in

schools and colleges. Implement those guidelines in a

proportion of school districts and colleges.

Suicide in adolescents and young adults (aged 15-24) remains the third

leading cause of death for this population. The onset of most major mental and substance use disorders is in this age range. A number of communities have already instituted guidelines for mental health screening and

referral of students demonstrating at risk behaviors for suicide (CDC,

1992). These efforts have been shown to reduce the suicide ideation and

attempt rates as well as to improve the overall provision of mental health

care for the school population (See Objectives 4.2 and 4.3) (Zenere &

Lazarus, 1997). Nevertheless, there are no national guidelines for mental

health or substance abuse screening and referral for at-risk students. Such

guidelines might include assessment tools and criteria, protocols, algorithms for assessing risk status, referral guidelines, and evaluation measures (Grossman & Kruesi, 2000).

DID YOU KNOW?

Persons who desire an early death during a serious or terminal

illness are usually suffering from a treatable depressive condition.
GOAL 8 GOALS AND OBJECTIVES FOR ACTION 103

NATIONAL STRATEGY FOR SUICIDE PREVENTION

Objective 8.4: By 2005, develop guidelines for schools on appropriate

linkages with mental health and substance abuse treatment services and implement those guidelines in a proportion of school districts.

It is not sufficient to identify students at risk in public and private

school systems without also ensuring that appropriate linkages to

receiving services are instituted.

The process of effecting a referral

for treatment services must be

carefully spelled out, tailored to

the special circumstances of the

school setting, and remain sensitive to the need for adolescents,

young adults and their families to

feel supported and protected while

receiving timely and effective interventions.

Objective 8.5: By 2005, increase the proportion of school districts in

which school-based clinics incorporate mental health

and substance abuse assessment and management into

their scope of activities.

Sometimes it is difficult to effect

linkages with mental health and

substance abuse services when

such services are not within close

proximity to school districts and

colleges, or when they are not

readily available in the community.

It would be advantageous to

increase the proportion of school

districts in which school-based

clinics incorporate mental health

IDEAS FOR ACTION

Establish a public/private working group

in your community to investigate ways to

provide effective mental health support

for schools.

Identify model programs currently existing in a wide variety of community settings and showcase them on the World

Wide Web.

IDEAS FOR ACTION

Assess availability of mental health and

substance abuse treatment services for

youth to determine need for school-based

clinical services.
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NATIONAL STRATEGY FOR SUICIDE PREVENTION

and substance abuse assessment and management as part of their mission

and scope of activities. When it is in the best interests of all concerned for

the student at risk to receive care within the school setting and not be

referred elsewhere, school-based clinics need to apply assessment and

management techniques appropriate to the age group that they serve.

Objective 8.6: By 2005, for adult and juvenile incarcerated populations, define national guidelines for mental health

screening, assessment and treatment of suicidal individuals. Implement the guidelines in correctional institutions, jails and detention centers.

For a variety of reasons, correctional institutions, jails, and detention

centers have not been designed to provide mental health assessment and

intervention programs and services, nor organized to offer suicide preventive intervention programs (see

Objective 4.5) (Hayes, 1997).

However, many individuals in these

institutional settings are at

increased risk for self-destructive

behaviors (WHO, 2000). Efforts

should focus on providing appropriate assessment and treatment

services to those individuals in correctional facilities, particularly juveniles who are in detention centers

and holding units (Bonner, 2000).

Objective 8.7: By 2005, define national guidelines for effective comprehensive support programs for suicide survivors.

Increase the proportion of counties (or comparable

jurisdictions) in which the guidelines are implemented.

Current estimates suggest that for every suicide, there are 6-8 individuals who have been closely associated with the person who has died by suicide. These family members, significant others, or acquaintances who have

experienced the loss of a loved one due to suicide may be at increased risk

IDEAS FOR ACTION

Work with professional correctional

organizations to identify and promote

model suicide assessment guidelines for

jails during the acute period of incarceration (first 48 hours).
GOAL 8 GOALS AND OBJECTIVES FOR ACTION 105

NATIONAL STRATEGY FOR SUICIDE PREVENTION

for self-destructive behaviors as well as for a range of adjustment problems, often directly linked to their sudden status as survivors. As these individuals organized into support groups and national advocacy organizations, they have documented the

benefit of effective comprehensive

support programs (Callahan,

2000). Although such programs

exist in many areas, there remain

many regions with a dearth of such

support groups. Making such programs available to those in need

will increase the likelihood of utilization and benefit.

Objective 8.8: By 2005, develop quality care/utilization management

guidelines for effective response to suicidal risk or

behavior and implement these guidelines in managed

care and health insurance plans.

Currently, there are no standardized utilization management guidelines

for use by health care provider systems and health insurance plans for the

effective response to, and treatment of, individuals at risk for suicide. In

part, due to the lack of uniform operational definitions for suicidal risk, suicide attempts, and other suicidal behaviors, such guidelines have been

lacking. With better definitions

and better surveillance techniques

to identify both individuals at risk

and those who might benefit from

certain types of interventions,

standardized utilization management guidelines can be developed,

and existing guidelines can be

field-tested and refined (Risk

Management Foundation of the

Harvard Medical Institutions,

1996).

IDEAS FOR ACTION

Develop and offer peer leadership training for facilitators of suicide survivors support groups.

IDEAS FOR ACTION

Work with managed care and insurance

providers to develop uniform operational

definitions for suicidal behaviors and

related terms in utilization management

guidelines.
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GOAL 9

IMPROVE REPORTING AND PORTRAYALS OF SUICIDAL

BEHAVIOR, MENTAL ILLNESS, AND SUBSTANCE ABUSE IN THE

ENTERTAINMENT AND NEWS MEDIA

WHY IS THIS GOAL IMPORTANT TO THE NATIONAL STRATEGY?

The media–movies, television, radio, newspapers and magazines–have

a powerful impact on perceptions of reality and on behavior. The

American Academy of Pediatrics has estimated that American children

and adolescents spend 22-28 hours per week viewing television, more

than any other activity except sleeping (APA, 1990). The Internet, while

not historically considered to be a part of the media, has become quite

important in terms of provision of information, and many

persons–including youth–spend many hours weekly viewing Web-based

presentations on a variety of subjects; however, there is no knowledge

currently available that addresses whether the depiction of suicide

through the Internet affects those at risk differently than through other

media.

Research over many years has found that media representations of suicide may increase suicide rates, especially among youth (Schmidtke &

Schaller, 2000; Velting & Gould, 1997). "Cluster suicides" and "suicide

contagion" have been documented (CDC, 1988; Gould et al., 1990) and

studies have shown that both news reports and fictional accounts of suicide in movies and television can lead to increases in suicide (Davidson &

Gould, 1989). It appears that imitation plays a role in certain individuals

engaging in suicidal behavior. In particular, suicides increase primarily in

the geographic area where a front-page suicide story was published with

the effect proportionate to the amount of publicity the suicide receives

(Phillips, 1985; Schmidtke & Schaller, 1998). Highly publicized suicides of

entertainment celebrities appear to produce imitation suicides most

powerfully (Wasserman, 1984).

It is widely acknowledged that the media can play a positive role in suicide prevention, even as they report on suicide or depict suicide and
GOAL 9 GOALS AND OBJECTIVES FOR ACTION 107

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related issues in movies and on television (Gould, 2001). The way suicide

is presented is particularly important. Changing media representation of

suicidal behaviors is one of several strategies needed to reduce the suicide rate.

Media portrayals of mental illness and substance abuse may also indirectly affect the suicide rate (Hawton et al., 1999). Negative views of

these problems or inaccurate depiction of treatment may lead individuals to deny they have a problem or be reluctant to seek treatment, and

untreated mental illness and substance abuse are strongly correlated

with suicide.

BACKGROUND INFORMATION AND CURRENT STATUS

There have been several attempts over the last two decades to address

the portrayal of suicide in the media. For example, the National Institute of

Mental Health and the Association for Media Psychology held a workshop

on violence prevention in 1984 in which action steps were developed to

address identified problems, but lack of funding precluded follow-through

(Berman, 1989). The Health Resources

and Services Administration supported

a workshop in 1989, convened by the

Association of State and Territorial

Health Officials and the New Jersey

Department of Health, that focused

specifically on suicide contagion. This

workshop produced a set of recommendations for health professionals in

dealing with the media and outlined

aspects of news coverage that can promote suicide contagion (O'Carroll &

Potter, 1994). These recommendations were published and disseminated.

Anecdotal reports suggest that the recommendations have proved to be

workable in some communities (Jobes et al., 1996). However, there is no

evidence that they have been widely adopted or that they have had a

measurable effect on the depiction of suicide or suicidal behaviors. Other

organizations have published guidelines on media coverage, including the

DID YOU KNOW?

Between 1952 and 1995, the incidence of suicide among adolescents

and young adults nearly tripled.
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National Institute of Mental Health, the American Association of

Suicidology, the American Psychological Association, and the American

Psychiatric Association. The Entertainment Industries Council, founded in

1983 by leaders in the entertainment industry to provide information,

awareness and understanding of major public health and social issues

among the entertainment industry and to audiences at large, published

and disseminated depiction suggestions on mental illness in collaboration

with the Carter Center in 1993, updated in 2001 (http://eiconline.org/creative/spotlighton/mentill/depict1.html). Such recommendations and guidelines have been promoted and made available to the media and the public, but again there is no clear evidence that they have changed the portrayal of suicide or suicidal behavior.

HOW WILL THE OBJECTIVES FACILITATE ACHIEVEMENT OF THE GOAL?

The objectives established for this goal are designed to foster consideration among media leaders of the impact of different styles of describing or

otherwise depicting suicide and suicidal behavior, to eliminate inflammatory coverage, and to encourage the presentation of content in the media that

can help prevent rather than increase suicide. Thus, these objectives incorporate elements of awareness, as well as intervention.

Objective 9.1: By 2005, establish an association of public and private

organizations for the purpose of promoting the accurate

and responsible representation of suicidal behaviors,

mental illness and related issues on television and in

movies.

In light of First Amendment issues, there is generally a resistance on the

part of the media to "guidelines" or other external attempts to influence

artistic expression in entertainment. However, once individuals in the media

have a clear understanding of the implications of the ways in which suicide

and other issues, including accurate depiction of mental illness and of treatment, are depicted, many see value in modifying their approaches

(Knickmeyer, 1996). This understanding is best achieved through collaborative action between the public health sector and media representatives.
GOAL 9 GOALS AND OBJECTIVES FOR ACTION 109

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Such public/private partnerships have been developed to address other

issues, such as interpersonal violence prevention. Monitoring the effects of

changes, providing feedback on these effects, conducting research, and

ensuring constant communication between media representatives and public health leaders can help sustain progress. An association of media leaders, together with public health professionals, with an organizational mission of responsibly addressing the depiction of suicide, mental illness and

substance use disorders could be a key to solidifying an ethic within the television and movie industries that would improve public health without

unduly restraining artistic expression.

Objective 9.2: By 2005, increase the proportion of television programs

and movies that observe promoting accurate and

responsible depiction of suicidal behavior, mental

illness and related issues.

Currently, no consensus recommendations have been formulated for

entertainment media that specifically

address the depiction of suicide and

suicidal behaviors. As noted earlier,

depiction recommendations do exist

for mental illness and substance use

disorders (see http://eiconline.org).

Once such recommendations are

developed, it will be important to work

towards their implementation, especially because depictions of suicide are

common in the entertainment media.

For example, a study conducted in the

late 1980s found that by the time adolescents were high school seniors, they had witnessed approximately 800

suicides on television, not all of them realistically portrayed (Radeck, undated). Widespread adherence to depiction recommendations should promote

a better public understanding of suicidal behavior and mental illness. Since

news reporters are also a part of that public, it is likely they too will have

their attitudes changed, which could affect their reporting of suicide.

IDEAS FOR ACTION

Implement a media monitoring

process to provide entertainment

media and sponsors of television programming informed support of appropriate coverage and constructive critiques of misleading or hurtful depictions of suicide, mental illness, substance use disorders, or mental health

and substance abuse treatments.
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Objective 9.3: By 2005, increase the proportion of news reports

on suicide that observe consensus reporting

recommendations.

Public health officials believe that it is not so much the reporting of

suicide that may lead to "copy-cat" suicides as it is the manner in which

suicide is reported. To minimize the likelihood of suicide contagion, news

reports can incorporate recommendations developed at the 1989 New

Jersey workshop discussed above. Participants agreed that reporting

should be concise and factual. Other suggestions include minimizing

repetitive, ongoing or excessive reporting of suicide; limiting morbid

details and sensationalism; and avoiding "how-to" descriptions of suicide

(O'Carroll & Potter, 1994). Information that can help to reduce suicide can

also be inserted in news stories, such as reporting about the complex

nature of suicide, listing help resources, explaining how to identify highrisk individuals, and describing available treatment for depression

(O'Carroll, 1996).

IDEAS FOR ACTION

Develop and provide press information kits that provide a resource

for reporting on suicide and contact information for local

spokespersons who may provide additional information.
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Objective 9.4: By 2005, increase the number of journalism schools

that include in their curricula guidance on the portrayal and reporting of mental illness, suicide and suicidal behaviors.

One way to foster responsible depiction of suicide and mental illness–that is, depictions that do not encourage suicide or stigmatize mental illness–is to encourage discussions of the implications of how news is

presented among journalism students. Little is now known about the

way suicide, suicidal behaviors, or mental illness and substance use disorders is addressed, if at all, in schools of journalism across the country.

It is important to integrate such discussions fully into all journalism

schools.

IDEAS FOR ACTION

Develop curriculum materials on reporting of suicide and mental illness for use by professors in schools of journalism.
112 GOALS AND OBJECTIVES FOR ACTION

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GOAL 10

PROMOTE AND SUPPORT RESEARCH ON

SUICIDE AND SUICIDE PREVENTION

WHY IS THIS GOAL IMPORTANT TO THE NATIONAL STRATEGY?

Much is known about the risk factors associated with suicide, but less

about how to modify certain risk factors effectively to reduce the likelihood

of suicidal behaviors occurring. Protective factors have been shown to

reduce risk for suicide, but little is known about how to enhance these protective factors with individuals already at risk (Felner, Felner, & Silverman

2000). Some good hints are available about what interventions may be

effective, but little information about the long term effects of these interventions and about the variables that may influence their effectiveness

(Silverman & Felner, 1995). For instance, variables regarding the intervention itself (for whom and for how long, how often, how intensively, and

under what circumstances) must be studied to determine which are critical in ensuring that the intervention works.

A great deal about the media and its effect on individuals is known, but

little about culturally appropriate messages and how to deliver them to targeted populations to reduce suicide (see Objective 9.1). By advancing a

comprehensive research agenda, industry and government, working

together, can contribute significantly to the development of a knowledgebase on the causes of suicide and the development of interventions aimed

at prevention.

BACKGROUND INFORMATION AND CURRENT STATUS

A good deal of information about individuals at risk for suicide has

emerged from epidemiological surveillance studies. Biological and genetic

research has begun to identify markers for increased risk for suicide. For

example, studies showing decreased 5-hydroxy indoleacetic acid in cerebrospinal fluid along with genetic linkage studies, suggest that certain individuals may be at increased risk for the expression of suicidal behaviors.
GOAL 10 GOALS AND OBJECTIVES FOR ACTION 113

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All suicides are highly complex. The volume of research on suicide and

suicide prevention has increased considerably in the past decade and has

generated new questions about why individuals become suicidal or remain

suicidal. The important contributions of underlying mental illness, substance abuse, and biological factors, as well as potential risk that comes

from certain environmental influences are becoming clearer. Increasing the

understanding of how individual and environmental risk and protective

factors interact with each other to affect an individual's risk for suicidal

behavior is the next challenge.

Like the U.S., other nations are working to build national suicide prevention plans on solid scientific evidence (see Introduction). Evaluation of

their efforts are underway and offer the opportunity to learn important

lessons from their experiences.

HOW WILL THE OBJECTIVES FACILITATE ACHIEVEMENT OF THE GOAL?

The field of suicidology has significantly advanced as a result of research

findings from many related fields including sociology, psychology, psychiatry, biochemistry, neuropharmacology, and epidemiology. These findings

have been translated into screening and assessment tools, treatment and

resiliency-building interventions, and treatment and symptom monitoring

techniques. Continued advancements in the prevention of suicidal behaviors can only come with solid support of a wide range of basic, clinical, and

applied research endeavors designed to enhance understanding of the etiology, development, and expression of

suicidal behaviors across the life span

as well as those factors which enhance

resiliency. Such enhanced understanding will lead to better assessment

tools, treatments, and preventive

interventions. It will also lead to more

effective and efficient therapeutic

interventions for survivors of suicide

attempts.

DID YOU KNOW?

More teenagers and young adults

die from suicide than from cancer,

heart disease, AIDS, birth defects,

stroke, pneumonia and influenza, and 

chronic lung disease, COMBINED.
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Objective 10.1: By 2002, develop a national suicide research agenda

with input from survivors, practitioners, researchers,

and advocates.

Everyone has a stake in the development and implementation of a

national suicide research agenda. Everyone who is touched by suicide has

a contribution to make to better understand the individual who has committed suicide and the suicidal process. A coordinated research agenda

will benefit everyone affected by suicide and other life-threatening

behaviors.

An agenda might address the who, what, when, where, why, how, and

how much questions of suicide. The targets for such an agenda might

include increased attention to high risk groups, gender and ethnic differences, geographical distribution, means restriction, economic

changes, surveillance, genetic contributions, protective factors, and psychotherapy and psychopharmacology as potential treatment and preventive interventions.

Such an agenda might include research on specific aspects of prevention, intervention, or postvention, including basic, applied, clinical, evaluation, community-based intervention, and media-based research.

Objective 10.2: By 2005, increase funding (public and private) for

suicide prevention research, for research on translating scientific knowledge into practice, and for training of researchers in suicidology.

Scientific knowledge must be translated into practice and general applications, including educational settings, justice, occupational, and elderly programs. Learning more about

how to transfer such knowledge

effectively will benefit all concerned.

Important findings and ideas for

implementation must not be overIDEAS FOR ACTION

Tie priorities for professional training

grants to the inclusion of suicidology

in their curriculums.
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looked or lost because their potential for rapid application are not immediately appreciated. A real need exists to improve the translation of basic

scientific research findings into recommendations and suggestions for

practical application.

Despite the increase in interest in suicide and suicide prevention research,

there remains a shortage of researchers trained in the field of suicidology and trained in research methods most applicable to suicide and suicide prevention.

Objective 10.3: By 2005, establish and maintain a registry of prevention activities with demonstrated effectiveness for

suicide or suicidal behaviors.

Basic, applied, clinical, and preventive intervention research must

focus more on suicide and life-threatening behaviors. Not only is it

important to support research in these areas, but also to review existing

research to gather those findings that have the most potential for application in community and clinical settings. By comparing and contrasting

outcomes and findings, appropriate decisions can be made about which

directions to pursue and which approaches are no longer fruitful. Having

access to such a registry that identifies evidence-based models or best

practices allows individuals or communities to apply them or build upon

them in developing local initiatives.
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Objective 10.4: By 2005, perform scientific evaluation studies of new

or existing suicide prevention interventions.

In promoting better research on suicide and suicide prevention, it is

important to develop better evaluation research tools, techniques, and

approaches to determine whether interventions do, in fact, work and

how effectively and efficiently they achieve the goals stated. Evaluation

studies may include measurements of cost-effectiveness, cost-offset, and

cost-benefit. It is only through carefully designed, implemented, and

evaluated intervention studies that better preventive interventions can be

provided to achieve the goal of reducing suicide rates in the nation. (See

Objective 4.8).

DID YOU KNOW?

In 1999, approximately 1 out of every 13 U.S. high school students

reported making a suicide attempt in the preceding 12 months.
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GOAL 11

IMPROVE AND EXPAND SURVEILLANCE SYSTEMS

WHY IS THIS GOAL IMPORTANT TO THE NATIONAL STRATEGY?

Surveillance has been defined as

the systematic and ongoing collection of data (Bonnie et al., 1999).

Surveillance systems are key to health

planning. They are used to track

trends in rates, to identify new problems, to provide evidence to support

activities and initiatives, to identify

risk and protective factors, to target

high risk populations for interventions, and to assess the impact of prevention efforts (Thacker & Stroup,

1994).

Data are needed at national, state and local levels. National data can

be used to draw attention to the magnitude of the suicide problem and

to examine differences in rates among groups (e.g., ethnic, age groups)

(see Figure 9) and locales (e.g., rural vs. urban). State and local data help

establish local program priorities and are necessary for evaluating the

impact of suicide prevention strategies.

BACKGROUND INFORMATION AND CURRENT STATUS

Nationally, suicide surveillance data come from death certificates. This

vital statistics information is available from the National Center for Health

Statistics, Centers for Disease Control and Prevention. Medical examiner

databases also provide some information related to suicide. The information on rates available from vital statistics databases obviously does

not include those deaths misclassified as homicides or accidents, and an

unknown number of others misclassified as natural causes, but which

DID YOU KNOW?

Every 17 minutes another life is lost to

suicide. Every day 86 Americans take

their own life and over 1500 attempt

suicide.

There are an estimated 8 to 25

attempted suicides for every one

death by suicide.
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may actually be suicides. Information available from death certificates is

limited and is not always complete. Prevention efforts would be

enhanced by more comprehensive information. However, such information is not now systematically collected.

Data on suicide attempts must come from sources designed for other

purposes, such as trauma registries and uniform hospital discharge data

sets. Trauma registries provide detailed information about the nature and

severity of an injury, the treatment provided, and the status of the

FIGURE 9:

SUICIDES AND SUICIDE RATES BY AGE GROUP –

UNITED STATES, 1998

Source: National Center for Health Statistics

n Rate

AGE GROUP IN YEARS
GOAL 11 GOALS AND OBJECTIVES FOR ACTION 119

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patient on discharge from the hospital. However, most trauma registries

include only "major" trauma cases, those that require at least a three-day

hospital stay (Bonnie et al., 1999). Moreover, many suicide attempts do

not lead to traumatic injuries (e.g., overdoses of medicines). Thus, trauma registries have only limited information on suicide attempts.

A uniform hospital discharge data set is another potential source of

information on suicide attempts. As suggested by its name, a hospital

discharge data set provides information only about those suicide

attempts that resulted in hospital treatment. Not all States require either

trauma registries or uniform hospital discharge data.

The State of Oregon is unique in that a 1987 law requires hospitals

treating a child under the age of 18 for injuries resulting from a suicide

attempt to report the attempt to the Oregon Health Division (Hopkins et

al., 1995). This data source provides important information for youth suicide prevention programming in Oregon.

Other possible sources of data on suicide attempts include mental

health agencies, psychiatric hospitals, poison control centers, universities

and colleges, child death review team reports, emergency departments,

and surveys. Limitations exist for all of these data sources, such as lack of

detail on the circumstances surrounding the suicide attempt (Children's

Safety Network, 2000). Detailed information is important because it may

lead to increased knowledge of how suicides can be prevented in the

future.

One problem in studying nonlethal suicidal behavior is lack of consensus about what terms should be used to refer to these types of behaviors

(O'Carroll et al., 1996). Self-injurious behavior exists on a continuum from

actions without conscious intent to die, to actions with lethal intent that

do not result in death (suicide attempts), to intentional, self-inflicted

death (suicide). Often it is difficult to identify a person's intent to die and

thus difficult to differentiate attempted suicide from self-injurious behavior in which there was no intent to die.
120 GOALS AND OBJECTIVES FOR ACTION GOAL 11

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HOW WILL THE OBJECTIVES FACILITATE ACHIEVEMENT OF THE GOAL?

The objectives established for this goal are designed to enhance the

quality and quantity of data available at national, state and local levels

on suicide and attempted suicide and ensure that the data are useful for

prevention purposes.

Objective 11.1: By 2005, develop and refine standardized protocols

for death scene investigations and implement these

protocols in counties (or comparable jurisdictions).

Death scene investigations can reveal important information about the

circumstances of a suicide and its method. This information can be used

to improve understanding of suicide and enhance prevention efforts.

Emergency medical technicians, police, medical examiners, and coroners

may all contribute to the collection of data.

The detail and specificity of death scene investigations vary by the

training and orientation of those who participate in them. The medical

examiner or coroner is seldom the

first to arrive at the scene of a suicide; prehospital care providers

and fire fighters are more likely to

arrive first. The core training curricula for such first responders

include little attention to death

scene investigation in general or

suicide scene preservation specifically. In many jurisdictions, prehospital care providers are required to attempt resuscitative efforts even

in the face of overwhelming evidence of death. Such resuscitation and

transport efforts disrupt evidence. Protocols defining situations that do

not require resuscitation and that specify important evidentiary findings

that should be preserved would help to address these problems. While

law enforcement officers are trained in death scene investigation, that

training is primarily geared towards the confirmation or denial of foul

play. Additional training in gathering evidence from a suicide scene

IDEAS FOR ACTION

Review local emergency medical services

protocols for suicide scene procedures

and revise as needed.
GOAL 11 GOALS AND OBJECTIVES FOR ACTION 121

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would provide data that should assist in prevention activities (MacKay,

1997). For example, recording the names of witnesses to the death or

close personal contacts of the decedent could help uncover essential

information about the decedent, e.g., statements and other behaviors

prior to the death, as well as personal and family histories. Testimonies

of these individuals may reveal insight into the intent, as well as relevant

risk and protective factors.

Objective 11.2: By 2005, increase the proportion of jurisdictions that

regularly collect and provide information for followback studies on suicides.

Follow-back studies consist of the collection of detailed information

about the victim, his or her circumstances, the immediate antecedents of

the suicide, and other important but less immediate antecedents. Data

sources include personal interviews and medical records. Follow-back

studies can be used to increase understanding of the causes of suicide

and to refine prevention strategies (Berman 1993; Clark & HortonDeutsch, 1992; Conwell et al., 1996). In some States, child death review

teams analyze suicides of young people, and information from these

reviews is used to assist in prevention programming.

IDEAS FOR ACTION

Determine if a local jurisdiction regularly completes follow-back

studies on completed suicides, and if not, advocate for such

studies.
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Objective 11.3: By 2005, increase the proportion of hospitals (including emergency departments) that collect uniform

and reliable data on suicidal behavior by coding

external cause of injuries utilizing the categories

included in the International Classification of

Diseases.

Consistent use of external cause of injury codes in hospital discharge

data and emergency department records would provide an extremely

valuable resource for the study and prevention of suicide. Emergency

physicians, in particular, have a

key role in ensuring that these

data are collected. Injury codes

include information about the

causes and circumstances of

injuries (the "how") and, in combination with other information in

the medical record, the effect of

different injuries on the body. The

codes can also be used to obtain information on cost of treatment.

External cause of injury codes were developed by the World Health

Organization as a part of the International Classification of Diseases. They

are standardized internationally and allow consistent comparisons of

data among communities, States, and countries (or across time for purposes of evaluation studies). As of January 1997, 17 States had some

type of requirement for such coding (Arizona, California, Connecticut,

Delaware, Georgia, Maryland, Massachusetts, Missouri, Nebraska, New

Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Vermont,

Washington, and Wisconsin) (Education Development Center, 1999).

IDEAS FOR ACTION

Advocate for mandated coding of external cause of injury by all hospitals.
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Objective 11.4: By 2005, implement a national violent death reporting system that includes suicides and collects information not currently available from death certificates.

A detailed, Federally-supported data system exists to assist policy-making for motor vehicle related deaths, but such a data system does not

exist for violent deaths, including those from suicide. As a result, much

of the public debate about violent deaths is based on limited rather than

comprehensive data. A national reporting system, which might consist of

information derived from a combination of sources, including death certificates, medical examiner or coroner's offices, and law enforcement

agencies, would fill a gap in current knowledge by providing consistent,

comparable data from all States.

Objective 11.5: By 2005, increase the number of States that produce

annual reports on suicide and suicide attempts, integrating data from multiple State data management

systems.

An annual State report on suicide describes the magnitude of the suicide problem in the State and how suicide differentially affects special

populations; thus, the data can be used to identify priorities for planning

and programming. The data can also help track trends in the suicide rate

over time and identify new problems related to suicide, such as changes

in the methods for completing suicide or in the suicide rate among certain groups. And finally, the data can help the State evaluate its suicide

prevention efforts.

IDEAS FOR ACTION

Encourage State health agencies to produce annual reports on suicide.
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Objective 11.6: By 2005, increase the number of nationally representative surveys that include questions on suicidal

behavior.

It is estimated that a far greater number of people attempt suicide

than is reflected in statistics based on medical care. Some people are

treated in a physician's office from which no reporting is ever made, and

others are not treated by medical personnel at all. Studies examining

nonfatal suicidal behavior have found that over 70 percent of persons

attempting suicide never seek health services (Crosby, Cheltenham, &

Sacks, 1999). Even the best of existing data on suicide underestimates

the burden it places on society (Rosenberg et al., 1987). The Youth Risk

Behavior Survey provides one source of information on youth suicide, but

there are no other nationally administered surveys that regularly include

questions about suicidal behavior. Such information would be quite useful in understanding the true scope of the problem and in designing

interventions.

Objective 11.7: By 2005, implement pilot projects in several States

that link and analyze information related to selfdestructive behavior derived from separate data systems, including for example law enforcement, emergency medical services, and hospitals.

The utility of data can be enhanced significantly when data sets are

linked. Such linked data can provide much more comprehensive information about an event, its circumstances, the occurrence and severity of

injury, the type and cost of treatment received, and the outcome in terms

of both mortality and morbidity (Bonnie et al., 1999). The National

Highway Traffic Safety Administration, U.S. Department of Transportation

has fostered and supported the development of linked data systems in

improving knowledge related to traffic injuries. It has found that many

important questions can be answered through analyses based on data linkage. However, significant barriers exist with respect to data linkage, including difficulties in obtaining access to various data sets, high costs, limited

resources for developing and maintaining databases, technical difficulties,

and issues of confidentiality (Bonnie et al., 1999). Some of these problems
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are being addressed, however, such as the development of "probabilistic

linkage" software that can track individual cases through multiple data sets

even in the absence of common identifiers. In short, linking data sets is not

a trivial undertaking, but the rewards are often substantial in terms of

higher quality data and more complete information.

DID YOU KNOW?

Suicide rates are consistently higher in

the western states than in the rest of

the U.S.
126 GOALS AND OBJECTIVES FOR ACTION CHAPTER 12

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CHAPTER 12

LOOKING AHEAD

INVESTMENT AND COLLABORATION

Designed to encourage and empower groups and individuals to work

together, the National Strategy for Suicide Prevention creates a framework for suicide prevention for the Nation. The stronger and broader the

support and collaboration, the greater the chance for the success of this

public health initiative. Suicide and suicidal behaviors can be reduced as

the general public gains more understanding about the extent to which

suicide is a major public health problem, about the ways in which it can

be prevented, and about the roles individuals and groups can play in prevention efforts.

The National Strategy is comprehensive and sufficiently broad so that

individuals and groups can select those objectives and activities that best

fit their interests, constituencies and resources. The plan's objectives suggest a number of roles for different groups. Individuals representing a

variety of occupational fields such as

health care, social work, education,

law and faith-based care should be

involved in implementing the plan.

Institutions such as community

groups, religious organizations, and

schools all have a necessary part to

play. Sites for suicide prevention work

include jails, emergency departments,

and the workplace. The survivors,

consumers and the media need to be partners as well. State and local

governments are key players, as is the Federal government, whose role is

to judiciously provide funding for research and programs that protect

and enhance the health and well-being of their citizens.

Ideally, the National Strategy will motivate and illuminate. But for the

NSSP to have any effect, people need to use it as a guideline to develop

DID YOU KNOW?

State Suicide Prevention Plans already

exist or are in the process of creation

in over 20 States.
CHAPTER 12 GOALS AND OBJECTIVES FOR ACTION 127

NATIONAL STRATEGY FOR SUICIDE PREVENTION

their own priorities. The National Strategy can serve as a model that can

be adopted or modified by States, communities, and tribes as they develop their own suicide prevention plan. The information on evidence-based

strategies included in this document can help. The National Strategy

articulates the framework for national efforts and provides legitimacy for

local groups to make suicide prevention a high priority for action. Taking

action will convey a message that we, as a society, do care about supporting our communities.

CHALLENGES TO OVERCOME

The knowledge base about suicide and suicide prevention remains

incomplete. Research resulting in the acquisition of new knowledge must

continue to contribute by suggesting new strategies and approaches.

Evaluation activities must be incorporated into all prevention efforts to

ensure ongoing monitoring and refinement.

In the last decade, suicide prevention efforts have received renewed

support from Federal and private sources. Most of these efforts have

taken the form of educational campaigns and development of health

education modules for school systems. The pharmaceutical industry has

developed new medications to treat mental and substance use disorders

that are often associated with suicidal behavior and there is promising

evidence that these medications do reduce suicidal behaviors among

those who receive them in therapeutic doses over sufficient time

(Jamison & Baldessarini, 1999; Meltzer & Okayli 1995). However, patients

may also need non-pharmacologic interventions to reduce their risk for

suicidality.

Educational institutions have increased their training in prevention sciences and health promotion. However, the courses offered may not

specifically address suicide, suicidal behaviors, mental health services, or

the prevention of mental or substance use disorders. New advances in

therapeutic modalities such as cognitive behavioral therapy, dialectical

behavioral therapy, and interpersonal psychotherapy, hold promise for

reducing suicidal behaviors in those individuals at risk (Hawton et al.,
128 GOALS AND OBJECTIVES FOR ACTION CHAPTER 12

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1998). Renewed attention has focused on building social and interpersonal competencies as protective factors against mental disorders

(Mrazek & Haggerty, 1994). Systemic

interventions, such as the Air Force

Suicide Prevention Program, have

made an impact (Litts et al., 1999).

Nevertheless, access to these quality

programs is not universal and not all

mental health centers or substance

abuse treatment facilities have the

available expertise to offer these

interventions.

Implementing a national suicide prevention strategy successfully

requires overcoming some specific obstacles and barriers. Some are wellknown to the prevention field in general, such as the real dilemma of

allocating scarce human and monetary resources among the many

deserving health-related prevention programs. Acquiring and maintaining appropriate levels of public and private funding for suicide prevention efforts can be a challenge. The potential impact on local, state, and

federal budgets must be carefully considered.

Another obstacle is the argument that prevention is a luxury and funds

should be allocated instead to treatment, which is of the moment. Both

are important and necessary and public health efforts work more effectively when these components operate in unison. In an oft-cited

metaphor, prevention is likened to the work of posting warnings and

constructing protective railings at the river's edge, while treatment is

seen as the work of pulling those who have fallen in and cannot swim

from the cold waters. There will always remain a role for both kinds of

work. One goal of prevention is to prevent those at risk from "drowning,"

because the treatment programs cannot always keep pace with the

demand for services.

Another challenge to overcome is the institutional tendency towards

short-term and isolated prevention planning. Because effective prevention efforts may take years to show true benefits, instituting plans in 2-

DID YOU KNOW?

A concerted, broadly-supported, community based effort reduced suicide in

the US Air Force by over 60% in five

years.
CHAPTER 12 GOALS AND OBJECTIVES FOR ACTION 129

NATIONAL STRATEGY FOR SUICIDE PREVENTION

to 5-year increments may not permit prevention efforts to come to

fruition. Additionally, suicide prevention goals and objectives must be

woven into the fabric of community and local human services, training,

and education. Standing alone, suicide prevention efforts fail to benefit

from the resources, experience and community acceptance of established

programs and services. There are challenges and complexities surrounding priority setting, data collection, measurement of progress, resource

allocation and programmatic refinement over time.

Probably the greatest challenge to the successful implementation of a

national suicide prevention strategy comes from the twin nemeses of

stigma and disparity: the societal stigma associated with mental illness,

substance abuse, and suicidal behaviors, and the current disparity in

access to mental health and substance abuse care compared to other

forms of health care. Taken together, these two threats–one of psychological and cultural origins, the other due to organizational and economic roadblocks–represent a formidable twin obstacle. Overcoming

them must engage the energies, political will and creativity of all members of society.

Collaboration is a keystone of the National Strategy. There is in our

Nation a tremendous human resource potential of volunteer and grassroots advocates who are committed to advancing suicide prevention

efforts. Many groups and individuals have been involved in developing

the plan's goals and objectives and as activities for implementing the

plan are developed, many others will be called upon to lend their support. The involvement of a diverse group of participants will lead to the

formation of partnerships for successful implementation. Everyone must

be involved for the plan to succeed and for the suicide rate to be

reduced.

Decisions about which diseases and conditions should receive the most

attention are difficult and complex. Opportunities arise only so often to

capture the spirit and attention of the public around a particular public

health problem. The momentum and activity focused in the last few years

on suicide and suicidal behaviors suggest that the time is right for bold and

concerted movement forward with suicide prevention efforts.
130 GOALS AND OBJECTIVES FOR ACTION CHAPTER 12

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NEXT STEPS

Beyond the written plan presented in this document, the National

Strategy for Suicide Prevention encompasses the development, promotion and support of programs that will be implemented in communities across the country. These activities are designed to achieve significant, measurable, and sustainable reductions in suicide and suicidal

behaviors. This requires a major investment in public health action. For

any preventive action to go forward, three ingredients are necessary: a

knowledge base, the public support for change, and a social strategy to

accomplish change (Atwood, Colditz, & Kawachi, 1997). The next steps

for the NSSP recognize that each ingredient is dependent upon the other,

and that balance among all three must be achieved to make progress.

A significant step is to develop an operating structure or coordinating

body for the National Strategy that reflects the essential need for a public/private partnership. Public (for instance Federal, State, and local officials) and private sector representation would guide public action. Private

sector representatives would include business, voluntary organizations,

survivor groups, faith-based groups, professional associations, and the

media. The coordinating body, with defined responsibility, funding,

authority, and accountability for its work, would be the national focus for

prevention activities and would provide a mechanism for engaging public will.

Development of an action agenda, complete with specific activities

defined for national, state, and community partners would ideally be

shepherded by the coordinating body although to expedite progress,

development of a coordinating body and an action agenda may proceed

in tandem. When stakeholders participate in the development of prevention activities, political will is generated for the resources to accomplish

them. Moreover, bridging the knowledge and practice communities in

this way leads to sound prevention activities applicable to specific cultures.

Some activities will be directed towards critical expansion of the

knowledge base with, for example, the addition of translational research
CHAPTER 12 GOALS AND OBJECTIVES FOR ACTION 131

NATIONAL STRATEGY FOR SUICIDE PREVENTION

connecting advances in neuroscience to "active preventive interventions"

(e.g., biological, social, psychological) that lower the risk of suicide, of

applied research that carries prevention science into community action,

and of research on program evaluation. This knowledge continuum supports development of practice guidelines for all disciplines and sectors

engaged in suicide prevention.

Ideally, objectives are measurable; that is, one is able to follow some

essential piece of information associated with the stated objective. This

information, known as a benchmark, or indicator, permits one to quantify the achievement of a result. For instance, in Objective 3.1 the benchmark (indicator) is the proportion of the public that views mental and

physical health as equal and inseparable components of overall health.

Thus, to track success in achieving an objective it is required to have identified at least one benchmark, a baseline (the measurement of the benchmark from which change will be assessed) and a target (the number or

percentage change desired in the benchmark). Not all objectives require

benchmarks to determine if the Nation has achieved them. Policy and

organizational objectives (see Objective 2.2) can often be deemed

accomplished simply by the fact of their having been established. 

Benchmarks can be a commonsense way to communicate to the public the value of their investment in suicide prevention activities. By measuring the same benchmark over time, one may determine the amount

and direction of change towards fulfilling the objective. In this way,

benchmark measures can guide decision making by providing information about the success or failure of efforts that are being applied in support of a particular objective.

Each objective in the U.S. National Strategy is potentially, if not practically, measurable. For some objectives, benchmark data may already

exist or its collection will be straightforward. For others, benchmarks

have not yet been identified or collecting information on the benchmark

may just not be practical at this time. For most of the objectives in Goals

and Objectives for Action, no baseline benchmark data has yet been

established. Without this baseline information, it is difficult to set a

numerical target for change, since it is not clear just how much progress
132 GOALS AND OBJECTIVES FOR ACTION CHAPTER 12

NATIONAL STRATEGY FOR SUICIDE PREVENTION

should be expected by the year 2005. Developing appropriate indicators,

determining baseline measures and establishing a benchmarking system

for National Strategy progress is a key next step.

Plans are already underway to launch the National Strategy for

Suicide Prevention website <http://www.mentalhealth.org/suicideprevention> and document clearinghouse so that the available knowledge can be in the hands of those who will be can use it for effective

decision-making in suicide prevention. The website/clearinghouse will

provide electronic linkages among partners involved in the NSSP to support their collaboration and progress. It will provide up-to-date information that can help shape public will.

Now is the time for making great strides in suicide prevention.

Implementing this National Strategy for Suicide Prevention provides the

means to realize success in reducing the toll of this serious public health

problem. The work ahead can extend public and private collaboration to

sustain action on behalf of all Americans because suicide prevention is

truly everyone's business.
GOALS AND OBJECTIVES FOR ACTION 133

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APPENDIX A

NSSP GOALS AND OBJECTIVES FOR ACTION: SUMMARY LIST

SECTION I: AWARENESS

1. Promote awareness that suicide is a public health problem that

is preventable

2. Develop broad-based support for suicide prevention

3. Develop and implement strategies to reduce the stigma associated with being a consumer of mental health, substance abuse

and suicide prevention services

SECTION 2: INTERVENTION

4. Develop and implement suicide prevention programs

5. Promote efforts to reduce access to lethal means and methods

of self-harm

6. Implement training for recognition of at-risk behavior and delivery of effective treatment

7. Develop and promote effective clinical and professional practices

8. Increase access to and community linkages with mental health

and substance abuse services

9. Improve reporting and portrayals of suicidal behavior, mental illness, and substance abuse in the entertainment and news media

SECTION 3: METHODOLOGY

10. Promote and support research on suicide and suicide prevention

11. Improve and expand surveillance systems
APPENDIX A GOALS AND OBJECTIVES FOR ACTION 155

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SECTION I: AWARENESS

1.PROMOTE AWARENESS THAT SUICIDE IS A PUBLIC HEALTH PROBLEM

THAT IS PREVENTABLE

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.

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.

Objective 1.3: By 2005, convene national forums to focus on issues

likely to strongly influence the effectiveness of suicide

prevention messages.

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.

2.DEVELOP BROAD-BASED SUPPORT FOR SUICIDE PREVENTION

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

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.
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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.

Objective 2.4: By 2005, increase the number of nationally organized

faith communities adopting institutional policies promoting suicide prevention.

3.DEVELOP AND IMPLEMENT STRATEGIES TO REDUCE THE STIGMA

ASSOCIATED WITH BEING A CONSUMER OF MENTAL HEALTH, SUBSTANCE

ABUSE AND SUICIDE PREVENTION SERVICES.

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.

Objective 3.2: By 2005, increase the proportion of the public that

views mental disorders as real illnesses that respond

to specific treatments.

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.

Objective 3.4: By 2005, increase the proportion of those suicidal

persons with underlying mental disorders who receive

appropriate mental health treatment.
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SECTION 2: INTERVENTION

4.DEVELOP AND IMPLEMENT COMMUNITY-BASED SUICIDE PREVENTION

PROGRAMS

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.

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.

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.

Objective 4.4: By 2005, increase the proportion of employers that

ensure the availability of evidence-based prevention

strategies for suicide.

Objective 4.5: By 2005, increase the proportion of correctional institutions, jails and detention centers housing either

adult or juvenile offenders, with evidence-based suicide prevention programs.

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.

Objective 4.7: By 2005, increase the proportion of family, youth and

community service providers and organizations with

evidence-based suicide prevention programs.
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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.

5.PROMOTE EFFORTS TO REDUCE ACCESS TO LETHAL MEANS AND METHODS

OF SELF-HARM

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.

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.

Objective 5.3: By 2005, develop and implement improved firearm safety design using technology where appropriate.

Objective 5.4: By 2005, develop guidelines for safer dispensing of medications for individuals at heightened risk of suicide.

Objective 5.5: By 2005, improve automobile design to impede carbon

monoxide-mediated suicide.

Objective 5.6:: By 2005, institute incentives for the discovery of new

technologies to prevent suicide.

6.IMPLEMENT TRAINING FOR RECOGNITION OF AT-RISK BEHAVIOR AND

DELIVERY OF EFFECTIVE TREATMENT

Objective 6.1: By 2005, define minimum course objectives for providers

of nursing care in assessment and management of suicide risk, and identification and promotion of protective

factors. Incorporate this material into curricula for nursing care providers at all professional levels.
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Objective 6.2: By 2005, increase the proportion of physician assistant

educational programs and medical residency programs

that include training in the assessment and management of suicide risk and identification and promotion of

protective factors.

Objective 6.3: By 2005, increase the proportion of clinical social work,

counseling, and psychology graduate programs that

include training in the assessment and management of

suicide risk, and the identification and promotion of protective factors.

Objective 6.4: By 2005, increase the proportion of clergy who have

received training in identification of and response to suicide risk and behaviors and the differentiation of mental

disorders and faith crises.

Objective 6.5: By 2005, increase the proportion of educational faculty

and staff who have received training on identifying and

responding to children and adolescents at risk for suicide.

Objective 6.6: By 2005, increase the proportion of correctional workers

who have received training on identifying and responding to persons at risk for suicide.

Objective 6.7: By 2005, increase the proportion of divorce and family

law and criminal defense attorneys who have received

training in identifying and responding to persons at risk

for suicide.

Objective 6.8: By 2005, increase the proportion of counties (or comparable jurisdictions such as cities or tribes) in which education programs are available to family members and

others in close relationships with those at risk for suicide.

Objective 6.9: By 2005, increase the number of recertification or licensing programs in relevant professions that require or promote competencies in depression assessment and management and suicide prevention.
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7.DEVELOP AND PROMOTE EFFECTIVE CLINICAL AND PROFESSIONAL

PRACTICES

Objective 7.1: By 2005, increase the proportion of patients treated

for self-destructive behavior in hospital emergency

departments that pursue the proposed mental health

follow-up plan.

Objective 7.2: By 2005, develop guidelines for assessment of suicidal

risk among persons receiving care in primary health

care settings, emergency departments, and specialty

mental health and substance abuse treatment centers.

Implement these guidelines in a proportion of these

settings.

Objective 7.3: By 2005, increase the proportion of specialty mental

health and substance abuse treatment centers that

have policies, procedures, and evaluation programs

designed to assess suicide risk and intervene to reduce

suicidal behaviors among their patients.

Objective 7.4: By 2005, develop guidelines for aftercare treatment programs for individuals exhibiting suicidal behavior

(including those discharged from inpatient facilities).

Implement these guidelines in a proportion of these settings.

Objective 7.5: By 2005, increase the proportion of those who provide

key services to suicide survivors (e.g., emergency medical

technicians, firefighters, law enforcement officers, funeral directors, clergy) who have received training that

addresses their own exposure to suicide and the unique

needs of suicide survivors.

Objective 7.6: By 2005, increase the proportion of patients with mood

disorders who complete a course of treatment or continue maintenance treatment as recommended.
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Objective 7.7: By 2005, increase the proportion of hospital emergency

departments that routinely provide immediate posttrauma psychological support and mental health education for all victims of sexual assault and/or physical

abuse.

Objective 7.8: By 2005, develop guidelines for providing education to

family members and significant others of persons receiving care for the treatment of mental health and substance abuse disorders with risk of suicide. Implement

the guidelines in facilities (including general and mental

hospitals, mental health clinics, and substance abuse

treatment centers).

Objective 7.9: By 2005, incorporate screening for depression, substance abuse and suicide risk as a minimum standard of

care for assessment in primary care settings, hospice,

and skilled nursing facilities for all Federally-supported

healthcare programs (e.g., Medicaid, CHAMPUS/TRICARE, CHIP, Medicare).

Objective 7.10: By 2005, include screening for depression, substance

abuse and suicide risk as measurable performance

items in the Health Plan Employer Data and

Information Set (HEDIS).

8.INCREASE ACCESS TO AND COMMUNITY LINKAGES WITH MENTAL HEALTH

AND SUBSTANCE ABUSE SERVICES

Objective 8.1: By 2005, increase the number of States that require

health insurance plans to cover mental health and substance abuse services on par with coverage for physical health.

Objective 8.2: By 2005, increase the proportion of counties (or comparable jurisdictions) with health and/or social services

outreach programs for at-risk populations that incorporate mental health services and suicide prevention.
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Objective 8.3: By 2005, define guidelines for mental health (including

substance abuse) screening and referral of students in

schools and colleges. Implement those guidelines in a

proportion of school districts and colleges.

Objective 8.4: By 2005, develop guidelines for schools on appropriate

linkages with mental health and substance abuse

treatment services and implement those guidelines in

a proportion of school districts.

Objective 8.5: By 2005, increase the proportion of school districts in

which school-based clinics incorporate mental health

and substance abuse assessment and management

into their scope of activities.

Objective 8.6: By 2005, for adult and juvenile incarcerated populations, define national guidelines for mental health

screening, assessment and treatment of suicidal individuals. Implement the guidelines in correctional institutions, jails and detention centers.

Objective 8.7: By 2005, define national guidelines for effective comprehensive support programs for suicide survivors.

Increase the proportion of counties (or comparable

jurisdictions) in which the guidelines are implemented.

Objective 8.8: By 2005, develop quality care/utilization management

guidelines for effective response to suicidal risk or

behavior and implement these guidelines in managed

care and health insurance plans.

9.IMPROVE REPORTING AND PORTRAYALS OF SUICIDAL BEHAVIOR, MENTAL

ILLNESS, AND SUBSTANCE ABUSE IN THE ENTERTAINMENT AND NEWS

MEDIA

Objective 9.1: By 2005, establish an association of public and private

organizations for the purpose of promoting the accurate

and responsible representation of suicidal behaviors, mental

illness and related issues on television and in movies.
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Objective 9.2: By 2005, increase the proportion of television programs and

movies that observe promoting accurate and responsible

depiction of suicidal behavior, mental illness and related

issues.

Objective 9.3: By 2005, increase the proportion of news reports

on suicide that observe consensus reporting

recommendations.

Objective 9.4: By 2005, increase the number of journalism schools that

include in their curricula guidance on the portrayal and

reporting of mental illness, suicide and suicidal behaviors.

SECTION 3: METHODOLOGY

10. PROMOTE AND SUPPORT RESEARCH ON SUICIDE AND SUICIDE

PREVENTION

Objective 10.1: By 2002, develop a national suicide research agenda

with input from survivors, practitioners, researchers,

and advocates.

Objective 10.2: By 2005, increase funding (public and private) for suicide prevention research, for research on translating

scientific knowledge into practice, and for training of

researchers in suicidology.

Objective 10.3: By 2005, establish and maintain a registry of prevention activities with demonstrated effectiveness for

suicide or suicidal behaviors.

Objective 10.4: By 2005, perform scientific evaluation studies of new

or existing suicide prevention interventions.
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11. IMPROVE AND EXPAND SURVEILLANCE SYSTEMS

Objective 11.1: By 2005, develop and refine standardized protocols

for death scene investigations and implement these

protocols in counties (or comparable jurisdictions).

Objective 11.2: By 2005, increase the proportion of jurisdictions that

regularly collect and provide information for followback studies on suicides.

Objective 11.3: By 2005, increase the proportion of hospitals (including emergency departments) that collect uniform and

reliable data on suicidal behavior by coding external

cause of injuries, utilizing the categories included in

the International Classification of Diseases.

Objective 11.4: By 2005, implement a national violent death reporting system that includes suicides and collects information not currently available from death certificates.

Objective 11.5: By 2005, increase the number of States that produce

annual reports on suicide and suicide attempts, integrating data from multiple State data management

systems.

Objective 11.6: By 2005, increase the number of nationally representative surveys that include questions on suicidal

behavior.

Objective 11.7: By 2005, implement pilot projects in several States

that link and analyze information related to selfdestructive behavior derived from separate data systems, including for example law enforcement, emergency medical services, and hospitals.
GOALS AND OBJECTIVES FOR ACTION 165

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APPENDIX B

EVALUATION OF SUICIDE PREVENTION PROGRAMS

As not everything can be done, there must be a basis for deciding which

things are worth doing. Enter evaluation.

M. Q. Patton (1997)

Evaluation is the tool we use to ensure that programs, such as those

that are designed to prevent suicide, accomplish what we intend.

Evaluation may answer certain questions that have been taken for granted but that have not been scientifically tested, especially those related to

proving the effectiveness of a program. Evaluation may also be used to

improve the functioning of a program. Both types of evaluation–sometimes referred to as outcome evaluation and process evaluation–can help

to ensure effective use of resources.

Weiss (1998) posits four defining elements of evaluation:

1. Evaluation is concerned with either the operations or the outcomes of a program; a few evaluations may address both.

2. Evaluation compares a program to a set of standards. The standards may be explicit, such as a statement of goals or objectives,

or implicit, in which one must deduce the standard. Evaluation

implies a judgment.

3. Evaluation is systematic. It is conducted with rigor and thoroughness.

4. Evaluation is purposeful. It is designed to provide information

that can improve a program or document the effects of one or

more aspects of it.

A process evaluation focuses on implementation. It describes how a

program operates, how it delivers services, and how well it carries out its

intended functions. By documenting a program's development and oper-
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ation, a process evaluation can provide some understanding of the performance of the program and information for potential replication. The

goal of a process evaluation may be to ensure that a project stays on

course and is faithful to the initial model. It may also be designed to provide the opportunity to make midcourse corrections, to modify aspects

of the program that are not working as originally intended, or to identify problems or gaps that need attention. Process evaluation can help a

project ensure accountability by comparing its actual performance with

expectations and explaining reasons for any differences. Such information can help program administrators understand why some activities

were more useful than others, leading to improved services in the future.

An outcome evaluation employs a causal framework; that is, an intervention is assumed to cause a particular outcome. This type of evaluation

is used to study the effectiveness of a program. It employs quantifiable

data to determine whether or not a program had the desired effects.

Examples might include a reduction in the suicide rate or in attempted

suicides, changes in knowledge among primary care physicians of treatment resources, or changes in the number of depressed people taking

antidepressants. While evaluation is often thought of in terms of measuring overall effectiveness, frequently less comprehensive questions can

be asked. For example, an evaluation might address the ability of an outreach program to actually contact people at risk and it might assess the

cost of doing so; another might examine the way in which health

provider characteristics affect the ability and/or willingness of these individuals to effectively engage persons at risk of suicide.

STEPS IN CONDUCTING AN EVALUATION

The key steps in evaluation are as follows:

l Engaging staff and other potential stakeholders in the evaluation

process.

l Focusing the evaluation design.

l Gathering evidence.
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l Justifying conclusions.

l Ensuring use and sharing lessons learned.

Engaging Staff and Stakeholders: Involving staff and stakeholders in

an evaluation ensures that their perspectives are understood. If they are

not engaged, the evaluation might overlook important elements of the

program. Stakeholders can also help to implement the evaluation. They

can improve its credibility and help the project address any potential ethical concerns.

There are several ways to involve stakeholders in an evaluation. These

include consulting with representatives from as many groups as possible;

developing an evaluation task force and including representatives of the

stakeholder groups; and providing timely feedback on the process of the

evaluation. An advisory committee might be formed to function

throughout the life of the project.

The provision of feedback to project staff and other relevant stakeholders on the ongoing progress of an evaluation is often overlooked,

resulting in missed opportunities to improve the evaluation and ensure

that its findings are ultimately used by the field. Examples of ways to provide feedback include weekly meetings with program staff; monthly discussions or roundtables with a larger group; newsletters; and/or biweekly memos from the evaluator(s) on insights and reflections for response

and comment. Ongoing dialogue and frequent communication are

essential elements in ensuring that providers remain engaged in the project; such communication may also assist the evaluation team to refine

the design and interpretations of the study.

Focusing the Evaluation Design: The evaluation question(s) drive the

study. There are many potential questions that can be asked in an evaluation. Patton (1997) identifies 57 alternative ways of focusing an evaluation, each type with a different purpose and associated question–and

these, he states, are illustrative only. Examples of ways to focus an evaluation and the types of questions relevant to each are shown in Table 1.
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FOCUS OF EVALUATION

Outcome:

Causal

Cost-Benefit

Effectiveness

Social and

Community

Indicators

Process:

Implementation

Descriptive

Context

DEFINING QUESTION OR APPROACH

What is the relationship between an intervention (as a treatment) and outcomes? Can the intervention be shown to have

resulted in the observed outcomes? Are other factors which

could contribute to an outcome adequately controlled?

What is the relationship between program costs and program

outcomes (benefits) expressed in dollars?

To what extent is the program effective in attaining its goals?

How can the program be more effective?

What social and economic data should be monitored to assess

the impacts of the program? What is the connection between

program outcomes and larger-scale social indicators, for example, unemployment?

To what extent was the program implemented as designed?

What issues surfaced during implementation that need attention in the future?

What happens in the program? (No "why" questions or

cause/effect analysis)

What is the environment within which the program operates

politically, socially, economically, culturally and scientifically?

How does this context affect the program?

TABLE 1

FOCUSING AN EVALUATION

Adapted from Patton, 1997.
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After defining one or more important questions, the program and

evaluation team must then determine whether or not it is possible to

answer them. Perhaps a question cannot be clearly stated or its elements

adequately defined. Or perhaps there is not a methodology that can be

used to answer the question. Or, while it may be theoretically possible to

design an evaluation study to answer a particular question, it may be

quite expensive to conduct the study and sufficient funds may be

unavailable. Determining whether or not a question can be asked clearly, whether there is a way to study it, and whether there is sufficient

money to undertake an appropriate study is sometimes referred to as an

"evaluability assessment." 

Many people now use a "logic model" as a way to identify evaluation

questions. A logic model is simply a diagram (perhaps a flow chart or a

table) that shows the relationships between program elements and presumed outcomes; it represents the theory of how and why the program

is assumed to work. By developing such a diagram, program stakeholders can sometimes clarify areas of particular interest for evaluation. An

example of a completed logic model is included at the end of this discussion.

Once the questions for the evaluation have been determined, the project team must design the methodology. Decisions are made on issues

such as the specification of groups that will be studied, the means by

which groups will be selected, time intervals for study, the kinds of comparisons that are planned, and the form in which data are to be collected. Either qualitative or quantitative data may be collected, sometimes

both. An evaluation question that addresses proving effectiveness, for

example, will usually require a formal research design that includes a

control group and the development of quantitative measures, but a

question that is concerned with understanding a project's responsiveness

to cultural issues will most likely employ methods such as interviews and

focus groups.
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Gathering Evidence: As a part of the study design, the evaluation team

will need to decide on the instruments for collecting it. Survey questionnaires, interview protocols, and coding forms are examples of instruments. In some cases, it is possible to use preexisting instruments; in

other cases, the evaluator will need to develop a new instrument. An

advantage of existing instruments is that they are often (but not always)

standardized (i.e., scores on particular items have been rated as "normal"

and "non-normal"), and they may have been established as valid and reliable (valid means the instrument measures what it is supposed to measure and reliable means that responses are consistent over time). The disadvantage of using existing instruments is that they may not be appropriate for the particular program being evaluated. For example, an instrument may refer to services not provided through the program, or it may

be inappropriate for the cultural or ethnic groups that make up a community.

Justifying Conclusions: In the data analysis phase of evaluation, the

information is interpreted and a judgment made about the meaning of

the data that has been collected. What are the answers to the questions

that have been posed and what do these answers mean? 

Generally, some standard will be used to judge the meaning of the

findings. For example, if one of the desired outcomes of a program is the

institution of or improvement in outreach services, a number by itself will

have little relevance in the absence of a standard. Is an outreach program

successful that reaches 15 percent of the population? The answer

depends on what the program and the community define as adequate

and appropriate. When diverse stakeholders have different standards,

they may disagree on the conclusions that may be drawn from the data

analysis.

Ensuring Use and Sharing Lessons Learned: Evaluation is only worth

doing if it leads to improvements in knowledge and program operations.

There is both a local and a universal component to utilization of evaluation findings. Evaluation should be important first of all to the stakeholders of the particular program that was evaluated; evaluation findings

should inform programmatic decision-making and address questions
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that are important to program staff and service recipients. Engaging

stakeholders throughout the evaluation process helps to ensure an evaluation that is relevant to the program and that may lead to changes in

procedures and policies, if necessary, or to enhanced support for the program.

The second audience for evaluation is outsiders with an interest in the

issue. Findings may help to improve the functioning of related projects,

convince policy makers of the importance of the program, and generate

wider support for the program. Evaluation findings presented in the

media can increase public understanding.

CONCLUSION

This discussion has provided a very brief overview of some issues related

to evaluation. It is intended to provoke thought and to suggest the

importance of evaluation for suicide prevention. More detailed information on evaluation may be found on the Web sites and in the books listed below.

USEFUL WEB SITES

http://www.cdc.gov/eval

This site, supported by the U.S. Department of Health and Human

Services, Centers for Disease Control and Prevention, provides a description of the public health approach to evaluation in a clear and straightforward manner. It includes links to other Web sites with additional

information on program evaluation, including numerous on-line publications that can be downloaded.

http://www.bja.evaluationwebsite.org

This site, supported by the U.S. Department of Justice, Bureau of

Justice Assistance, provides a primer on evaluation. While the examples

are oriented to projects of the Department of Justice, the text is generic

to evaluation of community-wide programs.
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http://www.wkkf.org/publications/evalhdbk

This site includes a downloadable version of the excellent evaluation

handbook developed by the W.K. Kellogg Foundation for its grantees. It

provides much useful information for evaluating projects that are community-based.

http://ctb.Isi.ukans.edu

This site includes over 3,000 downloadable pages on evaluating community programs. User friendly and comprehensive, it is maintained by

the University of Kansas.

USEFUL PUBLICATIONS

Afifi, A.A., Clark, V. (1990). Computer Aided Multivariate Analysis (2nd

ed.). New York: Chapman and Hall, 1990.

n A text on linear models and regression analysis.

Centers for Disease Control and Prevention. (1999). Framework for program evaluation in public health. Morbidity and Mortality Weekly Report,

48, 1-40.

n A description of the elements of a good evaluation for public health

programs, including standards for effective evaluation.

Kvale, S. (1996). InterViews: An introduction to qualitative research interviewing. Thousand Oaks, CA: Sage.

n A comprehensive book written for practitioners but also useful for

researchers.

Lunnenberg, C. (1994). Modeling experimental and observational data.

Boston: PWS-Kent.

n A text on linear models and regression analysis.

Maxwell, J.A. (1996). Qualitative research methods. Thousand Oaks, CA:

Sage.

n A comprehensive look at qualitative research.
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Patton, M.Q. (1997). Utilization-focused evaluation (3rd ed.). Thousand

Oaks, CA: Sage.

n A clear and readable text providing good guidance on evaluation

strategies that can lead to useful–and used–evaluations.

Rossi, P.H., & Freeman, H.E. (1993). Evaluation: A systematic approach

(5th ed.). Thousand Oaks, CA: Sage.

n A highly regarded text on evaluation.

Weiss, C. H. (1998). Evaluation methods for studying programs and policies (2nd ed.). Upper Saddle River, NJ: Prentice Hall.

n An easy-to-read and comprehensive text on evaluation.

Weitzman, E.A., & Miles, M.B. (1995). A software sourcebook: Computer

programs for qualitative data analysis. Thousand Oaks, CA: Sage.

n A sourcebook addressing the relative advantages of different computer programs for qualitative analysis.
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APPENDIX C

EXAMPLES OF RESEARCH EFFORTS THAT MAY YIELD

INFORMATION IMPORTANT TO SUICIDE PREVENTION EFFORTS

Preventive efforts to reduce suicide should be grounded in research

that provides information about modifiable risk and protective factors, as

well as about appropriate target populations on which to focus prevention efforts (see The Public Health Approach as Applied to Suicide,

Introduction). Once these are identified, prevention programs must be

carefully tested to determine if they are safe, truly effective, and worth

the considerable cost and effort needed to implement and sustain them.

Included in this appendix are examples of approaches for delivering

preventive interventions aimed at target populations and/or particular

settings. In the absence of clear evidence demonstrating that such

approaches are effective, ongoing studies are highlighted to show where

existing efforts are currently being tested, or approaches which could be

evaluated with regard to their potential to reduce suicide. Because completed suicide is a relatively rare event, many programs will be limited to

proving effectiveness in reducing suicide attempts and serious suicide

ideation, reducing risk factors strongly associated with suicide, or

strengthening protective factors.

PREVENTING YOUTH DEPRESSION AND VIOLENCE

Suicide is difficult to predict, but it does not usually "come out of the

blue." Many of the factors that put youth at risk for suicide are understood, specifically mental disorders, substance abuse, prior suicide

attempt, sexual abuse, impulsive and aggressive behavior, and access to

a firearm (USPHS, 1999). Logically, reducing such risk factors should also

reduce risk for suicide. While there are effective treatments for many of

the risk factors of suicide, including depression (Findling et al., 1999;

Lewinsohn & Clarke, 1999), and a growing number of ways to prevent

violence and to prevent and treat substance use (USPHS, 2001), the long-
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term outcome of these interventions in reducing suicide is not yet

known.

Prior research suggests 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 in the absence of effective

ways to improve self-or peer-referral, schools would need to screen for

youth at risk, and that school staff need to be trained to be aware of the

warning signs for suicidal youth, and have a plan of action for helping

youth at risk. The U.S. Department of Education recently issued Early

warning, timely response: A guide to safe schools which offers researchbased practices designed to assist school communities in early identification of these warning signs and in developing prevention, intervention

and crisis response plans (http://www.ed.gov/offices/OSERS/OSEP/earlywrn.html). Perhaps the greatest challenge for school-based suicide prevention efforts is monitoring and evaluation. A monitoring system has

been successfully used by the Dade County Public Schools to assess the

prevalence of suicidal behavior, identify the grade level and school classification of those youth most at risk, as well as assess progress of prevention efforts (Zenere & Lazarus, 1997). Screening approaches should

be carefully considered with regard to their costs and benefits, such as

the problem of over-identifying youth in need of services, lack of adequate and timely referrals, or inadvertently further stigmatizing youth at

risk.

Many of the established treatments known to reduce mental and substance use disorders have been tested on youth who typically have come

to the attention of care providers (parents, teachers, pediatricians).

Because mental disorders and substance use disorders are under-detected and under-treated in youth (U.S. Department of Health and Human

Services, 1999; http://www.sg.gov/library/mentalhealth/home.html),

another approach to prevention has been the use of school-based

screening to identify youth at risk. At least two screening approaches are

currently being investigated. One approach identifies youth at risk for

dropping out of school through poor attendance and failing grades, further evaluates those youth, and then provides various types of interventions to reduce the potential for suicide and substance use (Thompson &
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Eggert, 1999). To date, there is no strong evidence that this approach

reduces suicidality, but it has been shown to increase adolescents' sense of

personal control, which may have other long-term beneficial effects. In

another school-based approach, brief screening instruments are used to

identify youths with depressive symptoms and/or suicidal thoughts. They

are then evaluated in a more thorough manner and referred to appropriate treatment (Shaffer & Craft, 1999). The effectiveness of this approach

has yet to be evaluated. While such screening efforts are more likely to

detect youth at risk, they are not precise in their ability to detect only those

at risk for suicide. Because of the likelihood of identifying youth with multiple problems, including those not necessarily at risk for suicide, such

screening efforts can quickly burden a limited referral or service system.

The hazards of labeling and not treating youth detected in such screening

efforts must also be considered.

Another approach being promoted to identify at-risk youth who are not

yet in treatment is gatekeeper training, involving the education of adults

who regularly come in contact with suicidal youth in schools and the community. Some efforts also attempt to train youth so that they can refer

other youth at risk to sources of help. The Centers for Disease Control and

Prevention (CDC) has described a range of gatekeeper training approaches

(O'Carroll et al., 1992; http://www.cdc.gov/ncipc/pub-res/youthsui.htm).

Although some evidence suggests increased knowledge and improved attitudes toward helping suicidal youth following gatekeeper training programs, none has been systematically evaluated to determine if more youth

at risk are receiving treatment as a result of these programs or if the programs are preventing suicidal behavior.

Universal interventions encompass a broader health-promotion

approach. Such interventions are applied to all youth and typically focus on

promoting protective factors or halting the development or progression of

risk factors. These efforts are applied across home, school, and peer contexts.

Successful universal interventions commonly feature efforts to build

one's assets in social, problem solving, and other skills. Many initiated

early in a child's life (e.g., improving early parent-child relationships,
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enhancing problem solving skills; increasing adaptive social behavior)

have been shown effective in reducing aggression and early substance

use (e.g., see Catalano et al., 1998; for a review, Olds et al., 1998)

Although these programs modify risk and protective factors for suicide,

they have not been evaluated specifically for suicide as an outcome in

adolescence or young adulthood.

The Surgeon General recently reviewed the effectiveness of violence

prevention programs (USPHS, 2001), providing a comprehensive list of

model programs (http://www.surgeongeneral.gov/library/youthviolence/report.html).

Safe Schools/Healthy Students, a collaborative effort of the U.S.

Departments of Education, Justice, and Health and Human Services is

currently funding 77 school-based violence prevention programs across

the U.S. that offer opportunities to examine aspects of suicidal behavior

in this population (http://www.samhsa.gov/centers/cmhs/cmhs.html).

Programs with the goals of promoting healthy development, fostering

resilience, and preventing violence and suicidal ideation and behavior

have been planned and implemented. Data collection is ongoing and

promises to yield important information about the effectiveness of the

application of evidence-based practices on a large scale.

While a school setting can be considered a focus for a type of community-based prevention, other prevention approaches have considered

geographic areas, such as neighborhoods. Preventive interventions for

these contexts include building community assets or "collective efficacy"

(Sampson, Raudenbush, & Earls, 1997). Again, whether increased collective efficacy is associated with lower suicidality has yet to be demonstrated. The U.S. Air Force approach to reducing suicide can also be considered a type of community-based intervention for adults in a work setting (see below). Additionally, some universal "policy" interventions suggest that broad-based environmental changes can have an impact on suicide rates (See the example under Individuals with Substance Use

Disorders).
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IMPROVING FOLLOW-UP TREATMENT FROM EMERGENCY DEPARTMENTS

Because the vast majority of persons do not seek follow-up treatment

after attempting suicide (Piacentini et al., 1995), one approach being taken

to reduce repeat attempts is to refer individuals to treatment after they

have been seen in the emergency department (ED). Since adolescents and

young adults are more likely to make nonfatal suicide attempts, a number

of studies have focused on these subgroups. One study compared standard care to an intervention in which emergency department staff were

taught to recognize the seriousness of suicide attempts, to reinforce the

importance of outpatient treatment and to provide for an ED-based initial

family education/therapy session. When compared to standard care, this

enhanced ED intervention was shown to increase treatment attendance

and decrease depression among adolescent Latino suicide attempters.

(Rotheram-Borus et al., 2000). However, the sample size was too small to

determine whether the intervention had an effect on the number of future

suicide attempts. Another study currently being conducted is testing the

effectiveness of a cognitive-behavioral therapy intervention implemented

immediately after patients have been evaluated in an ED following a suicide attempt (see grant by Aaron Beck; http://www.nimh.nih.gov/research/

suiabs.cfm). The targets of the intervention are modifiable risk factors such

as substance abuse, depression, hopelessness, and suicidal ideation, which

are addressed through problem-solving strategies, utilization of social support, and increasing compliance with adjunctive medical, substance abuse,

psychiatric and social interventions.

PRIMARY CARE INTERVENTIONS FOR DEPRESSED ELDERS

Multiple studies have found that elderly are much more likely to have

contact with primary care doctors than mental health specialists in the

weeks preceeding their death. Follow-back studies have also shown that

the most common psychiatric disorder among elderly persons who have

died by suicide is a single episode of non-psychotic, unipolar major depression without comorbid illness (Conwell et al., 2001). Because this is the

most treatable type of depression, a logical approach to prevention that

has been recommended is to improve the screening and treatment of
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depression conducted in primary care practices. Improvement could come

about with the addition of screening measures, assistants dedicated to the

treatment of depression and other mental health issues, or through better

prescribing practices. A controlled study, PROSPECT (Prevention of Suicide

in Primary Care Elderly Collaborative Trial), is currently testing the effectiveness of using Health Specialists (HS) to collaborate with physicians helping them recognize depression, offer timely and appropriately targeted

treatment recommendations, and encourage patients to adhere to treatment. In addition, procedures are implemented to educate patients, families and physicians on depression and suicidal ideation (Bruce & Pearson,

1999).

PRISON/JAIL SUICIDE

Suicide is one of the leading causes of death in our Nation's jails (Bureau

of Justice Statistics, 1995). However, very little research or evaluation has

been conducted on the success of suicide prevention programs implemented in jail or prison settings. Although no research directly supports

any particular prevention approach in jails, guidelines for suicide prevention in jails have been implemented in some settings. Often programs are

multidimensional in nature, recommending steps such as adequate mental

health treatment, staff training in suicide prevention, intake

screening/assessment, increasing communication in detention settings,

changes in housing practices, changes in level of supervision/observation,

direct intervention after suicide attempts, and adequate reporting and follow-up (Hayes, 1999). Some States have implemented State-wide jail suicide prevention programs. Of these, New York and Texas have seen drops

in the rate of jail suicide since the programs were implemented. The

American Correctional Association, the National Commission on

Correctional Health Care, the National Juvenile Detention Association, and

other national organizations have developed guidelines for suicide prevention. However, the effect of these guidelines has not been studied. In addition, Lindsay Hayes has created a comprehensive suicide prevention plan

for both adult and child detention facilities that has yet to be evaluated

(Hayes, 1999).
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SPECIAL POPULATIONS AT RISK 

AMERICAN INDIANS AND ALASKA NATIVES

As illustrated in Figure 4, American Indians and Alaska Natives (AIAN)

have a 50 percent higher rate of suicide than the general U.S. population,

with young males having the highest risk (Indian Health Service, 1997). The

most common risk factors for suicide among young male AIANs is alcohol

and substance use, and depression. However, there are dramatic differences in suicide rates across tribes. Many tribes, in partnership with the

Indian Health Service (IHS) and other government agencies, have designed

and implemented programs intended to address suicide prevention and

intervention for suicide and related problems (Middlebrook et al., 2001).

Prevention efforts include reducing risk behaviors (alcohol and substance

use) and promoting protective factors ( increasing employment opportunities and promoting positive and encouraging attitudes among adults

toward AIAN youth). Unfortunately, too few descriptions and analyses of

these efforts have been published, and little is known about their effectiveness (see Middlebrook et al., 2001 for a review).

GAY, LESBIAN, AND BISEXUAL YOUTH

Several State and national studies have reported that high school students who report same-sex sexual behavior or self-identify as gay, lesbian, or bisexual (GLB) have higher rates of suicidal thoughts and

attempts in the past year compared to youth who report exclusively heterosexual sexual behavior or self-identify as heterosexual in orientation

(McDaniel & Purcell, 2001). Experts do not agree completely about the

best way to measure reports of adolescent suicide attempts, or sexual

orientation, so the data are subject to question. But they do agree that

efforts should focus on how to help GLB youth grow up to be healthy

and successful despite the obstacles that they face. Because school-based

programs limited to suicide awareness have not proven effective for

youth in general, and in some cases have led youth to consider suicide as

a normal response to stress or have caused increased distress in vulnera-
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ble youth (Vieland et al., 1991), there is reason to belive that they may

not be helpful for GLB youth either. Issues of stigma, labeling, privacy,

and appropriateness of referrals for youth needing services must be considered to ensure that prevention programs for sexual minority populations are safe and effective.

INDIVIDUALS WITH BORDERLINE PERSONALITY DISORDER

Three to nine percent of those diagnosed with Borderline Personality

Disorder (BPD) commit suicide, a rate comparable to that for people diagnosed with mood disorders and schizophrenia (Tanney, 2000). Recurrent

suicide attempts, self-injury, and impulsive aggression are often associated with BPD and often result in expensive emergency and inpatient treatment. To date, approaches to the prevention of suicidal behavior among

individuals with BPD have focused on treatment to reduce self-injurious

behavior with and without intent to die, including certain types of psychotherapy and pharmacotherapy. One psychosocial treatment – dialectical behavior therapy (DBT), a cognitive-behavioral treatment – has been

shown to significantly decrease self-injurious behaviors in BPD (Koerner &

Linehan, 2000). Although DBT has become increasingly popular as the

treatment of choice for suicidal patients with BPD, no replication studies

have been done other than those conducted by the developer. One study

is evaluating DBT and pharmacological approaches aimed at reducing selfinjurious behavior in individuals with BPD (see grant by Barbara Stanley,

http://www.nimh.nih.gov/research/suiabs.cfm).

INDIVIDUALS WITH SCHIZOPHRENIA

The risk for suicide among individuals with schizophrenia is comparable to the risk for individuals with mood disorder, substance abuse, and

BPD. In individuals with schizophrenia, the risk is particularly heightened

during the early stages of the illness, and has been found to increase

soon after inpatient discharge (Caldwell & Gottesman, 1990; Fenton,

2000). This suggests that adequate aftercare treatments may reduce risk

during this phase of disease management. Other approaches to reducing

suicide risk among individuals with schizophrenia include investigations

of medications that target the key symptoms of the disorder. In industry
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sponsored treatment trials, one of the new atypical anti-psychotic medications was observed to have the possible effect of reducing suicidal

behavior in persons with schizophrenia. To confirm these findings, the

International Clozaril/Leponex Suicide Prevention Trial will compare clozapine and olanzapine in 900 patients with schizophrenia and a history of

suicidality (Meltzer, 1999). If these findings indicate that clozapine is

effective in reducing suicidality, the makers of the drug clozapine plan to

seek FDA approval for this use.

INDIVIDUALS WITH SUBSTANCE USE DISORDERS

Individuals with substance use disorders, including alcoholism, are at

increased risk for suicide. Follow-back studies of suicide decedents have

shown that 15-56 percent of individuals had diagnoses of alcoholism

and/or other substance use and dependence, a rate much higher than

that in the population (Murphy, 2000). Alcohol and substance abuse

problems contribute to suicidal behavior in several ways. In addition to

increasing the risk of suicide directly through lowered inhibitions, people

who abuse substances or alcohol also tend to have other risk factors such

as depression and social and financial problems. Substance use and

abuse are also common among persons prone to be impulsive, and

among persons who engage in many types of high risk behaviors that

result in self-harm. Fortunately, there are a number of effective prevention efforts that reduce risk for substance abuse in youth, and there are

effective treatments for alcohol and substance use problems. While a

number of treatments have been found to be effective for the treatment

of substance abuse (National Institutes of Drug Abuse, 1999;

http://www.nida.nih.gov/podat/podatindex.html) and alcoholism

(National Institute on Alcohol Abuse and Alcoholism, 2000;

http://silk.nih.gov/silk/niaaa1/publication/aa49.htm), few have measured

concurrent effects of treatment on rates of suicide or suicide attempts.

Currently, some studies are looking at suicidal behavior among individuals who are abusing substances and are trying to treat substance use,

abuse and dependence along with other comorbid psychiatric problems,

as well as dealing with stressful life events (see Emergency Departments
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above). Some alcohol policies may be effective in reducing suicide

deaths. For example, an assessment of minimum legal drinking age

(MLDA) found that between 1970 and 1990, the suicide rate of 18- to

20-year-old youths living in States with an 18-year MLDA was 8 percent

higher than the suicide rate among 18- to 20-year-old youths in States

with a 21-year MLDA (Birckmayer & Hemenway, 1999).

INDIVIDUALS WITH MOOD DISORDERS

Mood disorders are very common among individuals who commit suicide, with 36-70 percent of individuals having a mood disorder at the

time of death (Barraclough et al. 1974; Foster et al., 1999; Henriksson et

al., 1993; Rich, Young, & Fowler, 1986). A number of long-term followup studies of individuals with bipolar disorder found that those who

remain on lithium maintenance treatment have a lower risk of suicide

than individuals who do not remain in treatment or are non-responsive

to lithium (Jamison, 2000). A study in progress is testing whether lithium

can prevent suicide attempts among individuals with bipolar disorder

who have previously attempted suicide (see grant by Maria Oquendo,

http://www.nimh.nih.gov/research/suiabs.cfm). The large, multisite

Systematic Treatment Enhancement Program for Bipolar Disorder (STEPBD) study will track the frequency of suicidal behavior and treatment

approaches used to minimize suicidal behavior (http://www.stepbd.org/).

Suicide prevention approaches in STEP-BD focus on reducing inclination

and minimizing opportunity through medication, psychosocial, and environmental interventions.

With regard to individuals with major depression, retrospective data

indicate that many who are at risk for suicide often receive inadequate

treatment (Oquendo et al., 1999). The Swedish Island of Gotland study

is an uncontrolled study that has inspired efforts to increase primary care

providers' abilities to detect and treat depression, and in turn reduce suicide (Rutz et al., 1989). An educational program for all general practitioners on the island to improve recognition and treatment for depression, the program was associated with more appropriate antidepressant
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medication prescriptions and fewer inpatient hospitalizations of

depressed individuals. The island had fewer adult female suicides in the

several years following the intervention (Rutz, 2001). While these results

suggest that some suicide deaths may be prevented through improving

the diagnosis and ongoing treatment of depression, possibly through the

education of providers and the public about depression treatment, controlled studies are needed to determine the effectiveness of these

approaches to reduce suicide, particularly among males.

POPULATIONS THAT NEED FURTHER ATTENTION

White males aged 24-55 constitute the greatest numbers of suicide

deaths in the U.S., yet this subgroup of individuals is the least likely to have

sought mental health treatment prior to death (Pirkis & Burgess, 1998).

Currently there are almost no prevention approaches aimed specifically at

preventing suicide among males who do not seek mental health treatment. One approach which shows promise is the prevention strategy used

by the Air Force (Centers for Disease Control and Prevention, 1999;

http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4846a1.htm). This

strategy is a multi-faceted approach to suicide prevention that intervened

at a community-wide level. Interventions included widespread and repeated suicide awareness and prevention training, gatekeeper training, screening questionnaires, changes in mental health confidentiality policy, and

messages from the Air Force Chief of Staff to change community attitudes

about seeking and providing help. Surveillance results suggest that the prevention program has been effective in reducing suicide among Air Force

personnel, in both majority and minority populations. Because this effort

was not experimentally controlled, however, it is not known if certain

aspects, or all approaches combined, were effective. Nevertheless, this

intervention demonstrates the potential for suicide prevention among late

adolescent and adult males in the U.S. through a combination of universal

and targeted interventions.
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SUMMARY AND FUTURE PROSPECTS

Rates of suicide and suicidal behavior and their risk factors vary across

age, gender and ethnic groups. The broad array of prevention strategies

described in this appendix reflect the variation in risk factors for different

subgroups, as well as the different types of disorders where suicide risk

is increased. Testing interventions in different settings are ways to study

these diverse risk groups. While the broad range of prevention

approaches may seem unsystematic, at the same time it suggests many

opportunities for individuals, organizations, and communities to consider who is at most risk for suicide and what are the strategies consistent

with our understanding of protective and risk factors to reduce suicide in

their communities.

If the costs of this behavior are so great, why is there so little information about what is effective in preventing suicide, suicidal behavior,

and suicidal thinking? One reason for the limited number of tested programs is concern among some researchers and academic institutions

about possible increased liability when conducting research with individuals at risk for suicide. Many researchers prefer to study problems that

do not carry such legal and ethical responsibilities. Efforts are underway

to increase the number of federally supported research efforts in this

area by providing researchers with guidance and tools to design safe and

ethical studies to test approaches to reducing suicidal behaviors (see

http://www.nimh.nih.gov/research/highrisksuicide.cfm). In addition, suicide deaths, and even suicidal behaviors, are relatively rare events, making it difficult for researchers to determine if a prevention program was

effective, unless administered to a very large population over multiple

years. Thus, suicide prevention research requires large numbers of participants and can be very expensive. Nevertheless, because "suicide prevention is everyone's business," communities and organizations can learn

more about persons at risk for suicide, consider the financial and social

costs of suicide and its risk factors, and work to implement and evaluate

prevention efforts appropriate for their communities.
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APPENDIX D

NSSP FEDERAL STEERING GROUP AGENCY DESCRIPTIONS

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

The Department of Health and Human Services (DHHS) is the U.S. government's principal agency for protecting the health of all Americans and

providing essential human services, especially for those who are least

able to help themselves. DHHS has 12 operating divisions as well as a

number of specialized offices, centers and programs. Among these specialized offices are the 10 DHHS Regional Offices dispersed throughout

the U.S. Each Regional Office has a Regional Director, Regional Health

Administrator and other HHS components. These offices play a critical

role in implementing HHS initiatives, coordinating intra- and inter-agency

activities serving as the liaison for the Secretary and agency heads with

key constituencies. Through these offices close contact is maintained

with State, local, and tribal entities served through HHS programs and

policies.

HHS' responsibilities include public health, biomedical research,

Medicare and Medicaid, welfare, social services, and more. Several of

them conduct and support important work in suicide prevention. These

have provided important leadership and effort in the development of this

National Strategy for Suicide Prevention : Goals and Objectives for

Action and have been part of the National Strategy for Suicide

Prevention Federal Steering Group (FSG) (see Acknowledgments).

A brief description of each of these agencies follows.
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Contact information:

The U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Washington, D.C. 20201

202-619-0257

Toll Free: 1-877-696-6775

e-mail: hhsmail@os.dhhs.gov

Web address: http://www.hhs.gov
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OFFICE OF THE SURGEON GENERAL

Mission: To protect and advance the health of the nation through educating the public and advocating for effective disease prevention and

health promotion activities.

The Surgeon General is a highly recognized symbol of national commitment to protecting and improving the public's health. Administering

a force of 6,000 U.S. Public Health Service Commissioned Corps officers,

the Surgeon General provides leadership in promoting the quality of

public health practice through advancement of appropriate standards

and research priorities.

Suicide prevention activities of the Office of the Surgeon General

include publication of The Surgeon General's Call to Action to Prevent

Suicide (DHHS, 1999) and Mental Health: A Report of the Surgeon

General (DHHS, 1999).

For Additional Information:

Surgeon General

Web address: http://www.surgeongeneral.gov
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CENTERS FOR DISEASE CONTROL AND PREVENTION

Mission: To promote health and quality of life by preventing and controlling disease, injury, and disability.

The Centers for Disease Control and Prevention (CDC) provides a system

of health surveillance to monitor and prevent outbreak of diseases, maintains national health statistics, and supports research into disease and

injury prevention. Through its centers, institutes and offices, the CDC works

with partners throughout the nation and the world to monitor health,

detect and investigate health problems, develop and advocate sound public health policies, implement prevention strategies, promote healthy

behaviors, foster safe and healthful environments, and provide leadership

and training.

Suicide prevention activities of CDC include efforts in the National Center

for Health Statistics, National Center for Chronic Disease Prevention and

Health Promotion, Division of Adolescent and School Health, and National

Center for Injury Prevention and Control. CDC maintains national data on

suicides, Youth Risk Behavior Survey, and publishes reports on self-directed

injury at all levels. Additional examples of CDC activities include promoting

collaborations in specific communities for suicide prevention and conducting research on suicidal behavior and program evaluation.

For Additional information:

Centers for Disease Control and Prevention

Web address: http://www.cdc.gov

http://www.cdc.gov.ncipc

http://www.safeyouth.org
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HEALTH RESOURCES AND SERVICES ADMINISTRATION

Mission: To improve the Nation's health by assuring equitable access to

comprehensive quality health care for all.

The Health Resources and Services Administration (HRSA) through the

activities of its four bureaus and three offices, helps to ensure health

resources for medically underserved populations. HRSA works to improve

and extend life for people living with HIV/AIDS, provide primary health

care to medically underserved people, improve health outcomes for

women and children through State programs, and train a health workforce that is both diverse and motivated to work in underserved communities.

Suicide prevention activities of HRSA include programs and activities in

the Bureau of Primary Health Care, HIV Aids Bureau, Maternal and Child

Health Bureau, and Office of Rural Health Policy. HRSA programs promote integration of primary care and mental health services; develop and

implement State suicide prevention plans and programs; ensure access to

appropriate screening and services for depression through grants, contracts, technical assistance, and conference sponsorship. Through funding from the Maternal and Child Health Bureau, the Children's Safety

Network has developed a Youth Suicide Prevention Fact Sheet packet

(http://www.edc.org/HHD/csn).

For additional information:

Health Resources and Services Administration

Web address: http://www.hrsa.gov
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INDIAN HEALTH SERVICE

Mission: To uphold the Federal government's obligation to promote

healthy American Indian and Alaska Native people, communities, and

cultures and to honor and protect the inherent sovereign rights of tribes.

The Indian Health Service (IHS) is the principal Federal health care

provider and health advocate for Indian people, and its goal is to assure

that comprehensive, culturally acceptable personal and public health

services are available and accessible to American Indian and Alaska

Native people. IHS supports network hospitals, health centers, school

health centers, health stations, and urban Indian health centers.

Suicide prevention activities of IHS include consultation and technical

assistance for tribes related to suicide prevention through 12 Area

Offices. Additionally IHS operates 12 regional alcohol and substance

abuse treatment centers for youth 12-18 years of age which includes

careful assessment of suicidal ideation and suicide prevention education.

For additional information:

Indian Health Service

Web address: http://www.ihs.gov
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NATIONAL INSTITUTES OF HEALTH

Mission: To uncover new knowledge that will lead to better health for

everyone.

The National Institutes of Health (NIH) comprises 25 separate institutes

and centers that conduct and support research to acquire new knowledge

to help prevent, detect, diagnose, and treat disease and disability, from the

rarest genetic disorder to the common cold. As the world's premier medical research organization, these institutes and centers support 35,000

research projects nationwide. Among several institutes that address suicide

(National Institutes of Drug Abuse (NIDA), Child Health and Human

Development (NICHD), and Alcohol Abuse and Alchoholism (NIAAA)), the

National Institute of Mental Health (NIMH) supports the greatest proportion of research related to suicide. NIMH aims to diminish the burden of

mental illness through achieving better understanding, treatment, and prevention of mental illness.

Suicide prevention activities of the NIMH include fundamental research

in neuroscience, behavioral science, and genetics of mental illnesses and

suicidal behavior, as well as research that directly impacts the treatment of

individuals with mental disorders and those at high risk for suicidal behavior, including clinical trials and studies of treatment and preventive interventions in "real world" settings. The NIMH Suicide Research Consortium

maintains a web site that includes suicide facts, currently funded studies,

active NIMH program announcements pertaining to suicide research, a bibliography, reviews of measures of suicidality, and ethical and safety issues

to consider in conducting research with persons at high risk for suicidality.
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For additional Information:

National Institutes of Health

Web address: http://www.nih.gov

National Institute of Mental Health Suicide Research Consortium

Web address: http://www.nimh.nih.gov/research/suicide.htm
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SUBSTANCE ABUSE AND MENTAL HEALTH 

SERVICES ADMINISTRATION

Mission: To improve the quality and availability of prevention, treatment, and rehabilitative services in order to reduce illness, death, disability, and cost to society resulting from substance abuse and mental illnesses.

The Substance Abuse and Mental Health Services Administration

(SAMHSA) provides funding to the States to support and maintain substance abuse and mental health services through Federal block grants.

SAMHSA funds hundreds of programs nationwide to increase the use

and improve prevention and treatment methods shown by research to be

effective through "Knowledge Development and Application" grants.

SAMHSA is comprised of three Centers of which one is the Center for

Mental Health Services (CMHS). CMHS focuses on providing leadership in

the delivery of mental health services, generating and applying new

knowledge, and establishing national mental health policy. The majority

of activities directly related to suicide prevention are initiated by CMHS.

Suicide prevention activities of CMHS center on initiating national

grant programs to implement and evaluate suicide prevention activities.

CMHS is involved in developing suicide prevention guidelines for use in

our Nation's schools as well as supporting efforts to identify, through inschool assessment, those children at greatest risk of suicide. In addition,

SAMHSA sponsors conferences, workshops and meetings to further

national goals for suicide prevention.

For additional information:

Substance Abuse and Mental Health Services Administration

Web address: http://www.samhsa.gov
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Center for Mental Health Services

Web address: http://www.samhsa.gov/centers/cmhs/cmhs.html

Federal Agency Liaisons to the NSSP Federal Steering Group

Department of Agriculture

Alma C. Hobbs, Ph.D.

Department of Defense

Elspeth Cameron Ritchie, M.D.

Department of Education

Bill Modzeleski

Department of Interior

Larry Blair

Department of Justice

Federal Bureau of Investigations

Unit Chief, Employee Assistance Program

Federal Bureau of Prisons

Vicki Verdeyen, Ph.D.

Department of Labor

Cate Sutter, J.D., L.L.M.

Department of Veterans Affairs

Larry Lehmann, M.D.

National Science Foundation

Patricia White, Ph.D.

Office of National Drug Control Policy

Darlind Davis

National Highway Traffic Safety Administration

Steve Wood, Rulemaking Attorney

Administration on Aging

Holly Schumann
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APPENDIX E

GLOSSARY

Activities – the specific steps that will be undertaken in the implementation of a plan; activities specify the manner in which objectives

and goals will be met.

Adolescence – the period of physical and psychological development

from the onset of puberty to maturity.

Advocacy groups – organizations that work in a variety of ways to

foster change with respect to a societal issue.

Affective disorders – see mood disorders.

Anxiety disorder – an unpleasant feeling of fear or apprehension

accompanied by increased physiological arousal, defined according

to clinically derived standard psychiatric diagnostic criteria.

Best practices – activities or programs that are in keeping with the

best available evidence regarding what is effective.

Biopsychosocial approach – an approach to suicide prevention that

focuses on those biological, psychological and social factors that may

be causes, correlates, and/or consequences of mental health or mental illness and that may affect suicidal behavior.

Bipolar disorder – a mood disorder characterized by the presence or

history of manic episodes, usually, but not necessarily, alternating

with depressive episodes.

Causal factor – a condition that alone is sufficient to produce a disorder.

Cognitive/cognition – the general ability to organize, process, and

recall information.
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Community – a group of people residing in the same locality or sharing a common interest.

Comprehensive suicide prevention plans – plans that use a multifaceted approach to addressing the problem; for example, including

interventions targeting biopsychosocial, social and environmental

factors.

Comorbidity – the co-occurrence of two or more disorders, such as

depressive disorder with substance abuse disorder.

Connectedness – closeness to an individual, group or people within

a specific organization; perceived caring by others; satisfaction with

relationship to others, or feeling loved and wanted by others.

Consumer – a person using or having used a health service.

Contagion – a phenomenon whereby susceptible persons are influenced towards suicidal behavior through knowledge of another person's suicidal acts.

Culturally appropriate – a set of values, behaviors, attitudes, and

practices reflected in the work of an organization or program that

enables it to be effective across cultures; includes the ability of the

program to honor and respect the beliefs, language, interpersonal

styles, and behaviors of individuals and families receiving services.

Culture – the integrated pattern of human behavior that includes

thoughts, communication, actions, customs, beliefs, values, and institutions of a racial, ethnic, faith or social group.

Depression – a constellation of emotional, cognitive and somatic

signs and symptoms, including sustained sad mood or lack of pleasure.

Effective – prevention programs that have been scientifically evaluated and shown to decrease an adverse outcome or increase a beneficial one in the target group more than in a comparison group.

Elderly – persons aged 65 or more years.
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Environmental approach – an approach that attempts to influence

either the physical environment (such as reducing access to lethal

means) or the social environment (such as providing work or academic opportunities).

Epidemiology – the study of statistics and trends in health and disease across communities.

Evaluation – the systematic investigation of the value and impact of

an intervention or program.

Evidence-based – programs that have undergone scientific evaluation and have proven to be effective.

Follow-back study – the collection of detailed information about a

deceased individual from a person familiar with the decedent's life

history or by other existing records. The information collected supplements that individual's death certificate and details his or her circumstances, the immediate antecedents of the suicide, and other

important but less immediate antecedents.

Frequency – the number of occurrences of a disease or injury in a

given unit of time; with respect to suicide, frequency applies only to

suicidal behaviors which can repeat over time.

Gatekeepers – those individuals in a community who have face-toface contact with large numbers of community members as part of

their usual routine; they may be trained to identify persons at risk of

suicide and refer them to treatment or supporting services as appropriate.

Goal – 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.

Health – the complete state of physical, mental, and social wellbeing, not merely the absence of disease or infirmity.

Health and safety officials – law enforcement officers, fire fighters,

emergency medical technicians (EMTs), and outreach workers in

community health programs.
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Healthy People 2010 – the national prevention initiative that identifies opportunities to improve the health of all Americans, with specific and measurable objectives to be met by 2010.

Indicated prevention intervention – intervention designed for individuals at high risk for a condition or disorder or for those who have

already exhibited the condition or disorder.

Intentional – injuries resulting from purposeful human action

whether directed at oneself (self-directed) or others (assaultive),

sometimes referred to as violent injuries.

Intervention – a strategy or approach that is intended to prevent an

outcome or to alter the course of an existing condition (such as providing lithium for bipolar disorder or strengthening social support in

a community).

Means – the instrument or object whereby a self-destructive act is

carried out (i.e., firearm, poison, medication).

Means restriction – techniques, policies, and procedures designed to

reduce access or availability to means and methods of deliberate selfharm.

Methods – actions or techniques which result in an individual inflicting self-harm (i.e., asphyxiation, overdose, jumping).

Mental disorder – a diagnosable illness characterized by alterations

in thinking, mood, or behavior (or some combination thereof) associated with distress that significantly interferes with an individual's

cognitive, emotional or social abilities; often used interchangeably

with mental illness.

Mental health – the capacity of individuals to interact with one

another and the environment in ways that promote subjective wellbeing, optimal development and use of mental abilities (cognitive,

affective and relational).
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Mental health problem – diminished cognitive, social or emotional

abilities but not to the extent that the criteria for a mental disorder

are met.

Mental health services – health services that are specially designed

for the care and treatment of people with mental health problems,

including mental illness; includes hospital and other 24-hour services,

intensive community services, ambulatory or outpatient services,

medical management, case management, intensive psychosocial

rehabilitation services, and other intensive outreach approaches to

the care of individuals with severe disorders.

Mental illness – see mental disorder.

Mood disorders – a term used to describe all mental disorders that

are characterized by a prominent or persistent mood disturbance;

disturbances can be in the direction of elevated expansive emotional

states, or, if in the opposite direction, depressed emotional states;

included are Depressive Disorders, Bipolar Disorders, mood disorders

due to a medical condition, and substance-induced mood disorders.

Morbidity – the relative frequency of illness or injury, or the illness or

injury rate, in a community or population.

Mortality – the relative frequency of death, or the death rate, in a

community or population.

Objective – a specific and measurable statement that clearly identifies what is to be achieved in a plan; it narrows a goal by specifying

who, what, when and where or clarifies by how much, how many, or

how often.

Outcome – a measurable change in the health of an individual or

group of people that is attributable to an intervention.

Outreach programs – programs that send staff into communities to

deliver services or recruit participants.
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Personality disorders – a class of mental disorders characterized by

deeply ingrained, often inflexible, maladaptive patterns of relating,

perceiving, and thinking of sufficient severity to cause either impairment in functioning or distress.

Postvention – a strategy or approach that is implemented after a crisis or traumatic event has occurred.

Prevention – a strategy or approach that reduces the likelihood of

risk of onset, or delays the onset of adverse health problems or

reduces the harm resulting from conditions or behaviors.

Protective factors – factors that make it less likely that individuals

will develop a disorder; protective factors may encompass biological,

psychological or social factors in the individual, family and environment.

Psychiatric disorder – see mental disorder.

Psychiatry – the medical science that deals with the origin, diagnosis, prevention, and treatment of mental disorders.

Psychology – the science concerned with the individual behavior of

humans, including mental and physiological processes related to

behavior.

Public information campaigns – large scale efforts designed to provide facts to the general public through various media such as radio,

television, advertisements, newspapers, magazines, and billboards.

Rate – the number per unit of the population with a particular characteristic, for a given unit of time.

Residency programs – postgraduate clinical training programs in

special subject areas, such as medicine.

Resilience – capacities within a person that promote positive outcomes, such as mental health and well-being, and provide protection

from factors that might otherwise place that person at risk for

adverse health outcomes.
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Risk factors – those factors that make it more likely that individuals

will develop a disorder; risk factors may encompass biological, psychological or social factors in the individual, family and environment.

Screening – administration of an assessment tool to identify persons

in need of more in-depth evaluation or treatment.

Screening tools – those instruments and techniques (questionnaires,

check lists, self-assessments forms) used to evaluate individuals for

increased risk of certain health problems.

Selective prevention intervention – intervention targeted to subgroups of the population whose risk of developing a health problem

is significantly higher than average.

Self-harm – the various methods by which individuals injure themselves, such as self-laceration, self-battering, taking overdoses or

exhibiting deliberate recklessness.

Self-injury – see self-harm.

Sociocultural approach – an approach to suicide prevention that

attempts to affect the society at large, or particular subcultures within it, to reduce the likelihood of suicide (such as adult-youth mentoring programs designed to improve the well-being of youth).

Social services – organized efforts to advance human welfare, such

as home-delivered meal programs, support groups, and community

recreation projects.

Social support – assistance that may include companionship, emotional backing, cognitive guidance, material aid and special services.

Specialty treatment centers (e.g., mental health/substance

abuse) – health facilities where the personnel and resources focus on

specific aspects of psychological or behavioral well-being.

Stakeholders – entities, including organizations, groups and individuals, that are affected by and contribute to decisions, consultations

and policies.
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Stigma – an object, idea, or label associated with disgrace or

reproach.

Substance abuse – a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to

repeated use; includes maladaptive use of legal substances such as

alcohol; prescription drugs such as analgesics, sedatives, tranquilizers, and stimulants; and illicit drugs such as marijuana, cocaine,

inhalants, hallucinogens and heroin.

Suicidal act (also referred to as suicide attempt) – a potentially

self-injurious behavior for which there is evidence that the person

probably intended to kill himself or herself; a suicidal act may result

in death, injuries, or no injuries.

Suicidal behavior – a spectrum of activities related to thoughts and

behaviors that include suicidal thinking, suicide attempts, and completed suicide.

Suicidal ideation – self-reported thoughts of engaging in suiciderelated behavior.

Suicidality – a term that encompasses suicidal thoughts, ideation,

plans, suicide attempts, and completed suicide.

Suicide – death from injury, poisoning, or suffocation where there is

evidence that a self-inflicted act led to the person's death.

Suicide attempt – a potentially self-injurious behavior with a nonfatal outcome, for which there is evidence that the person intended to

kill himself or herself; a suicide attempt may or may not result in

injuries.

Suicide attempt survivors – individuals who have survived a prior

suicide attempt.

Suicide survivors – family members, significant others, or acquaintances who have experienced the loss of a loved one due to suicide;

sometimes this term is also used to mean suicide attempt survivors.
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Surveillance – the ongoing, systematic collection, analysis and interpretation of health data with timely dissemination of findings.

Unintentional – term used for an injury that is unplanned; in many

settings these are termed accidental injuries.

Universal preventive intervention – intervention targeted to a

defined population, regardless of risk; (this could be an entire school,

for example, and not the general population per se).

Utilization management guidelines – policies and procedures that

are designed to ensure efficient and effective delivery (utilization) of

services in an organization.