2012 National Strategy for Suicide Prevention: 

GOALS AND OBJECTIVES FOR ACTION 

A report of the U.S. Surgeon General 

and of the National Action Alliance for Suicide Prevention 
September 2012 

Acknowledgements 

The development of this document was supported by the United States Department of Health 
 

and Human Services (HHS), Substance Abuse and Mental Health Services Administration 
 

(SAMHSA), through Grant No. SMO59945 to Educational Development Center, Inc., for the 
 

Suicide Prevention Resource Center. Design and review were supported by Gallup, under Contract 
 

No. HHS28300001T/HHS2832007000231, Ref No. 283-07-2301, SAMHSA, HHS.



Public Domain Notice 

All material appearing in this publication is in the public domain and may be 

reproduced or copied without permission. Citation of the source is appreciated. 

Electronic Access 

This publication may be downloaded or ordered at 

www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/index.html 

or 

www.actionallianceforsuicideprevention.org/NSSP 

or 

www.samhsa.gov/nssp 

Suggested Citation 

U.S. Department of Health and Human Services (HHS) Office of the Surgeon General 

and National Action Alliance for Suicide Prevention. 2012 National Strategy for Suicide 

Prevention: Goals and Objectives for Action. Washington, DC: HHS, September 2012. 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Preface from the Surgeon General 

As U.S. Surgeon General and co-lead of the National Strategy for Suicide Prevention Task Force, I am 

honored to present the 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. 

A little more than 10 years ago, one of my predecessors, Surgeon General David Satcher, issued the first 

National Strategy for Suicide Prevention. This document was a landmark that helped launch an organized 

effort to prevent suicide across the nation. But a great deal has changed since that document was issued in 

2001, and so I am proud to follow in Dr. Satcher’s footsteps and release this updated strategy to help guide 

and galvanize us all to address the tragedy and the burden of suicide. 

The strategy-revision process was initiated and overseen by the National Action Alliance for Suicide 

Prevention, of which I am honored to be a member and to which I am particularly grateful. This 

innovative public-private partnership represents a new approach to enlisting all Americans in the fight to 

prevent suicide. Its multisectoral nature has great promise to really move us forward in this effort. 

Suicide is a problem that touches the lives of many Americans. Many of us know a friend or a loved one 

who has attempted or died from suicide. Perhaps we have considered or attempted suicide ourselves. 

Some of us may have been affected as a result of a suicide in our community, school, workplace, or place 

of worship. 

Despite these very personal experiences, most Americans are surprised to learn that between 2001 and 

2009, an average of 33,000 suicide deaths occurred each year in the United States. Suicide is among the top 

five causes of death for adults under age 45 in the United States, and in 2009, more Americans died from 

suicide than from motor vehicle traffic-related injuries. 

Those who die by suicide are far from the only ones affected by this tragedy. Suicide exacts a heavy toll on 

those left behind as well. Loved ones, friends, classmates, neighbors, teachers, faith leaders, and colleagues 

all feel the effect of these deaths. Sadly, these deaths are just one measure of the challenge we face. For 

every American who dies by suicide, many others attempt suicide, and many more suffer the despair that 

leads them to consider taking their own life. Fortunately, it doesn’t have to be this way. There is much we 

can do, and the strategy that follows provides ways each of us can do our part. 

The effect of suicide on communities across our nation goes beyond the personal. Suicide affects some of 

the most important concerns of our time. Suicide among those who serve in our Armed Forces and among 

our veterans has been a matter of national concern. The largest number of suicidal deaths each year occurs 

among middle-aged men and women, sapping the workforce we need to grow our economy. The fact that 

suicidal behavior occurs among some of our most marginalized citizens is a call to action we must embrace. 

Reducing the number of suicides requires the engagement and commitment of people in many sectors 

in and outside of government, including public health, mental health, health care, the Armed Forces, 

business, entertainment, media, and education. This update of the strategy drew on suicide prevention 

experts from all these sectors, and I want to express my thanks to those who contributed to this document. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

As the Surgeon General, I want to help make Americans aware of the heavy burden suicide imposes on our 

nation, and more importantly, do everything I can to help reduce the toll that suicide takes on America. 

That is what this document is all about. 

No matter where we live or what we do every day, each of us has a role in preventing suicide. Our actions 

can make a difference. While a document alone will not prevent a single suicide, I hope that this document 

will help spur and leverage all of our actions so we can make real progress now in preventing suicide. We 

have no time to waste. 

Regina M. Benjamin, MD, MBA 

VADM, U.S. Public Health Service 

Surgeon General
 


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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

From the National Council for Suicide Prevention 

As the member organizations of the National Council for Suicide Prevention (NCSP), we are pleased to 

offer our support for the updated National Strategy for Suicide Prevention. We believe it will focus suicide 

prevention in our nation now and in the years ahead. 

As a council composed of the leading national not-for-profit organizations dedicated to suicide prevention 

and to supporting survivors of suicide loss, we are grateful for the efforts to ensure that the new National 

Strategy was thoughtful, comprehensive, and included clear goals for reducing the incidence of suicide in 

America. We commend all those involved, specifically the National Strategy for Suicide Prevention Task 

Force, for carrying forward the excellent work started by former Surgeon General David Satcher and for 

leading this initiative to update and revise the National Strategy for Suicide Prevention. 

Revising the National Strategy was no small task. It required the collective wisdom, expertise, and input 

from researchers and scientists, clinicians and health experts, those who have attempted suicide, and 

those who are bereaved by suicide, as well as many other stakeholders. It required input from multiple 

sectors—public, private, and nonprofit—as well as time and money. Ultimately, it required making difficult 

but important decisions regarding priorities for the future. We thank you for doing all of this, especially in 

light of the current economic climate. 

The members of the NCSP are grateful for the opportunity to have served as advisors in the development 

of this document. After a decade of advancements in suicide prevention, we remain concerned that the 

nation is still in a period of rising suicide rates. Therefore, we believe that the timing for a revised National 

Strategy is right and that it offers an improved framework for achieving our ultimate goal of saving lives. 

We also believe that the new National Strategy reflects the history of what we have learned about suicide 

prevention and advances our understanding of best approaches to reducing the incidence of suicide. 

Further, it will serve as a template for states, tribes, local communities, and public and private entities as 

they work to prevent suicide. 

The NCSP stands ready to join our partners in the public and private sectors to fully implement the revised 

National Strategy. Through the collective expertise of the NCSP member organizations and through our 

willingness to collaborate with others, we remain dedicated to working aggressively to prevent further loss 

of life from suicide and to the improved health of all our citizens. 

Respectfully submitted, 

Alan L. Berman, Ph.D.	 	 Dale Emme Donna Holland Barnes, Ph.D. 

American Association of Suicidology	 	 Yellow Ribbon Suicide National Organization for People of 

Prevention Program Color Against Suicide Alan Ross 

Samaritans USA Daniel J. Reidenberg, Psy.D. Phillip Satow 

Suicide Awareness Voices The Jed Foundation Clark Flatt 

of Education The Jason Foundation	 	 Robert Gebbia 

American Foundation for 

Suicide Prevention 

PAGE 5 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

From the National Action Alliance for Suicide Prevention 

As co-chairs of the National Action Alliance for Suicide Prevention (Action Alliance), we are honored to 

present this revised version of the National Strategy for Suicide Prevention. 

This strategy recognizes that suicide is a complicated issue that requires equally complex solutions. 

Effective solutions need to incorporate multiple approaches at multiple levels. Effective prevention 

programs and policies stress the importance of wellness, resiliency, and protective factors; effective suicide 

response and intervention programs address risk factors, mental health and substance abuse services, and 

crisis response for those who are struggling with suicidal behaviors; and effective support programs are 

required for those who have been touched by suicide or suicidal behavior. 

We believe that suicide is preventable when the right resources and services are in place. We also recognize 

that there is a lot of work to do to ensure that those who are most in need receive the services and support 

they require. It is our hope that this strategy will continue to guide suicide prevention efforts and save lives 

in communities across the United States. 

The original National Strategy for Suicide Prevention called for the establishment of a public-private 

partnership to help guide the implementation of the goals and objectives recommended in the National 

Strategy. Launched in September 2010 by Health and Human Services Secretary Kathleen Sebelius 

and Defense Secretary Robert Gates, the Action Alliance is that partnership. The Action Alliance was 

established with a clear mission: to advance the National Strategy for Suicide Prevention by championing 

suicide prevention as a national priority, catalyzing efforts to implement high-priority objectives of the 

National Strategy, and cultivating the resources needed to sustain progress. 

This report is the culmination of the efforts of the Action Alliance’s National Strategy Revision Task Force, 

co-led by Surgeon General Regina Benjamin and Jerry Reed, Director of the Suicide Prevention Resource 

Center. It represents the voice and input of countless individuals from across the country who provided 

thoughtful comments and feedback throughout the revision process. 

The Action Alliance is committed to advancing the National Strategy for Suicide Prevention. We will 

continue to identify and advance high-priority objectives of the National Strategy that require leverage and 

coordination at the national level. 

Thank you for your dedication to preventing suicide. 

The Honorable John M. McHugh 

Secretary of the Army	 	

Public Sector Co-Chair	 	

The Honorable Gordon H. Smith 

President and CEO 

National Association of Broadcasters 

Private Sector Co-Chair 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

National Strategy for Suicide Prevention Task Force 

Co-Leads 

Regina Benjamin, M.D., M.B.A. 

Surgeon General, Vice Admiral 

U.S. Public Health Service 

U.S. Department of Health and Human Services 

Public Sector Co-Lead 

Task Force Members 

Carl Bell, M.D. 

President and CEO 

Community Mental Health Council 

Director 

Institute for Juvenile Research 

Department of Psychiatry, School of Medicine 

University of Illinois at Chicago 

Derek Blumke 

Cofounder and Former President 

Student Veterans of America 

Brian Boon, Ph.D. 

President and CEO 

Commission on Accreditation of Rehabilitation Facili ties 

Michael Botticelli, M.Ed. 

Director 

Bureau of Substance Abuse Services 

Massachusetts Department of Public Health 

Eric Caine, M.D. 

Chair 

Department of Psychiatry 

University of Rochester Medical Center 

Brian Dyak 

President and CEO 

Entertainment Industries Council, Inc. 

James M. Galloway, M.D., F.A.C.P., F.A.C.C. 

Assistant U.S. Surgeon General, USPHS 

Regional Health Administrator 

U.S. Department of Health and Human Services 

Michael Hogan, Ph.D. 

Commissioner 

New York State Office of Mental Health 

Jerry Reed, Ph.D., M.S.W. 

Vice President and Director 

Suicide Prevention Resource Center 

Education Development Center, Inc. 

Private Sector Co-Lead 

John (Jack) R. Jordan, Ph.D. 

Founder and Director 

Family Loss Project 

Ira Katz, M.D., Ph.D. 

Senior Consultant 

U.S. Department of Veterans Affairs 

Melvin A. Kohn, M.D., M.P.H. 

Director and State Health Officer 

Oregon Public Health Division 

Oregon Health Authority 

Richard McKeon, Ph.D., M.P.H. 

Chief, Suicide Prevention Branch 

Substance Abuse and Mental Health 

Services Administration 

U.S. Department of Health and Human Services 

Richard Ramsay, M.S.W., R.S.W. 

Professor Emeritus of Social Work 

University of Calgary, Canada 

Daniel J. Reidenberg, Psy.D., F.A.P.A. 

Executive Director 

Suicide Awareness Voices of Education 

Scott Ridgway, M.S. 

Executive Director 

Tennessee Suicide Prevention Network 

Morton Silverman, M.D. 

Senior Medical Advisor 

Suicide Prevention Resource Center 

Eduardo Vega, M.A. 

Executive Director 

Mental Health Association of San Francisco 

PAGE 7 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


Dedication 

To those who have lost their lives by suicide,
 


To those who struggle with thoughts of suicide,
 


To those who have made an attempt on their lives,
 


To those caring for someone who struggles,
 


To those left behind after a death by suicide,
 


To those in recovery, and
 


To all those who work tirelessly to prevent suicide and suicide attempts in our nation.
 


We believe that we can and we will make a difference.
 


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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Contents 

Introduction ......................................................................................................... 10 

Strategic Direction 1: ............................................................................................ 29 

Healthy and Empowered Individuals, Families, and Communities 

Strategic Direction 2: ............................................................................................ 40 

Clinical and Community Preventive Services 

Strategic Direction 3:............................................................................................ 50


Treatment and Support Services 

Strategic Direction 4:............................................................................................ 66



Surveillance, Research, and Evaluation 

Appendix A: ......................................................................................................... 75



National Strategy for Suicide Prevention Goals and Objectives for Action Summary List 

Appendix B: ......................................................................................................... 81



Crosswalk of Goals and Objectives from 2001 to 2012
 


Appendix C: ......................................................................................................... 94



Brief History of Suicide Prevention in the United States 

Appendix D: ....................................................................................................... 101



Groups With Increased Suicide Risk 

Appendix E: ....................................................................................................... 131



General Suicide Prevention Resources 

Appendix F: ....................................................................................................... 138



Glossary 

Appendix G: ....................................................................................................... 145



Federal Working Group Agency Descriptions 

Acknowledgments............................................................................................... 157



References......................................................................................................... 164



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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 

Introduction 

Suicide is a serious public health problem that causes immeasurable pain, suffering, and loss to individuals, 

families, and communities nationwide. Many people may be surprised to learn that suicide was one of the 

top 10 causes of death in the United States in 2009.1

 And death is only the tip of the iceberg. For every 

person who dies by suicide, more than 30 others attempt suicide.2

 Every suicide attempt and death affects 

countless other individuals. Family members, friends, coworkers, and others in the community all suffer 

the long-lasting consequences of suicidal behaviors. 

Key Facts: 

Suicide is the 10th leading cause 

of death, claiming more than 

twice as many lives each year as 

does homicide.1 

On average, between 2001 

and 2009, more than 33,000 

Americans died each year as a 

result of suicide, which is more 

than 1 person every 15 minutes.1 

More than 8 million adults report 

having serious thoughts of suicide 

in the past year, 2.5 million 

report making a suicide plan in 

the past year, and 1.1 million 

report a suicide attempt in the 

past year.3 

Almost 16 percent of students 

in grades 9 to 12 report having 

seriously considered suicide, 

and 7.8 percent report having 

attempted suicide one or more 

times in the past 12 months.4 

Suicide places a heavy burden on the nation in terms of the 

emotional suffering that families and communities experience as 

well as the economic costs associated with medical care and lost 

productivity. And yet suicidal behaviors often continue to be met 

with silence and shame. These attitudes can be formidable barriers to 

providing care and support to individuals in crisis and to those who 

have lost a loved one to suicide. 

More than a decade has passed since Surgeon General David Satcher 

broke the silence surrounding suicide in the United States by issuing 

The Surgeon General’s Call to Action to Prevent Suicide.5

 Published 

in 1999, this landmark document introduced a blueprint for suicide 

prevention and guided the development of the National Strategy 

for Suicide Prevention (National Strategy). Released in 2001, the 

National Strategy set forth an ambitious national agenda for suicide 

prevention consisting of 11 goals and 68 objectives.6 

What has changed since the National Strategy was released in 2001? 

Where have efforts been successful, and where is more work needed? 

What new findings from scientific research can help enhance suicide 

prevention efforts and improve the care provided to those who have 

been affected by suicide? What lessons learned can help guide suicide 

prevention efforts in the years to come? 

To assess progress made to date and identify remaining challenges, 

the Substance Abuse and Mental Health Services Administration 

(SAMHSA) commissioned the report Charting the Future of Suicide 

Prevention.

7

 Published in 2010, the report identified substantial 

achievements in suicide prevention in the years following the release 

of the National Strategy. Examples include the enactment of the 

Garrett Lee Smith Memorial Act, the creation of the National Suicide Prevention Lifeline (800–273– 

TALK/8255) and its partnership with the Veterans Crisis Line, and the establishment of the Suicide 

Prevention Resource Center (SPRC). Other areas of progress include the increased training of clinicians 

PAGE 10 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

and community members in the detection of suicide risk and appropriate response, and enhanced 

communication and collaboration between the public and private sectors on suicide prevention. The 

report also described remaining challenges and identified priority areas for action. 

Informed by this assessment, the National Action Alliance for Suicide Prevention (Action Alliance), a 

public-private partnership focused on advancing the National Strategy, formed an expert task force to 

revise and update the National Strategy. This document is the product of that task force’s deliberations and 

also reflects substantial input from individuals and organizations nationwide with an interest in suicide 

prevention. The revised National Strategy is a call to action that is intended to guide suicide prevention 

actions in the United States over the next decade. 

The National Strategy includes 13 goals and 60 objectives that have been updated to reflect advances in 

suicide prevention knowledge, research, and practice, as well as broader changes in society and health 

care delivery that have created new opportunities for suicide prevention. Some of the major developments 

addressed in the revised National Strategy include: 

A better understanding of how suicide is related to mental illness, substance abuse, trauma, violence, 

and other related issues; 

New information on groups that may be at an increased risk for suicidal behaviors; 

Increased knowledge of the types of interventions that may be most effective for suicide prevention; and 

An increased recognition of the importance of implementing suicide prevention efforts in a 
 

comprehensive and coordinated way.
 


Because suicide is closely linked with mental illness,8

 in the past, suicide prevention was often viewed as 

an issue that mental health agencies and systems should address. However, the vast majority of persons 

who may have a mental disorder do not engage in suicidal behaviors.9

 Moreover, mental health is only one 

of many factors that can influence suicide risk. For example, enhancing connectedness to others has been 

identified as a strategy for preventing suicidal behaviors and other problems.10 All of us can play a role in 

helping to make this protective factor more widely available. 

Suicide prevention is not exclusively a mental health issue. It is a health issue that must be addressed at 

many levels by different groups working together in a coordinated and synergistic way. Federal, state, 

tribal, and local governments; health care systems, insurers, and clinicians; businesses; educational 

institutions; community-based organizations; and family members, friends, and others—all have a role to 

play in suicide prevention. The revised National Strategy reflects this understanding. 

Suicide prevention efforts must involve a wide range of partners and draw on a diverse set of resources and 

tools. The National Strategy seeks to do so by integrating suicide prevention into the mission, vision, and 

work of a wide range of organizations and programs in a comprehensive and coordinated way. 

A comprehensive approach to suicide prevention is described on page 12. In this description, a person 

who is struggling with depression and thoughts of suicide is given the services and support he or she needs 

to recover from these challenges and regain a sense of complete physical, mental, emotional, and spiritual 

health and well-being. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


A Comprehensive Approach to Suicide Prevention 

This description highlights some of the many clinical and community services and supports that should be 

available to a person who struggles with depression and thoughts of suicide. 

In the community, when the person interacts with family members, friends, physicians, and others: 

Reduced prejudice about mental disorders and suicide makes it more likely that the person will let 

others know about symptoms and seek help; 

Responsible media reporting of mental illness and suicide reduces prejudice and prevents contagion; 

A well-implemented public awareness campaign raises cognizance of the signs and symptoms of 

mental disorders and risks for suicide and of where help is available locally; 

Training of community service providers makes it easier to identify the person at risk and increases 

appropriate referrals; 

Systems are in place to ensure that the person is referred to and safely transported to the appropriate 

facility for evaluation; and 

Reducing access to lethal means makes it less likely that the person will engage in suicidal behaviors. 

At the primary care provider or emergency department: 

Screening improves the likelihood that the person will receive appropriate evaluation and treatment; 

Training on recognition of risk and quality of care increases the likelihood of a good outcome; 

The care provider accurately diagnoses and records the problems and ensures that the appropriate 

public health surveillance systems are notified or made aware of the diagnoses; 

The implementation of trauma-informed policies and practices ensures that the person is treated 

with respect and in a way that promotes healing and recovery; 

Easy access to mental health care referrals for individuals with suicide risk increases the likelihood of 

a better outcome; 

Education efforts by health care providers increase knowledge of the warning signs of suicide risk 

among the individual and his or her family and/or support network; and 

Continuous care and improved aftercare leads to better monitoring and followup of the at-risk 

individual over time. 

In the community, while receiving care: 

Reduced prejudice regarding mental health issues and suicide leads to greater acceptance by family 

members and friends; 

The availability of high-quality mental health services that are linguistically and culturally appropriate 

makes it less likely that depression or related problems will recur; 

Sharing information, with the person’s permission, among care providers allows treatment to be 

better coordinated and collaborative; and 

Resources are available to offer social support, resiliency training, problem-solving skills, and other 

protective factors to the person and his or her family members and/or support network. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


In the community, after the person recovers: 

Education efforts help the person and his or her family members and/or support network maintain 

physical, mental, emotional, and spiritual health and well-being; and 

Systems are in place to evaluate the effectiveness and efficiency of the interventions provided. 

This is an example of an integrated, synergistic, multilevel approach to suicide prevention. The National 

Strategy for Suicide Prevention challenges all who play a role in suicide prevention to integrate and 

coordinate efforts to ensure that these types of strategies are implemented in a comprehensive and 

collaborative way. 

Understanding Suicide 

Although some people may perceive suicide as the act of a troubled person, it is a complex outcome 

that is influenced by many factors. Individual characteristics may be important, but so are relationships 

with family, peers, and others, and influences from the broader social, cultural, economic, and 

physical environments. 

There is no single path that will lead to suicide. Rather, throughout life, a combination of factors, such as a 

serious mental illness, alcohol abuse, a painful loss, exposure to violence, or social isolation may increase 

the risk of suicidal thoughts and behaviors. 

Risk and Protective Factors 

Suicide prevention efforts seek to reduce the factors that increase the risk for suicidal thoughts and 

behaviors and increase the factors that help strengthen, support, and protect individuals from suicide. 

Risk factors are characteristics that make it more likely that a person will think about suicide or engage 

in suicidal behaviors.10 Although risk factors generally contribute to long-term risk, stressful events, such 

as relationship problems, financial difficulties, or public humiliation could provide the impetus for a 

suicidal act.10 

Protective factors are not just the opposite or lack of risk factors. Rather, they are conditions that promote 

strength and resilience and ensure that vulnerable individuals are supported and connected with others 

during difficult times, thereby making suicidal behaviors less likely. 

Risk and protective factors for suicidal behaviors can be found at many levels, from the individual to the 

community and society at large. The social ecological model (see figure on page 15) provides a useful 

framework for viewing these factors along four levels of influence: individual, relationship, community, 

and societal. The figure lists the major risk and protective factors for suicidal behaviors identified in the 

literature.10-12 Because these factors can vary between individuals and across settings, the examples listed in 

the figure are not comprehensive. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


Key Terms 

t Affected by suicide. All those who may feel the effect of suicidal behaviors, including those 

bereaved by suicide, community members, and others. 

t Behavioral health. A state of mental and emotional being and/or choices and actions that 

affect wellness. Behavioral health problems include mental and substance use disorders 

and suicide. 

t Bereaved by suicide. Family members, friends, and others affected by the suicide of a loved 

one (also referred to as survivors of suicide loss). 

t Means. The instrument or object used to carry out a self-destructive act (e.g., chemicals, 

medications, illicit drugs). 

t Methods. Actions or techniques that result in an individual inflicting self-directed injurious 

behavior (e.g., overdose). 

t Suicidal behaviors. Behaviors related to suicide, including preparatory acts, suicide 

attempts, and deaths. 

t Suicidal ideation. Thoughts of engaging in suicide-related behavior. 

t Suicide. Death caused by self-directed injurious behavior with any intent to die as a result of 

the behavior. 

t Suicide attempt. A nonfatal, self-directed, potentially injurious behavior with any intent to 

die as a result of the behavior. A suicide attempt may or may not result in injury. 

These definitions reflect how these terms are used in the National Strategy for Suicide 

Prevention. For more information, including detailed definitions used in suicide surveillance, 

see the glossary in Appendix F. 

PAGE 14 
PAGE 15 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION

EXAMPLES OF RISK AND PROTECTIVE FACTORS IN A SOCIAL 

ECOLOGICAL MODEL

Coping and problem

Safe and supportive 

school and community 

environments 

Sources of continued 

care after psychiatric 

hospitalization 

solving skills 

Connectedness to individuals,

Availability of physical 

and mental health care 

Restrictions on lethal 

means of suicide 

family, community, and social Reasons for living (e.g., 

institutions children in the home) 

Supportive relationships with Moral objections to 

health care providers suicide 

PROTECTIVE 

FACTORS 

SOCIETAL COMMUNIITY RELATIONSHIP INDIVIDUAL

RISK 

FACTORS 

Availability of lethal Few available sources of High conflict or violent Mental illness

means of suicide supportive relationships relationships 

Substance abuse 

Unsafe media portrayals Barriers to health care Family history of suicide 

of suicide (e.g., lack of access to Previous suicide attempt 

providers or medications, 

prejudice) Impulsivity/aggression 

Adapted from: Dahlberg LL, Krug EG. Violence—a global public health problem. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. 

World report on violence and health. Geneva, Switzerland: World Health Organization; 2002:1–56.

Suicide is closely linked with mental and substance use disorders13 and shares risk and protective factors with other 

types of self-directed violence,14 interpersonal violence,15 and other related problems. As a result, efforts to reduce 

the risk factors and to increase the protective factors for suicide are likely to also help prevent or reduce these and 

other problems. For example, a comprehensive suicide prevention program implemented by the U.S. Air Force (see 

box on page 21) was found to not only prevent suicide but also to reduce family violence and homicide.16

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

The Prevalence of Suicidal Behaviors 

Estimates from the Centers for Disease Control and Prevention (CDC) indicate that 36,909 people died 

from suicide in the United States in 2009, the most recent year for which these data are available.1

 In 

absolute numbers, this represents an increase from 2008, when 36,035 people died from suicide.17 

The graph: United States Suicide Rates, 1950–2009, shows changes in the suicide rate from 1950 to 2009. 

Within this time period, suicide rates were lowest in 2000, at 10.44 per 100,000 people. They have since 

increased to 11.77 per 100,000 people.1 

SOURCE: Death data are from the National Vital Statistics System operated by the National Center for Health Statistics, CDC. 

Age-adjusted rates for 1950–2009 were obtained from WISQARS (www.cdc.gov/injury/wisqars). 

The prevalence of suicide varies by region and state. Suicide rates are higher in the western part of the 

country than in other regions (see map on page 17).1 

Suicide rates are only part of the picture. Existing data indicate that many people think about suicide and 

may also engage in suicidal behaviors. During 2008 and 2009, an estimated 8.3 million (annual average) 

adults aged 18 years and older (3.7 percent of the adult U.S. population) reported having suicidal thoughts 

in the past year.18 The prevalence of having suicidal thoughts ranged from 2.1 percent in Georgia to 6.8 

percent in Utah. In addition, an estimated 1 million adults in the United States reported making a suicide 

attempt in the past year. 

Suicide-related thoughts and behaviors are also common among youth. According to the 2011 Youth Risk 

Behavior Survey, more than 1 in 7 high school students nationwide reported having seriously considered 

attempting suicide in the 12 months before the survey.4

 In addition, 7.8 percent of students, or about 1 in 

13 reported having attempted suicide in the past year. 

PAGE 16 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

SOURCE: Death data are from the National Vital Statistics System operated by the National Center for Health Statistics, CDC. 

Age-adjusted rates for 2009 were obtained from WISQARS (www.cdc.gov/injury/wisqars). 

Many barriers make it difficult to know exactly how common suicidal behaviors are in the general 

population and in particular subgroups. Suicides are often underreported, in part because it may be 

difficult to determine intent. In some cases, existing data collection instruments may fail to include 

questions that would help determine the prevalence of suicidal behaviors among particular groups. For 

example, because death certificates do not indicate sexual orientation and gender identity, rates of deaths 

by suicide in lesbian, gay, bisexual, and transgender (LGBT) populations are unknown. The quality of 

some death investigations needs to improve. Additionally, in some states, key data sources such as death 

certificates and medical examiner reports may not yet be linked. The National Violent Death Reporting 

System (NVDRS)19 helps to address this limitation, but the system is currently available in only 18 states. 

Data on the national prevalence of suicide are available from a related online system, Web-Based Injury 

Statistics Query and Reporting System (WISQARS).20 

PAGE 17 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Differences Among Groups 

Existing data suggest important differences among demographic and other groups regarding suicidal 

thoughts and behaviors. For example, women are more likely than men to have thoughts about suicide 

and to attempt suicide, but men are more likely than women to die by suicide.19 Suicide methods also 

differ. Overall, men are more likely to use firearms in a suicide attempt, and women are more likely to 

use poisoning.1 

45 

40 

35 

30 

25 

20 

15 

10 

5 

0 

Age Group in Years 

SOURCE: Death data are from the National Vital Statistics System operated by the National Center for Health Statistics, CDC. 

Age-adjusted rates for 2009 were obtained from WISQARS (www.cdc.gov/injury/wisqars). 

Although white men 75 years of age and older have the highest rates of suicide, most deaths from suicide 

occur among white men in midlife, who make up a larger part of the population.1

 Suicide rates among 

young people 15–24 years of age are generally not higher than among adults. However, because young 

people are less likely than older people to die from medical conditions such as heart disease and cancer, 

suicide is one of the top three causes of death in this population, along with unintentional injuries and 

homicides.1

 Moreover, suicidal behaviors are particularly common among some subgroups of youth. 

For example, it is estimated that 14 to 27 percent of American Indian/Alaska Native adolescents have 

attempted suicide.21-23 

Having a mental and/or a substance use disorder can greatly increase the risk for suicidal behaviors.13 

Suicide rates are particularly high among individuals with mood disorders such as major depression and 

bipolar disorders. Suicidal thoughts and/or behaviors are common among patients with bipolar disorders, 

and suicide rates are estimated to be more than 25 times higher for these patients than among the general 

population.24, 25 Another mental disorder that may increase the risk for suicide is schizophrenia. Suicide 

has been estimated to occur in approximately 5 percent of patients with this disorder.26 

PAGE 18 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Alcohol and drug abuse are second only to mood disorders as the most frequent risk factors for suicidal 

behaviors. In 2008, alcohol was a factor in approximately one-third of suicides reported in 16 states.27 

Having both a substance use disorder and a mental disorder, particularly a mood disorder, also has been 

found to increase suicide risk.28 

Some medical conditions, including cancer and chronic diseases that impair physical function and/or lead 

to chronic pain, also may increase the risk for suicidal behaviors.29 Research also suggests that engaging 

in acts of self-injury may lead to suicide later in life.30 This has been found to be true in cases when the 

self-injury involves the intent to die, as well as in cases when there is no suicidal intent (also referred to as 

nonsuicidal self-injury, or NSSI).31 

Warning Signs of Suicide 

Talking about wanting to die;
 


Looking for a way to kill oneself;



Talking about feeling hopeless or having no purpose;
 


Talking about feeling trapped or being in unbearable pain;
 


Talking about being a burden to others;
 


Increasing the use of alcohol or drugs;



Acting anxious, agitated, or reckless;



Sleeping too little or too much;



Withdrawing or feeling isolated;



Showing rage or talking about seeking revenge; and



Displaying extreme mood swings.



The more of these signs a person shows, the greater the risk of suicide. Warning signs are associated with 

suicide but may not be what causes a suicide. 

What To Do 

If someone you know exhibits warning signs of suicide: 

Do not leave the person alone; 

Remove any objects that could be used in a suicide attempt; 

Call the U.S. National Suicide Prevention Lifeline at 800–273–TALK/8255; and 

Take the person to an emergency room or seek help from a medical or mental health professional. 

Adapted from Recommendations for Reporting on Suicide website (www.reportingonsuicide.org.) 

PAGE 19 
 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Individuals in some settings, systems, and professions may be at an increased risk for suicidal thoughts 

and/or behaviors compared to the general population. Suicide is often the most common cause of death 

in secure justice settings.32 More than 400 suicides occur each year in local jails at a rate three times 

greater than among the general population, and suicide is the third leading cause of death in prisons.33-35 

In the past decade, increases in the rate of suicide among members of the U.S. Armed Forces has led to 

the implementation of extensive prevention programs in all branches of the military. In addition, concern 

about suicide among veterans has also led to extensive suicide prevention efforts. There is also concern 

that youth in the foster care system may be at an increased risk for suicidal behaviors and other related 

problems.36, 37 More research is needed to better understand suicide risk among this population and to 

develop appropriate responses. 

Other groups identified as having a higher risk for suicidal thoughts and/or behaviors than the general 

population include LGBT populations38 and individuals who have been bereaved by suicide.39 For more 

information on these and other groups, see Appendix D. 

More research is needed to better understand why suicide rates may be particularly low among some 

groups, such as African American women. In 2009, the suicide rate among black women aged 20–59 

years was 2.77 per 100,000, the lowest rate among adults in this age range.1

 It is possible that factors such 

as greater social support, larger extended families, and deeper religious views against suicide may help 

protect some groups from suicide. A better understanding of these and other protective factors would help 

inform future suicide prevention efforts. 

Preventing Suicide 

Suicide prevention requires a combination of universal, selective, and indicated strategies.9 Universal 

strategies target the entire population. Selective strategies are appropriate for subgroups that may be at 

increased risk for suicidal behaviors. Indicated strategies are designed for individuals identified as having a 

high risk for suicidal behaviors, including someone who has made a suicide attempt. 

Just as suicide has no one single cause, there is no single prevention activity that will prevent suicide. To be 

successful, prevention efforts must be comprehensive and coordinated across organizations and systems 

at the national, state/territorial, tribal, and local levels. As with other health promotion efforts, suicide 

prevention programs should be culturally attuned and locally relevant. 

PAGE 20 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Evidence-Based and Promising Practices 

Advances in research and practice have created new opportunities for suicide prevention. For example, 

new evidence suggests that a number of interventions may be particularly useful for helping individuals 

at risk for suicide. Some of these proven strategies are: the use of cognitive behavior therapy,40, 41 crisis 

lines,42 and efforts that promote continuity of care for individuals being treated for suicide risk.43 More is 

also known about the effectiveness and risks associated with antidepressant use by some groups with high 

suicide risk.44 These tools and approaches need to be refined and made more available and accessible. 

Recent evaluations have identified system-wide interventions that combine multiple suicide prevention 

strategies and that are sustained over time as being particularly promising. For example, the experience 

of the U.S. Air Force Suicide Prevention Program (AFSPP)16 (see box) has shown that leadership, policy, 

practices, and accountability can combine to produce very impressive successes. These findings should be 

shared and adapted for use in different settings. 

U.S. Air Force Suicide Prevention Program (AFSPP) 

Since 1996, the U.S. Air Force has implemented a community-based suicide prevention program 

featuring 11 initiatives. Strategies include: 

Increasing awareness of mental health services and encouraging help-seeking behaviors; 

Involving leadership; 

Including suicide prevention in professional training; 

Developing a central surveillance system for tracking fatal and nonfatal self-injuries; 

Allowing mental health professionals to deliver community preventive services in nonclinical settings; 

Establishing trauma stress response teams; and 

Conducting a behavioral health survey to help identify suicide risk factors. 

Evaluation findings indicate that the program reduced the risk of suicide among Air Force personnel 

by one-third.16 Participation in the program was also linked to decreases in homicide, family violence 

(including severe family violence), and accidental death. 

Research has also helped clarify the link between early childhood adverse events and suicide later in 

life, and of the role of connectedness in protecting individuals from a wide range of health problems, 

including suicide.45 Efforts that promote overall health and that help build positive relationships can play 

an important role in suicide prevention. As a result, suicide prevention must be integrated into the work 

of a broad range of partners that provide programs and services in these areas. Suicide prevention is 

everyone’s business. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Two online resources—the National Registry of Evidence-Based Programs and Practices (NREPP) 

and the Best Practices Registry (BPR)—are helping to disseminate these findings so they may be more 

widely used. NREPP, a searchable online registry maintained by the Substance Abuse and Mental Health 

Services Administration (SAMHSA), provides information on more than 220 interventions supporting 

mental health promotion, substance abuse prevention, and mental health and substance abuse treatment. 

BPR, a registry that focuses specifically on suicide prevention programs, is maintained by the national 

Suicide Prevention Resource Center (SPRC) in collaboration with the American Foundation for Suicide 

Prevention, with funding from SAMHSA.46 More information on these and other resources is included in 

Appendix E. 

The 2012 National Strategy for Suicide Prevention 

The 2012 National Strategy for Suicide Prevention represents the culmination of an intensive consultation 

process coordinated by the National Action Alliance for Suicide Prevention (Action Alliance), a national 

partnership composed of more than 200 representatives from the public and private sectors. Launched 

in September 2010, the Action Alliance is dedicated to advancing the National Strategy by championing 

suicide prevention as a national priority, catalyzing efforts to implement high-priority objectives, and 

cultivating the resources needed to sustain progress. 

Chaired by the Honorable John M. McHugh, Secretary of the Army, and the Honorable Gordon H. Smith, 

President and CEO of the National Association of Broadcasters, the Action Alliance brings together highly 

respected national leaders representing more than 200 organizations. At its core is an executive committee 

supported by several task forces (see Organizational Chart). 

NATIONAL ACTION ALLIANCE FOR SUICIDE PREVENTION 
 

ORGANIZATIONAL CHART



PRIVATE SECTOR MEMBERS (Senior executives of leading 

for-profit and nonprofit organizations, philanthropic organizations, 

researchers and practitioners, and survivors of suicide loss and 

attempts) 

PUBLIC SECTOR MEMBERS and EX OFFICIO MEMBERS 

NATIONAL COUNCIL FOR 

SUICIDE PREVENTION 

NATIONAL COUNCIL FOR 

SUICIDE PREVENTION 

PRIVATE S ECTOR 

CO­-CHAIR 

PRIVATE SECTOR 

CO-CHAIR 

SECRETARIAT SECRETARIAT

PUBLIC SECTOR 

CO­ CHAIR 

PUBLIC SECTOR 

CO-CHAIR 

AD HOC 

ADVISORY GROUPS 

AD HOC 

ADVISORY GROUPS 

FEDERAL WORKING 

GROUP ON SUICIDE 

PREVENTION 

FEDERAL WORKING 

GROUP ON SUICIDE 

PREVENTION 

ADVISORY GROUPS 

PAGE 22 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 

In 2010, the Action Alliance created an expert task force dedicated to the National Strategy for Suicide 
 

Prevention. The task force implemented a revision process that included the following sources of input: 
 

An online survey conducted on the Action
 


Alliance website;
 


Listening sessions held in conjunction with
 


national conferences;
 


Two workshops in Washington, DC, in June 2011; and 

Review of drafts by members of the Action Alliance and 

its task forces, other national and international experts, 

and others with an interest in suicide prevention. 

Several key documents (see box at right) and findings from 

suicide prevention strategies implemented by countries such 

as Australia and the United Kingdom also informed the 

development of the revised National Strategy. 

The 2012 National Strategy for Suicide Prevention is closely 

aligned with the National Prevention Strategy,47 which was 

developed by the National Prevention, Health Promotion, 

and Public Health Council as established by the Affordable 

Care Act. The comprehensive National Prevention Strategy’s 

goal is to increase the number of Americans who are healthy 

at every stage of life, by shifting from a focus on sickness 

and disease to a focus on wellness and prevention. Three of 

its seven priority areas—mental and emotional well-being, 

preventing drug abuse and excessive alcohol use, and injuryand violence-free living—are directly related to suicide 

prevention. Like the National Prevention Strategy, the 2012 

National Strategy for Suicide Prevention emphasizes that 

prevention should be woven into all aspects of our daily 

lives. Everyone—government, business, academics, health 

care industry, communities, and individuals—has a role in 

helping to prevent suicide. 

Key Documents Informing the 

Revision 

t National Prevention Strategy, National 

Prevention, Health Promotion, and 

Public Health Council, 2011 

t HealthyPeople 2020, U.S. 

Department of Health and Human 

Services, 2010 

t Charting the Future of Suicide 

Prevention, SPRC and SPAN 

USA, 2010 

t Preventing Mental, Emotional, and 

Behavioral Disorders Among Young 

People: Progress and Possibilities, 

IOM, 2009 

t Reducing Suicide: A National 

Imperative, IOM, 2002 

t World Report on Violence and Health, 

WHO, 2002 

t Prevention of Suicide: Guidelines for 

the Formulation and Implementation 

of National Strategies, UN, 1996 

PAGE 23 
onal Well

Violen

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


Organization of the 2012 National Strategy for Suicide Prevention 

The 2012 National Strategy for Suicide Prevention is organized into four interconnected strategic 

directions (see figure): 

1. Healthy and Empowered Individuals, Families, and Communities 

2. Clinical and Community Preventive Services 

3. Treatment and Support Services 

4. Surveillance, Research, and Evaluation 

ORGANIZATION OF GOALS AND OBJECTIVES 
 

Mental & Emoti -Being 

Injury- & 

ce-Free Living 

4 

Surveillance, 

Research, & 

Evaluation 

Healthy & Empowered Individuals, 1 

2 

Clinical & Community 

Preventive Services 

Families, & Communities 

3 Treatment & Support 

Services 

Preventing Suicidal Behaviors 

Preventing Drug Abuse & Excessive

Alco

hol Use 

This organization represents a slight 

change from the AIM (Awareness, 

Intervention, Methodology) framework 

adopted in the 2001 National Strategy. 

The Awareness area has been included 

under Healthy and Empowered Individuals, 

Families, and Communities. The goals 

and objectives formerly included in 

the Intervention area have been spread 

across the first three strategic directions. 

Methodology has been expanded to include 

not only surveillance and research but also 

program evaluation. The 2001 goals and 

objectives have been updated, revised, and 

in some cases, replaced to reflect advances 

in knowledge and areas where the 

proposed actions have been completed. 

For a list of the revised goals and 

objectives, see Appendix A. A crosswalk 

from the original to the revised list is provided in Appendix B. 

The four strategic directions are interrelated and interactive, rather than stand alone areas. Several broad 

themes are at the core of the National Strategy and are addressed across all four strategic directions (see 

box on page 25). 

Although some groups have higher rates of suicidal behaviors than others, the goals and objectives do 

not focus on specific populations or settings. Rather, they are meant to be adapted to meet the distinctive 

needs of each group, including new groups that may be identified in the future as being at an increased 

risk for suicidal behaviors. Appendix D provides information on groups currently identified as having 

suicide risk. 

PAGE 24 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


Suicide prevention interventions, products, and services 

should be tailored to the cultural, linguistic, and other 

needs of each group. As an example, the National Standards 

on Culturally and Linguistically Appropriate Services 

(CLAS),48 issued by the U.S. Department of Health and 

Human Services (HHS) Office of Minority Health, can be 

a useful resource for providing health care services that 

are culturally and linguistically appropriate. Additional 

information about making information and services 

appropriately accessible to persons with disabilities and to 

people who have a limited English proficiency may be found 

at the Office for Civil Rights website (www.hhs.gov/ocr). 

Themes Shared Across 

Strategic Directions 

Suicide prevention efforts should: 

t Foster positive public dialogue; 

counter shame, prejudice, and 

silence; and build public support for 

suicide prevention; 

t Address the needs of vulnerable 

groups, be tailored to the cultural 

and situational contexts in which 

they are offered, and seek to 

eliminate disparities; 

t Be coordinated and integrated with 

existing efforts addressing health 

and behavioral health and ensure 

continuity of care; 

t Promote changes in systems, policies, 

and environments that will support 

and facilitate the prevention of suicide 

and related problems; 

t Bring together public health and 

behavioral health; 

t Promote efforts to reduce access to 

lethal means among individuals with 

identified suicide risks; and 

t Apply the most up-to-date knowledge 

base for suicide prevention. 

Looking Ahead 

The 2012 National Strategy for Suicide Prevention 

represents a comprehensive, long-term approach to 

suicide prevention. The goal of saving lives, as measured 

by sustainably lower national and regional suicide rates, 

can only be achieved by a mosaic of coherent actions that 

complement each other. 

Suicide occurs in all parts of our society and in all regions, 

affecting people of all ages. No group is immune, and the 

factors that contribute to these preventable deaths are 

multiple and complex. Thus, no single approach will suffice. 

The 13 goals and 60 objectives included in the National 

Strategy are meant to work together in a synergistic way 

to promote wellness, increase protection, reduce risk, and 

promote effective treatment and recovery. They represent 

a roadmap that, when followed, will lead to the vision of a 

nation free from the tragic experience of suicide. 

Identifying Priority Areas for Action 

The goals and objectives in the revised National Strategy are 

broad in scope and encompass a wide range of activities. 

Many different groups at the local, regional, and national levels (e.g., federal or local government, 

educational institutions, workplaces, health systems) can play a role in advancing particular objectives. 

As a result, it is not possible to include specific target dates for the completion of each objective, as was 

done in the 2001 National Strategy. All groups that have an interest in suicide prevention can use the goals 

PAGE 25 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

and objectives to identify their own priority areas, thereby contributing to the full implementation of the 

National Strategy. 

A careful assessment of needs, resources, and opportunities can help guide the identification of priorities. 

As an example, the Action Alliance conducted this type of assessment to identify its four priority areas 

for 2012–14: 

1. Integrating suicide prevention into health care reform and encouraging the adoption of similar 

measures in the private sector; 

2. Transforming health care systems to significantly reduce suicide; 

3. Changing the public conversation about suicide and suicide prevention; and 

4. Increasing the quality, timeliness, and usefulness of surveillance data regarding suicidal behaviors. 

Each priority area is aligned with one or more National Strategy objectives (see table listing Action 

Alliance priority areas for 2012–14 on page 27). For example, priority area 2—Transforming health care 

systems to significantly reduce suicide—is closely linked with Objective 8.1—Promote the adoption of 

“zero suicides” as an aspirational goal by health care and community support systems that provide services 

and support to defined patient populations. Evidence from several system-level interventions conducted in 

the United States as well as abroad (see box for lessons from the United Kingdom on page 28) suggests that 

this type of approach has a tremendous potential for saving lives. 

Several considerations helped guide the development of this action agenda. 

Potential effect on suicide-related morbidity and mortality. Reducing the burden of suicide in the nation 

is a key area of concern. The selection of priority areas must take into account the potential for saving 

lives, preventing injury, and lowering the costs associated with suicidal behaviors. For example, because 

the greatest numbers of suicide deaths occur among white men in midlife, efforts targeting this group 

may have the greatest short-term effect on reducing the suicide rate. Similarly, efforts targeting high-risk 

groups, such as persons who have attempted suicide, may have the potential to help lower suicide rates 

more quickly than other strategies. 

Existing opportunities for action. In selecting areas for action, it is important to take advantage of 

existing programs, opportunities, and resources, including initiatives that are already underway and that 

could be expanded or brought to scale in the short term. Examples include expanding the NVDRS system 

to additional states and territories and promoting the adoption of system-level approaches to suicide 

prevention and major depression that have been implemented by the U.S. Air Force16 and the Henry Ford 

Health System,49 among others. 

Availability of data for measuring progress. Assessing the availability of sources of data for measuring 

progress is another key consideration. Although the surveillance of suicide-related data has improved 

over the years, data may not yet be available to measure progress toward every objective in the National 

Strategy. When data sources are not available, mechanisms for collecting the data must be put into place so 

that progress can be measured and monitored in future years. 

PAGE 26 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


ACTION ALLIANCE PRIORITY AREAS: 2012–14 

Priority Area National Strategy Objective(s) Implementation 

1. Integrate suicide 

prevention into health 

care reform and 

encourage the adoption 

of similar measures in the 

private sector. 

2. Transform health care 

Objective 1.5: Integrate suicide 

prevention into all relevant health 

care reform efforts. 

Objective 8.1: Promote the adoption 

Work in partnership with the 

Centers for Medicare & Medicaid 

Services (CMS) to ensure that 

suicide prevention is integrated 

into CMS’s policies and program 

guidance to providers under 

Medicare and Medicaid. 

Promote the adoption of “zero 

systems to significantly of “zero suicides” as an aspirational suicides” as an organizing goal 

reduce suicide. goal by health care and community for clinical systems care for 

support systems that provide services defined populations. Recruit early 

and support to defined patient adopters to implement the Suicide 

populations. Care in Systems framework within 

their respective organizations and 

3. Change the public 

conversation about 

suicide and suicide 

prevention. 

4. Increase the quality, 

timeliness, and usefulness

of surveillance data 

regarding suicidal 

behaviors. 

Objective 2.1: Develop, implement, 

and evaluate communication efforts 

designed to reach defined segments 

of the population. 

Objective 2.3: Increase 

communication efforts conducted 

online that promote positive messages 

and support safe crisis intervention 

strategies. 

Objective 11.1: Improve the 

highlight successful programs. 

Leverage the media and 

national leaders to change 

the national narratives about 

suicide and suicide prevention 

to messages that promote hope, 

connectedness, social support, 

resilience, treatment, and 

recovery. 

Work with CDC to improve the 

timeliness of reporting vital records quality, timeliness, and usefulness 

data. of the data collected and to 

Objective 11.2: Improve the 

usefulness and quality of suiciderelated data. 

expand existing data systems. 

Partners and roles. The 60 objectives included in the National Strategy address various areas, including 

health promotion; treatment of high-risk individuals; care for those who have been bereaved by suicide; 

and issues related to surveillance, research, and evaluation. The selection of priority objectives must take 

into account existing organizations, agencies, or other groups that may be interested and able to contribute 

to progress in specific areas. These partners may be willing to take on specific roles, such as serving as the 

lead organization for a priority area or helping to collect data and measure progress. 

These types of considerations may be useful to other groups as they identify their own priority areas for 

action. Each group is encouraged to identify the objective(s) that are most relevant to the individuals 

they serve, and where its actions are most likely to yield positive results. The sections that follow provide 

examples of how different groups can help advance the goals and objectives in each of the National 

Strategy’s four strategic directions. 

PAGE 27 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

The National Strategy hopes to energize and sustain the efforts of those who already are engaged in suicide 

prevention by demonstrating how their work is connected to a larger movement aimed at addressing 

this serious problem. For those not yet engaged, the National Strategy identifies areas where their future 

contributions can make a difference in advancing suicide prevention in their communities. For those 

experiencing a suicide loss or struggling with thoughts of suicide, the National Strategy provides ideas on 

how to turn pain into recovery and hope for a better future. 

Making this vision a reality requires all members of our communities to be involved. Each and every 

one of us has a role to play in preventing suicide and promoting health, resilience, recovery, and wellness 

for all. 

Lessons From the United Kingdom 

The adoption of a range of suicide prevention recommendations by mental health systems across England 

and Wales has been found to greatly reduce suicide rates among patients. A 2012 study examined 

changes in suicide rates as public sector mental health service settings began to implement the following 

nine suicide prevention recommendations:50 

Providing 24-hour crisis teams;



Removing ligature points (materials that could be used for suicide);



Conducting followup with patients within 7 days of discharge; 
 

Conducting assertive community outreach, including providing intensive support for people with 
 

severe mental illness;



Providing regular training to frontline clinical staff on the management of suicide risk;



Managing patients with co-occurring disorders (mental and substance use disorder);



Responding to patients who are not complying with treatment;



Sharing information with criminal justice agencies; and



Conducting multidisciplinary reviews and sharing information with families after a suicide.



In 1998, few of the 91 mental health services in the study were carrying out any of these 

recommendations. By 2004, about half were implementing at least seven recommendations, and by 

2006, about 71 percent were doing so. Over time, as more recommendations were implemented, suicide 

rates among patients declined. Each year, from 2004 to 2006, mental health services that implemented 

seven or more recommendations had a lower suicide rate than those implementing six or fewer. Among all 

recommendations, providing 24-hour crisis care was linked to the largest decrease in suicide rates. 

PAGE 28 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Strategic Direction 1:
 
 

Healthy and Empowered Individuals, 
 

Families, and Communities



The goals and objectives in this strategic direction seek to create supportive environments that will 

promote the general health of the population and reduce the risk for suicidal behaviors and related 

problems. As noted in the Introduction, suicide shares risk and protective factors with mental and 

substance use disorders, trauma, and other types of violence, such as bullying and domestic violence. 

As a result, a wide range of partners can contribute to suicide prevention, including organizations and 

programs that promote the health of children, youth, families, working adults, older adults, and others in 

the community. All of these partners should integrate suicide prevention into their work. 

Eliminating the biases and prejudices associated with suicidal behaviors, mental and substance use 

disorders, and exposure to violence is a key area of concern within this strategic direction. In particular, 

there is a need to increase the understanding that mental and substance use disorders respond to specific 

treatments and that recovery is possible. 

Communication efforts, such as campaigns and social marketing interventions, can play an important 

role in changing knowledge, attitudes, and behaviors to promote suicide prevention. Safe and positive 

messages addressing mental illness, substance abuse, and suicide can help reduce prejudice and promote 

help seeking. These types of messages can help create a supportive environment in which someone 

who is experiencing problems feels comfortable seeking help, and where families and communities feel 

empowered to link a person in crisis with sources of care and assist the person in attaining or regaining a 

meaningful life. 

Goal 1. Integrate and coordinate suicide prevention activities across 

multiple sectors and settings. 

Suicide prevention should be infused into programs carried out in diverse settings and systems, such 

as workplaces, schools, law enforcement and criminal justice settings, health care provider offices, 

community-based agencies, and faith-based organizations. Greater coordination of efforts among 

different stakeholders and settings can increase the reach and effect of suicide prevention activities, while 

preventing duplication and promoting greater cost-effectiveness of efforts. 

In particular, it is important to take advantage of existing programs and efforts that address risk and 

protective factors for suicidal behaviors, including programs that may not yet include suicide prevention as 

an area of focus. For example, many school-based programs seek to prevent drug use and violence among 

youth by building problem-solving skills and increasing connectedness to teachers, mentors, and other 

caring adults in the community. These types of strategies can also be useful for suicide prevention. 

PAGE 29 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

An example of a coordinated approach addressing multiple issues that share risk and protective factors 

is the Good Behavior Game.51 This universal classroom behavior management method, used in first- and 

second-grade classrooms, has been shown to contribute to the prevention of suicidal ideation, as well 

as drug and alcohol use disorders, regular smoking, antisocial personality disorder, delinquency, and 

incarceration for violent crimes. Several replications have provided similar results. 

Objective 1.1: Integrate suicide prevention into the values, culture, leadership, 

and work of a broad range of organizations and programs with a role to support 

suicide prevention activities. 

Suicide prevention should be integrated into the work of all organizations and programs that provide 

services and support in the community. These organizations and programs include, but are not limited to: 

Businesses, employers, and workplaces; 

Faith-based programs; 

Family, youth, and community service providers and organizations; 

Funeral homes; 

Hotlines, crisis lines, and call centers; 

Organizations and programs that provide health care; 

State and local aging services networks, and other programs that support older adults; and 

Educational institutions, law enforcement, the justice system, and other institutions in 
 

the community.
 


Health care providers, teachers, social workers, employers, members of the business community, and other 

local resources can play an important role in suicide prevention. Strategies to involve these stakeholders 

include obtaining support from members of school boards and other administrative structures, and 

infusing suicide prevention into key professional meetings. Chambers of commerce and trade associations 

can also be helpful partners in engaging the business community. 

Integrating suicide prevention into the work of these community partners will promote greater 

understanding of suicide and help counter the prejudice, silence, and denial that can prevent individuals 

from seeking help. It also will support the delivery of suicide prevention activities that are culturally 

competent, safe, and available to individuals who may lack access to health care. 

Objective 1.2: Establish effective, sustainable, and collaborative suicide 

prevention programming at the state/territorial, tribal, and local levels. 

Suicide prevention is often organized differently at the state/territorial, tribal, and local levels, which 

can make it difficult for the many agencies and programs involved in suicide prevention to work 

collaboratively. Increased coordination of suicide prevention activities among these various partners could 

PAGE 30 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

help improve services and outcomes, while promoting the greater sustainability of suicide prevention 

efforts over the long term. The type of collaboration that will work best may vary by state/territory, tribe, 

or community. 

Clarifying each agency’s areas of focus and responsibility may be an important first step. This clarification 

can make it easier for different agencies to work together and to obtain support for their respective suicide 

prevention efforts. It also may be useful to identify a lead agency at the state and local levels that could help 

bring together different partners with a role to play in suicide prevention. As an example, a recent report 

from the Safe States Alliance identifies ways to organize and coordinate violence prevention efforts.52 

The report presents the consensus of an expert panel regarding the roles that public health agencies at 

the federal, state/territorial, tribal, and local levels could play in the prevention of violence, including 

suicide prevention. 

Objective 1.3: Sustain and strengthen collaborations across federal agencies to 

advance suicide prevention. 

Because suicide affects many different groups and is related to mental health, substance abuse, trauma, 

violence, injury, and other issues, many federal agencies have a role to play in suicide prevention. The 

Federal Working Group (FWG) is an important mechanism for maintaining collaboration across these 

agencies (see Appendix G for more information). Formed in 2000, the FWG brings together several 

federal agencies to share information and coordinate efforts. The group meets regularly and publishes a 

Compendium of Federal Activities. 

Although sharing information and coordinating efforts across agencies is useful, a more proactive and 

dedicated approach could have a greater effect in preventing suicide in the nation. For example, the 

improved coordination of funding priorities at the federal level could help strengthen the infrastructure 

for delivering suicide prevention services at the state/territorial, tribal, and local levels. 

Objective 1.4: Develop and sustain public-private partnerships to advance 

suicide prevention. 

The 1996 United Nations (U.N.) report addressing the development of national strategies for suicide 

prevention recommended that no single agency, organization, or governmental body have sole 

responsibility for suicide prevention.53 Taking into account this recommendation, the 2001 National 

Strategy called for the creation of a national public and private partnership to advance and coordinate 

the implementation of suicide prevention in the United States.6

 This partnership is the National Action 

Alliance for Suicide Prevention (Action Alliance), formed in September 2010 to catalyze, cultivate, and 

champion the cause of suicide prevention. 

The 2001 National Strategy also called for the development of state suicide prevention plans. Nearly all 

states have developed a statewide plan, but the plans vary in focus and depth. Although most plans cover 

the lifespan, many have limited funding to implement suicide prevention activities. While developing a 

state suicide prevention plan is an important first step, more work is needed to implement these plans 

PAGE 31 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

fully. The development of partnerships with the private sector at the state/territorial, tribal, and local levels 

would help strengthen and advance the implementation of suicide prevention plans. 

Objective 1.5: Integrate suicide prevention into all relevant health care 

reform efforts. 

Changes in health care systems and policies provide important opportunities for integrating and 

enhancing suicide prevention efforts. Health care reform efforts that increase access to care for mental and 

substance use disorders can greatly contribute to suicide prevention. Examples include federal and state 

parity laws requiring equal health insurance coverage for care for behavioral health (i.e., care for mental 

and/or substance use disorders) as for physical health problems. Health care reform efforts can also be 

used to create financial incentives for incorporating suicide prevention activities into clinical settings, 

and to encourage the better coordination or integration of physical and behavioral health services. As an 

example, the Prevention and Public Health Fund created by the Affordable Care Act provides support to 

states and communities for integrating these services. 

Efforts addressing changes to health care systems can provide opportunities to expand the use of practices 

that are known to prevent suicide. For example, promoting the early identification of individuals with 

high suicide risk and increasing the availability of effective treatments and followup care are important 

strategies for improving health outcomes among these patients. 

Integrating suicide prevention into health care reform is one of the four priority objectives identified by the 

Action Alliance for 2012–14. The Action Alliance is working in partnership with the Centers for Medicare 

& Medicaid Services (CMS) to ensure that suicide prevention is integrated into CMS policies and program 

guidance to providers under Medicare and Medicaid. For example, as part of an incentive program 

encouraging providers and hospitals nationwide to adopt electronic health records, CMS is considering the 

adoption of quality measures specifically related to suicide.54 In addition, the Action Alliance is working 

with other HHS Operating Divisions, such as the Health Resources and Services Administration, to 

incorporate suicide prevention into health care reform. 

Goal 2. Implement research-informed communication efforts designed 

to prevent suicide by changing knowledge, attitudes, and behaviors. 

A wide range of communication efforts, such as communication campaigns and social marketing 

interventions, can play an important role in suicide prevention. These efforts can help change knowledge, 

attitudes, and behaviors among specific segments of the population; this can promote changes in the 

environment that will support suicide prevention. For example, the dissemination of positive messages 

that focus on recovery and hope can help reduce the biases and prejudices associated with mental and 

substance use disorders and with suicide. Using these interventions can increase understanding of the 

barriers to seeking help and provide information that will empower individuals to take action. 

Communication efforts addressing suicide prevention should be research-based and reflect safe messaging 

recommendations specific to suicide. The channels and messages that are most appropriate will vary 

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depending on the targeted segment of the population. For example, messages targeting policymakers 

can promote the understanding that suicide is a preventable public health problem, and that mental and 

physical health are equal and inseparable components of overall health. Family members and friends may 

benefit from messages conveying the idea that mental and substance use disorders are real illnesses that 

respond to specific treatments. Individuals in crisis may benefit from information regarding crisis lines 

and other sources of assistance. These efforts should be conducted at multiple levels and align with other 

suicide prevention interventions, such as training programs for health care providers or school-based 

suicide prevention programs. 

Objective 2.1: Develop, implement, and evaluate communication efforts designed 

to reach defined segments of the population. 

Research findings from communication, social marketing, and other relevant disciplines should inform 

the development of all communication efforts addressing suicide prevention. For example, communication 

campaigns addressing suicide prevention should incorporate the principles of effectiveness identified in 

the literature. These principles include conducting formative research, using behavior theory, segmenting 

the audience, identifying and using effective channels and messages, conducting process evaluation to 

ensure high message exposure, and using an appropriate design for outcome evaluation.55 Making Health 

Communication Programs Work,

56 a resource guide created by the National Cancer Institute, may be 

useful to program planners implementing health communication efforts addressing suicide prevention. 

Another useful resource is Centers for Disease Control and Prevention’s (CDC) online Gateway to Health 

Communication & Social Marketing Practice.57 

Communication efforts should target defined audiences, or segments of the population, such as groups 

with higher suicide risk (see Appendix D), school personnel, or others. Demographic factors, such as 

age, income, or gender, may be used to identify different audience segments, along with factors related 

to the action being promoted. Efforts promoting behavior change should convey a clear call to action 

and provide specific information the audience needs to act. For example, a media campaign that tries to 

motivate individuals in crisis to seek help should provide information on the warning signs for suicide and 

on where to go for help (see Introduction for this information). 

Objective 2.2: Reach policymakers with dedicated communication efforts. 

Communications efforts designed to educate policymakers are especially important because policy and 

systems change are long lasting and efficient ways to advance suicide prevention. These policymakers 

may include federal, state, and local officials; tribal council members; and institutional and organizational 

leaders and their research and policy staff, among others. To be most effective, messages should link to 

specific actionable requests and reflect an understanding of broader issues of concern to the policymaker. 

However, HHS grant or contract funds may not be used in connection with activities designed to 

influence policymakers. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

An important first step to educating policymakers may be increasing their understanding of suicide, 

its impact on their constituents and stakeholders, and effective solutions. These outcomes can motivate 

leaders to take action by promoting suicide prevention initiatives, policies, and programs. Describing 

effective programs of federal, state/territorial, tribal, and nonprofit agencies and local coalitions will help 

build support for suicide prevention plans. It also may be useful to share evaluation data that show success 

in reducing risk and increasing protective factors for suicide. 

Suicide prevention can address sensitive topics such as the use of alcohol and other substances. There 

is also growing consensus among researchers that prejudice and discrimination play a role in the higher 

rates of mental disorders and suicide attempts among some populations.58 Placing the focus on promoting 

public safety may help diffuse these types of tensions. Communications efforts should be framed in ways 

that will speak to diverse policymakers at the national, state, tribal, and local levels, and build broad 

support for suicide prevention. 

Objective 2.3: Increase communication efforts conducted online that promote 

positive messages and support safe crisis intervention strategies. 

Technology is changing the way we communicate, and the pace at which new communications tools are 

introduced continues to accelerate. These media and applications include interactive educational and 

social networking websites, e-mail outreach, blogs, mobile apps, and programs using mobile devices and 

texting. Mobile health apps have become increasingly popular, particularly among young adults.59 Other 

innovative applications currently being developed and applied to suicide prevention include virtual worlds, 

gaming, and text analysis.60 

Emerging media and applications provide new opportunities for suicide prevention, particularly for 

persons who may be socially isolated or otherwise difficult to reach. A promising example is the chat line 

operated by the U.S. Department of Veterans Affairs (VA) crisis line call center.61 Another example comes 

from the social media website Facebook. With the rise of cyberbullying and suicidal status updates, in 

2012, Facebook announced a new feature allowing users to anonymously report their friends’ suicidal 

posts. The person posting suicidal content receives an e-mail from Facebook with instructions on how 

to start a private chat with an online crisis representative from the National Suicide Prevention Lifeline 

(800–273–TALK/8255). Mobile apps are also now available to help people with depression chart their 

moods and access crisis lines. 

Suicide prevention efforts must consider the best ways to use existing and emerging communication 

tools and applications, such as websites and social media, to promote effective suicide prevention efforts, 

encourage help seeking, and provide support to individuals with suicide risk. While more research is 

needed on how to best use emerging communication in suicide prevention, some guidance is available 

on best practices for the use of social media in health promotion. A guide from CDC offers several 

recommendations, such as: carefully planning how social media fits into an overall communications effort, 

understanding the level of effort needed to maintain these channels, and using these tools strategically by 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

making choices based on audience.62 Another CDC publication provides guidance on how to write more 

effectively using social media channels, such as Facebook, Twitter, and mobile phone text messaging.63

Suicide prevention programs that incorporate emerging technologies have a responsibility to ensure the 

safety of users. They should consider in advance how to monitor these channels regularly and respond 

to disclosures of suicidal thoughts or behaviors. These programs should include links to online crisis 

resources, such as the Lifeline (800–273–TALK/8255). In addition, because many of these media include 

user-generated content, it is important to think about how to ensure that messages are positive and 

promote hope, connectedness, social support, resiliency, and help seeking. 

Objective 2.4: Increase knowledge of the warning signs for suicide and of how 

to connect individuals in crisis with assistance and care. 

Family members, friends, teachers, coaches, coworkers, and others can play an important role in 

recognizing when someone is in crisis and connecting the person with sources of help. However, many of 

these persons may not know the warning signs of suicidal behavior or where a distressed person can go for 

help (see warning signs in the Introduction). It is crucial to widely disseminate information on warning 

signs, skills for interacting with individuals in crisis, and available resources (see Appendices D and E). In 

doing so, it is important to use communication strategies that are research-based, thoughtfully planned, 

and designed to meet the needs of specific groups. Incorporating stories of individuals who received help 

and benefited may motivate others to take action. 

In particular, there is a need to increase awareness of the role of crisis lines, such as the National Suicide 

Prevention Lifeline/Veterans Crisis Line (800–273–TALK/8255) and other local crisis services, in 

providing services and support to individuals in crisis. These service providers connect individuals in crisis 

with local sources of quality support, risk assessment, and thoughtful intervention. A crisis line that offers 

followup calls and services after an acute crisis can also help enhance safety and connect individuals with 

appropriate care and services. New and emerging technologies, such as telehealth, chat and text services, 

and online support groups, also show promise in allowing people to connect virtually to sources of care. 

Goal 3. Increase knowledge of the factors that offer protection from 

suicidal behaviors and that promote wellness and recovery. 

Although knowledge of effective treatment for mental and substance use disorders has increased over the 

years, the prejudice associated with these disorders and with suicide continues to prevent many individuals 

from seeking help. There is a need to support efforts to eliminate prejudice and discrimination, and to 

increase awareness of the factors that can help offer protection from suicide risk. 

As noted in the Introduction, connectedness to others, including family members, teachers, coworkers, 

community organizations, and social institutions, has been identified as an important protective factor.45 

These positive relationships can help increase a person’s sense of belonging, foster a sense of personal 

worth, and provide access to sources of support. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

It is also important to increase the understanding that mental and substance abuse disorders are treatable 

and that recovery is possible. All in the community should understand the important role they can 

play in promoting resilience and wellness and in promoting the full recovery of those who may be 

experiencing problems. 

Objective 3.1: Promote effective programs and practices that increase protection 

from suicide risk. 

Many factors can help prevent suicide by promoting physical, mental, emotional, and spiritual wellness. As 

noted in the Introduction, these protective factors include problem-solving skills and social support that 

can help individuals cope with emotional distress. The use of these tools should be the norm rather than 

the exception. They should be taught at early ages to strengthen the ability of individuals and communities 

to overcome challenges and crises. 

Connectedness to others is another key protective factor that reduces suicide risk. Several programs that 

have been shown to decrease suicidal thoughts or behaviors include connectedness components. For 

example, a program for American Indian/Alaska Native (AI/AN) youth engaged natural helpers from the 

neighborhood to identify and connect with at-risk youth.64 Connectedness was also the main component 

of a post-crisis suicide prevention program for adults who presented in a hospital emergency department 

(ED) for nonfatal, suicidal behaviors.65 Evidence from these and other programs suggest that promoting 

connectedness is a viable strategy for preventing suicidal behaviors. 

Policies and programs that foster social connectedness can help promote mental and physical health and 

recovery. In particular, these programs and policies should focus on the groups that may be the most 

isolated or marginalized. For example, social isolation can contribute to suicide and suicide attempts 

among older adults, many of whom may have lost friends and family and/or have activity limitations that 

make it difficult to stay connected with others. Family connectedness has been found to play an especially 

strong protective role against suicidal behaviors among lesbian, gay, and bisexual youth.66 

Many groups and organizations in the community, including schools, other youth-serving organizations, 

faith-based organizations, and local aging services networks, can contribute to suicide prevention by 

enhancing connectedness. These organizations can help ensure that social support is more widely available 

from peers and others. Specific training addressing suicide prevention could enhance these providers’ 

ability to provide support to individuals at risk and make appropriate referrals. 

Objective 3.2: Reduce the prejudice and discrimination associated with suicidal 

behaviors and mental and substance use disorders. 

Bias, prejudice, and discrimination discourage many people from seeking help, or even from sharing the 

psychological distress that could lead to suicidal behaviors. In some cases, cultural or religious beliefs 

that oppose suicide may help protect some individuals from suicidal behaviors. In others, they may 

present barriers to help seeking and can increase the distress of those who have been bereaved by suicide. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Strategies for addressing cultural or religious beliefs related to suicidal behaviors will be most effective 

when they are grounded in a full understanding of and respect for the cultural context of these beliefs. 

Broad communication, public education, and public policy efforts are needed to promote mental health, 

increase understanding of mental and substance use disorders, and eliminate barriers to help seeking. 

These efforts should increase awareness that no one is immune from experiencing these disorders. Seeking 

treatment should be seen not as a sign of weakness, but as a step toward recovery. 

Objective 3.3: Promote the understanding that recovery from mental and 

substance use disorders is real and possible for all. 

Social attitudes, bias, and discrimination often present barriers to treatment and undermine the recovery 

of persons with mental or substance use disorders. Friends and family, health professionals, and others 

may at times be overly protective or pessimistic about what someone with a mental or substance use 

disorder will be able to achieve. These attitudes can undermine the person’s hope for the future and ability 

to recover. A better understanding of crisis, trauma, and recovery can help individuals and groups in the 

community promote resilience and wellness among all. 

It is important to increase awareness that, in most cases, individuals who have a mental or substance use 

disorder can recover and regain or attain meaningful lives. The disorder does not define the individual 

and, in fact, the experience can provide an opportunity for reflection and change. Family members, peers, 

mentors, individuals who have attempted suicide, individuals who have been bereaved by suicide, and 

members of the faith community can be important sources of support. These individuals can help promote 

hope and motivation for recovery; provide support for addressing specific stressors, such as the loss of a 

job; and help foster a sense of meaning, purpose, and hope. 

Goal 4. Promote responsible media reporting of suicide, accurate 

portrayals of suicide and mental illnesses in the entertainment 

industry, and the safety of online content related to suicide. 

Americans spend a substantial amount of time with communications media, including computers and 

mobile devices. The media can contribute to suicide prevention by helping to combat prejudice, providing 

opportunities for peer-to-peer support, and linking individuals in crisis with sources of help. In contrast, 

when not used responsibly, the media can work against suicide prevention. Cluster suicides and suicide 

contagion have been documented.67 Studies have shown that both news reports and fictional accounts of 

suicide in movies and television can lead to increases in suicide. As a result, it is important to encourage 

the media to present accurate and responsible portrayals of suicide and related issues (e.g., mental and 

substance use disorders, violence). 

Too often, portrayals in the news and entertainment media perpetuate the misperception that suicide 

cannot be prevented. There is a need to shift the focus of these portrayals to stories of those who have 

struggled, found help and appropriate treatment, and recovered. Stories addressing mental illness, 

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substance abuse, and/or suicidal behaviors should promote hope, resiliency, and recovery. This approach 

can motivate family, friends, and others to provide support and protection to individuals who may be at 

risk for suicide and make it easier for a person in crisis to seek help and regain a meaningful life. 

Objective 4.1: Encourage and recognize news organizations that develop and 

implement policies and practices addressing the safe and responsible reporting 

of suicide and other related behaviors. 

Responsible, culturally competent coverage of suicide and other related behaviors can play an important 

role in preventing suicide contagion. Shortly after the 2001 National Strategy was released, several public 

and private groups came together to develop and promote a set of media recommendations entitled 

Reporting on Suicide: Recommendations for the Media. These recommendations were disseminated to 

the media through national, state, and tribal organizations. A followup workshop aimed at updating the 

recommendations took place in August 2009. Recommendations for media reporting of suicide were 

issued in April 2011 and are posted online (www.reportingonsuicide.org).68 

Objective 4.2: Encourage and recognize members of the entertainment industry 

who follow recommendations regarding the accurate and responsible portrayals 

of suicide and other related behaviors. 

Depictions of suicide are common in the entertainment media. In 2009, the Entertainment Industries 

Council created a guide for the entertainment industry entitled Picture This: Depression and Suicide 

Prevention.

69 The guide can help creators of entertainment content provide responsible portrayals of 

suicidal behaviors, mood disorders, and related issues. 

Recognition programs and other incentives can help promote greater awareness and adoption of these 

recommendations. Two examples are the PRISM Awards and the Voice Awards. The Voice Awards honor 

consumers and peer leaders who share their stories of recovery, as well as writers and producers who have 

given a voice to people with behavioral disorders by incorporating dignified, respectful, and accurate 

portrayals of these individuals into film and television productions. A nationally televised awards show, 

the PRISM Awards recognize the accurate depiction of substance abuse and mental illness prevention, 

treatment, and recovery in film, television, interactive, music, DVD, and comic book entertainment. 

Objective 4.3: Develop, implement, monitor, and update guidelines on the 

safety of online content for new and emerging communication technologies and 

applications. 

Recommendations relevant to new media are included on the website addressing the safe reporting of 

suicide discussed under Objective 4.1. All websites that post content developed by online users should 

adopt best practices to promote safety. At a minimum, the site should have a help center with supportive 

materials, policies addressing online safety, and information on crisis resources. Whenever possible, sites 

that host content generated by users should implement the latest recommendations on how to promote 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

the online safety of users. These recommendations should be continuously reviewed and updated 

to address new technologies, applications, and uses. As new media tools come into widespread use, 

recommendations related to suicide prevention should be continuously reviewed and updated for use with 

these technologies. 

Objective 4.4: Develop and disseminate guidance for journalism and mass 

communication schools regarding how to address consistent and safe messaging 

on suicide and related behaviors in their curricula. 

Schools of journalism, film, and other disciplines in the communications field play an important role 

in training future journalists, writers, editors, photographers, directors, and other producers of media 

content. The responsible depiction of suicidal behaviors and behavioral disorders should be addressed in 

educational curricula of these schools and by the professions’ ethics governing bodies. 

Because the sensational sells, many forces may push journalists to cover suicide in ways that are not 

consistent with suicide prevention. Curriculum guidance should recognize this reality and make 

the case for the responsible portrayal of suicide in ways that will resonate with journalists and other 

content developers. 

What You Can Do to Advance the Goals and Objectives in Strategic 

Direction 1 of the National Strategy for Suicide Prevention 

The Federal Government Can: 

Provide information on suicide prevention to the federal workforce. (Objective 1.1)



Participate in the National Action Alliance for Suicide Prevention, a public-private partnership 
 

dedicated to advancing the National Strategy for Suicide Prevention. (Objective 1.4)



Ensure that promotion of the National Strategy for Suicide Prevention is included in the overall 
 

advancement and oversight of the National Prevention Strategy. (Objective 1.4)
 


State, Territorial, Tribal, and Local Governments Can: 

Identify a lead agency to coordinate and convene public and private stakeholders, assess needs 

and resources, and develop and implement a comprehensive strategic suicide prevention plan. 

(Objective 1.2) 

Develop and implement an effective communications strategy for promoting mental health and 

emotional well-being that incorporates traditional and new media. (Objective 2.1) 

Disseminate Recommendations for Reporting on Suicide to news organizations. (Objective 4.1) 

Businesses and Employers Can: 

Implement organizational changes to promote the mental and emotional health of employees. 
 

(Objectives 1.1 and 3.1)



Ensure that mental health services are included as a benefit in health plans and encourage 
 

employees to use these services as needed. (Objective 1.5)



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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


Health Care Systems, Insurers, and Clinicians Can: 

Communicate messages of resilience, hope, and recovery to patients, clients, and their families with 

mental and substance use disorders. (Objective 3.3) 

Schools, Colleges, and Universities Can: 

Implement programs and policies to prevent abuse, bullying, violence, and social exclusion. 

(Objectives 1.1 and 3.1) 

Implement programs and policies to build social connectedness and promote positive mental and 

emotional health. (Objectives 1.1 and 3.1) 

Integrate information about the responsible depiction of suicide and suicide-related behaviors into 

the curricula of schools of journalism, film, and other communications disciplines. (Objective 4.4) 

Nonprofit, Community-, and Faith-Based Organizations Can: 

Participate in local coalitions of stakeholders to promote and implement comprehensive suicide 

prevention efforts at the community level. (Objective 1.2) 

Develop and implement communication strategies that convey messages of help, hope, and 

resiliency. (Objectives 2.1 and 3.2) 

Provide opportunities for social participation and inclusion for those who may be isolated or at risk. 

(Objective 3.1) 

Individuals and Families Can: 

Build strong, positive relationships with family and friends. (Objective 3.1) 

Become involved in their community (e.g., mentor or tutor youth, join a faith or spiritual community, 

reach out to older adults in the community). (Objective 3.1) 

Strategic Direction 2: 
 

Clinical and Community Preventive Services



Suicide affects people of all ages in all parts of the country. The factors that contribute to these preventable 

deaths are multiple and complex. Some of the factors that can increase the risk for suicidal behaviors 

may be longstanding, such as having a substance use disorder. Others, such as the loss of a loved one or 

career failure, may be recent events that could increase the immediate risk for suicidal behaviors. Suicide 

prevention requires that support systems, services, and resources be in place to promote wellness and help 

individuals successfully navigate these challenges. 

Clinical and community-based programs and services play a key role in promoting wellness, building 

resilience, and preventing suicidal behaviors among various groups. Clinical preventive services, including 

suicide assessment and preventive screening by primary care and other health care providers, are crucial to 

assessing suicide risk and connecting individuals at risk for suicide to available clinical services and other 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

sources of care. Screening for depression and alcohol misuse have been endorsed by the United States 

Preventive Services Task Force and are now covered as preventive services under Medicare. 

A wide range of community partners, including schools, workplaces, and faith-based organizations, 

also have an important role to play in delivering prevention programs and services to diverse groups 

at the local level. These community-based professionals and organizations should be competent in 

serving various groups, including racial, ethnic, sexual, and gender minorities, in a way that is culturally 

and linguistically appropriate. Greater coordination among community and clinical preventive service 

providers can have synergistic effects in preventing suicide and related behaviors. 

Goal 5. Develop, implement, and monitor effective programs that 

promote wellness and prevent suicide and related behaviors. 

Suicide prevention requires that appropriate community-based and preventive clinical supports be 

available at the state/territorial, tribal, and local levels to assist individuals with suicide risk. These 

programs should support the active participation of a diverse range of community members in suicide 

prevention programs, including professionally trained helpers and other care providers. Clinical and 

community-based services should seek to promote wellness, reduce risk factors, increase resilience and 

protective factors, link individuals in crisis with appropriate services and supports, and address the 

environmental and social conditions that can contribute to suicidal behaviors. 

In developing, implementing, and monitoring programs, it is critical to use suicide prevention strategies 

that have been shown to be effective. As noted in the Introduction, two important resources for identifying 

evidence-based programs and best practices are NREPP and BPR. For more information on these and 

other resources, see Appendix E. 

Objective 5.1: Strengthen the coordination, implementation, and evaluation 

of comprehensive state/territorial, tribal, and local suicide prevention 

programming. 

The goal of saving lives can only be achieved by a combination of efforts at multiple levels. States, 

territories, tribes, and communities can play an important role in implementing suicide prevention 

programs that can meet the needs of diverse groups. In doing so, it is important to involve multiple 

partners, including agencies and organizations involved in public health, behavioral health, injury 

prevention, and other areas. 

Suicide prevention efforts should engage multiple partners and sectors, focus on the entire lifespan, 

and provide services that are culturally and geographically appropriate. Although most states have a 

suicide prevention plan in place, there is much variation among plans. For example, while most plans 

focus on the entire lifespan, some address only children and/or youth. Most plans do not include 

private sector involvement. Furthermore, many do not identify staff positions that are fully dedicated 

to suicide prevention and that can support the work of planning, implementation, and evaluation at the 

community level. It is also important to ensure that suicide prevention efforts include a diverse mix of 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

community level participants. In addition, these efforts should be evaluated and modified accordingly to 

assure effectiveness. 

Objective 5.2: Encourage community-based settings to implement effective 

programs and provide education that promote wellness and prevent suicide and 

related behaviors. 

Many institutions, agencies, and organizations in the community have a role to play in promoting 

health, reducing risk factors, increasing protective factors, training personnel who are in contact 

with individuals with suicide risk, and providing support to individuals in crisis. As noted in the 

Institute of Medicine’s (IOM) 2009 report Preventing Mental, Emotional, and Behavioral Disorders Among 

Young People: Progress and Possibilities, these settings include the home, school, and neighborhood 

agencies. A few examples include: 

Faith-based organizations; 

Institutions in the justice system; 

Law enforcement institutions; 

Organizations providing health care; 

Organizations serving older adults; 

Schools, youth-serving organizations, colleges, universities, and vocational training institutions; 

Veterans service organizations; and 

Workplaces. 

Engaging these and other community groups can greatly expand the reach of suicide prevention efforts, 

making it possible to provide assistance and support to individuals who may be most vulnerable 

and/or underserved. 

Objective 5.3: Intervene to reduce suicidal thoughts and behaviors in 

populations with suicide risk. 

As noted in the Introduction, several groups may be at an increased risk for suicidal behaviors. Risk and 

protective factors can vary across communities and change over time. Different interventions are needed 

to meet the distinctive needs of these diverse groups. Local and state suicide prevention programs must 

continuously identify at-risk groups and develop and implement programs tailored to these groups’ unique 

needs. Each planned initiative should also rigorously assess outcomes, both desired and unanticipated. 

Many seemingly sensible prevention programs have proven futile, in large part because they were not 

designed to carefully define, monitor, and assess important implementation steps. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Several groups that have a higher risk for suicidal behavior are listed in Appendix D, which includes 

information on specific risk and protective factors, evidence-based interventions and best practices for 

suicide prevention, and resources. 

Objective 5.4: Strengthen efforts to increase access to and delivery of effective 

programs and services for mental and substance use disorders. 

Having a serious mental disorder such as major depression or bipolar disorders is a recognized risk factor 

for suicidal behaviors.71 This is particularly true if the person also has a substance use disorder. Yet many 

individuals with these disorders lack access to behavioral health care. 

Health care systems should be encouraged to recognize and respond to mental and substance use problems 

in the same way they respond to physical health problems. Parity laws, which have been enacted at the 

federal and state levels, seek to accomplish this by requiring that health care plans provide the same level of 

benefits (e.g., visit limits, deductibles, copayments) for a mental or substance use disorder as for a physical 

health problem. 

Greater coordination among the different programs that provide services addressing mental health, 

substance use, and physical health care will also increase access to care. This coordination can range from 

information sharing among different service providers to the delivery of these various services in the same 

setting. These linkages will help provide multiple access points for behavioral health care (many “right 

doors” to treatment), thereby helping to ensure that individuals who may be at risk for suicidal behaviors 

are connected to appropriate sources of care. 

Goal 6. Promote efforts to reduce access to lethal means of suicide 

among individuals with identified suicide risk. 

Restricting access to suicide methods that are highly lethal and commonly used is a proven strategy for 

decreasing suicide rates.72, 73 While some suicidal crises last a long time, others are short-lived. Reducing 

access to lethal means during periods of crisis can make it more likely that the person will delay or survive 

a suicide attempt. In either case, the person’s odds of long-term survival are improved. 

In 2009, about half of suicides in the United States resulted from the use of firearms, followed by 

suffocation (24 percent), poisons and drug overdoses (14 percent), carbon monoxide gas (3 percent), and 

jumps (2 percent).1

 Psychological autopsy studies, other case control studies, and ecologic studies have 

found that firearm access is a risk factor for suicide in the United States.74-77 Individuals who own firearms 

are not more likely than others to have a mental disorder or have attempted suicide.78-80 Rather, the risk of 

a suicide death is higher among this population because individuals who attempt suicide by using firearms 

are more likely to die in their attempts than those who use less lethal methods. 

Individuals experiencing significant distress or who have a recent history of suicidal behavior should 

not have easy access to means that may be used in a suicide attempt, including firearms, other weapons, 

medications, illicit drugs, chemicals used in the household, other poisons, or materials used for hanging 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

or suffocation. Installing bridge barriers or otherwise restricting access to popular jump sites may also 

prevent deaths, depending on specific local conditions. 

Although this goal focuses on reducing access to lethal means among individuals at risk, evidence for 

means restriction has come from situations in which a universal approach was applied to the entire 

population. For example, the detoxification of domestic gas in the United Kingdom and discontinuation 

of highly toxic pesticides in Sri Lanka were universal measures associated with 30 percent and 50 percent 

reductions in suicide, respectively.81, 82 

Objective 6.1: Encourage providers who interact with individuals at risk for 

suicide to routinely assess for access to lethal means. 

Professionals who provide health care and other services to patients or clients at risk for suicide and their 

families and other caregivers are in a unique position to ask about the presence of lethal means and work 

with these individuals and their support networks to reduce access. These professionals may include health 

care providers, social service workers, clergy, first responders, school personnel, professionals working in 

the criminal justice system, and others who may interact with individuals in crisis. These providers can 

educate individuals with suicide risk and their loved ones about safe firearm storage and access, as well 

as the appropriate storage of alcoholic beverages, prescription drugs, over-the-counter medications, and 

poisons that may be available in the household. However, many may fail to do so, or do so only when a 

patient is identified as being at a very high risk for suicide. 

There are steps that can be taken to prevent accidents as well as suicides. Providers should also 

educate patients and care providers about reducing the stock of medicine in the medicine cabinet to a 

nonlethal quantity, and locking medicines that are commonly abused (e.g., prescription painkillers and 

benzodiazepines, which are medications used to induce sleep, relieve anxiety and muscle spasms, and 

prevent seizures). This approach can be useful in helping to prevent suicide, as well as unintentional 

overdoses and substance abuse. 

Objective 6.2: Partner with firearm dealers and gun owner groups to incorporate 

suicide awareness as a basic tenet of firearm safety and responsible firearm 

ownership. 

Among persons who attempt suicide, those who use firearms are more likely to die than those who use 

other means. Reaching out to gun owners, firearm dealers, shooting clubs, hunting organizations, and 

others to promote firearm safety and increase their involvement in suicide prevention is an important 

strategy for reducing suicide risk. 

Most firearm safety educational materials focus on the prevention of accidents rather than suicide. 

Brochures and websites promoting firearm safety to gun owners could include a statement regarding the 

importance of being alert to signs of suicide in a loved one and keeping firearms out of the person’s reach. 

For example, all firearms in the household could be temporarily stored with a friend or relative or in 

storage facility. At a minimum, all guns should be securely locked away from the vulnerable person’s access 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

until he or she has recovered. Partnering with gun-owner groups to craft and deliver this message will help 

ensure that it is culturally relevant, technically accurate, comes from a trusted source, and does not have an 

anti-gun bias. 

Most gun-owner groups promote the safe storage of firearms when not in use (i.e., stored locked and 

unloaded, with ammunition locked separately) to protect against accidents, theft, and unauthorized use. 

The safe storage of firearms among the general population can help prevent suicide, particularly from 

attempts that take place during short-lived crises and attempts made by individuals living in a household 

where firearms are present. Gun-owner groups are in an excellent position to promote this message. 

Objective 6.3: Develop and implement new safety technologies to reduce access 

to lethal means. 

Many safety technologies can help prevent suicide by reducing access to lethal means of self-injury. New 

technologies can also be used to prevent suicide by poisoning by reducing the carbon monoxide content 

of motor vehicle exhaust, restricting pack sizes to prevent overdoses of more toxic medications, and 

encouraging the use of electronic pill dispensing lockboxes for people who rely on medication but are 

at risk of overdosing. Options for preventing suicide from jumps include incorporating architecturally 

unobtrusive barriers into the original design of high bridges and/or retrofitting bridges that are currently 

popular jump sites. These types of approaches should be used more widely. There is also a need to research, 

develop, and implement other technologies that will prevent suicide by reducing access to lethal means. 

Goal 7. Provide training to community and clinical service providers 

on the prevention of suicide and related behaviors. 

All community-based and clinical prevention professionals whose work brings them into contact with 

persons with suicide risk should be trained on how to address suicidal thoughts and behaviors and on how 

to respond to those who have been affected by suicide. These professionals include: 

Adult and child protective service professionals; 

Bank, mortgage, and financial service providers; 

Crisis line staff and volunteers; 

Divorce, family law, criminal defense, and other attorneys, as well as others involved in the criminal 

and civil justice systems; 

Employee assistance programs and other human resource professionals in the workplace; 

Educators and school personnel; 

Faith-based professionals; 

First responders, including law enforcement, fire department, and EMS; 

Funeral home directors and staff; 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Health care providers, including behavioral health care professionals; 

Professionals who serve the military and veterans; 

Providers of aging services; and 

Social service and human service providers. 

Training programs should be tailored to the specific needs and roles of the providers and be regularly 

updated and refreshed to reflect new knowledge in the field and over time. 

Objective 7.1: Provide training on suicide prevention to community groups that 

have a role in the prevention of suicide and related behaviors. 

Thousands of first responders, crisis line volunteers, law enforcement professionals, clergy, teachers, 

school counselors, individuals working in the justice system and/or in law enforcement, and others who 

are on the frontlines of suicide prevention should be trained on suicide prevention. A number of training 

curricula exist to address the distinct needs of these various groups.83 These training programs should 

continue to be implemented, evaluated, and updated. New programs should be developed to meet the 

needs of different at-risk populations and types of community service providers. In addition, there is a 

need to make education programs available to family members and others who are in close relationships 

with persons at risk for suicide or who have been affected by suicidal behaviors. 

Objective 7.2: Provide training to mental health and substance abuse providers 

on the recognition, assessment, and management of at-risk behavior, and the 

delivery of effective clinical care for people with suicide risk. 

Mental health and substance abuse providers should have the essential foundation of attitudes, knowledge, 

and clinical prevention skills to address and reduce suicide risk and increase protective factors among 

patients. Caring for individuals with suicide risk requires being able to work collaboratively with the 

patient. Skill development, practice using those skills, and a culture of shared responsibility can help build 

comfort, confidence, and competency to engage and care for these individuals. 

Training programs for mental health and substance abuse providers should seek to: 

Increase feelings of confidence and empowerment in working with patients with suicide risk; 

Address the emotional and legal issues associated with adverse patient outcomes, including death 
 

by suicide;
 


Equip practitioners with attitudes, knowledge, and skills to cope with sentinel events (unanticipated 

events resulting in death or serious physical or psychological injury), along with effective clinical 

preventive procedures to minimize risk of litigation; 

Educate practitioners about how to exchange confidential patient information appropriately to
 


promote collaborative care while safeguarding patient rights;
 


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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Address the value of a team-based approach to management of suicide risk; 

Provide practitioners with clinical preventive skills to engage in shared services for persons with
 


suicide risk, including addressing the value of shared responsibility and collaborative care, and 
 

increasing knowledge and skills for communicating collaboratively with patients, families, significant 
 

others, and other providers to ensure continuity of care;
 


Include cultural competency training components specifically focused on ethnic/racial identity 
 

formation and LGBT identity development; and
 


Address the provision of effective support services for those who have been bereaved by suicide. 

These training objectives should guide the development of the core education and training guidelines 

discussed under Objective 7.3. 

Objective 7.3: Develop and promote the adoption of core education and training 

guidelines on the prevention of suicide and related behaviors by all health 

professions, including graduate and continuing education. 

All education and training programs for health professionals, including graduate and continuing education 

programs for these professions, should adopt core education and training guidelines addressing the 

prevention of suicide and related behaviors. All degree-granting undergraduate and graduate programs 

in relevant professions should include these guidelines as a part of their curricula. Programs should also 

ensure that graduates achieve the relevant core competencies in suicide prevention appropriate for their 

respective discipline. For example, guidelines for the graduate and continuing education of clinicians 

should address the safer dispensing of medications for individuals at high risk for suicide. A useful 

resource for primary care providers is the review article Practical Suicide-Risk Management for the Busy 

Primary Care Physician, which provides a summary of how to identify patients at risk for suicide, assess 

them, and manage suicide risk.84 

Objective 7.4: Promote the adoption of core education and training guidelines 

on the prevention of suicide and related behaviors by credentialing and 

accreditation bodies. 

The inclusion of core education training in recertification or licensing programs can help ensure that 

professionals who have completed training acquire competence in addressing suicidal behaviors and 

remain competent over time. In most states and territories, physicians, psychologists, social workers, 

nurses, and other health professionals must complete licensing examinations or recertification programs 

in order to maintain active licenses and/or professional certifications. Accrediting and credentialing 

organizations should promote evidence-based and best practice suicide prevention training for the 

organizations and practitioners they accredit or credential. In addition, because suicide shares risk and 

protective factors with mental and substance use disorders, as well as with trauma and interpersonal 

violence, suicide-related curricula should be linked with training on these related topics. Accreditation 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

standards should be encouraged to require that professionals be trained and tested on that content via 

certification and licensing exams. 

Many groups, including state governments, can help support the incorporation of suicide prevention into 

the training of professionals in various disciplines. As an example, the State of Washington has passed 

a law requiring that a broad array of health professionals (e.g., mental health counselors, psychologists, 

family therapists) complete a training program in suicide prevention at least once every 6 years. Known as 

the Matt Adler Suicide Assessment, Treatment, and Management Training Act of 2012, the law comes into 

effect in January 2014. 

Objective 7.5: Develop and implement protocols and programs for clinicians 

and clinical supervisors, first responders, crisis staff, and others on how to 

implement effective strategies for communicating and collaboratively managing 

suicide risk. 

Communication and collaboration across multiple levels of care is a key to the successful management 

of suicide risk. Clinical preventive and communication protocols for clinicians and clinical supervisors, 

emergency workers, crisis staff, professionals who provide adult and child protective services, and others 

providing support to individuals with suicide risk can help improve communication and collaborative 

management of suicide risk. Care for individuals with suicide risk must be comprehensive and continuous 

until the risk is reduced. Each setting and service provider has an important role in verifying that the 

subsequent supportive services have the information and resources they need in order to help keep the 

individual safe. 

Protocols and programs for clinicians and clinical supervisors, first responders, crisis staff, and 

others should address the implementation of effective strategies for improving communication and 

collaboratively managing suicide risk. In particular, there is a need to promote the sharing of information 

among different providers and the use of team-based care for managing suicide risk. 

A promising example of a collaborative care approach to suicide prevention is the Prevention of Suicide in 

Primary Care Elderly: Collaborative Trial (PROSPECT). Conducted in 20 primary care practices in urban, 

suburban, and rural areas, the study found that collaborative care was more effective than treatment as 

usual in reducing suicide risk in patients aged 60 years or older.85 Care managers, including social workers, 

nurses, and psychologists, implemented the intervention, which helped physicians to recognize depression, 

offered recommendations, monitored depressive symptoms and side effects, offered interpersonal 

psychotherapy (IPT) to patients who refused medication, and provided followup, including making house 

calls to patients unable to travel. At the end of this 2-year trial, suicidal ideation was 2.2 times less likely in 

the collaborative care group than in the comparison group. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


What You Can Do to Advance the Goals and Objectives in Strategic 

Direction 2 of the National Strategy for Suicide Prevention 

The Federal Government Can: 

Provide education, training, and resources on the signs and symptoms of suicide and suicidal 

behaviors and where to go for help. (Objectives 5.2, 5.3, and 7.1) 

Support states, tribes, and communities in the implementation of suicide prevention interventions 

and policies. (Objectives 5.1 and 5.2) 

State, Territorial, Tribal, and Local Governments Can: 

Identify groups at risk and work with various stakeholders to implement suicide prevention policies 

and programs that address the needs of these groups. (Objectives 5.2 and 5.3) 

Sponsor trainings and disseminate information on means restriction to mental health providers, 

professional associations, and patients and their families. (Objective 6.1) 

Sponsor medication take-back days and ongoing methods for the disposal of unwanted medications 

(e.g., secure collection kiosks at police departments or pharmacies). (Objective 6.1) 

Businesses and Employers Can: 

Train employees and supervisors to recognize coworkers in distress and respond appropriately. 
 

(Objectives 5.2 and 7.1)



Health Care Systems, Insurers, and Clinicians Can: 

Screen for mental health needs, including suicidal thoughts and behaviors, and make referrals to 

treatment and community resources, as needed. (Objective 5.3) 

Incorporate lethal means counseling into suicide risk assessment protocols and address means 

restriction in safety plans. (Objective 6.1) 

Increase the capacity of health care providers to deliver suicide prevention services in a linguistically 

and culturally appropriate way. (Objective 7.2) 

Schools, Colleges, and Universities Can: 

Ensure that students at risk of suicide have access to mental health and counseling services and are 

encouraged to use those services. (Objective 5.2) 

Train relevant school staff to recognize students at potential risk of suicide and refer to appropriate 

services. (Objective 7.1) 

Integrate appropriate core suicide prevention competencies into relevant curricula (e.g., nursing, 

medicine, allied health, pharmacy, social work, education). (Objective 7.3) 

Nonprofit, Community-, and Faith-Based Organizations Can: 

Implement suicide prevention programs that address the needs of groups at risk for suicide and that 

are culturally, linguistically, and age appropriate. (Objective 5.3) 

Initiate partnerships with firearm advocacy groups (e.g., retailers, shooting clubs, manufacturers, 

firearm retail insurers) to increase suicide awareness. (Objective 6.2) 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


Educate clergy, parent groups, schools, juvenile justice personnel, rehabilitation centers, defense 

and divorce attorneys, and others about the importance of promoting efforts to reduce access to 

lethal means among individuals at risk for suicide. (Goal 6) 

Individuals and Families Can: 

Learn the signs and symptoms of suicide and suicidal behaviors and how to reach out to those who 

may be at risk. (Objective 5.3) 

Store household firearms locked and unloaded with ammunition locked separately and take 
 

additional measures if a household member is at high risk for suicide. (Objective 6.1)



Dispose of unwanted medications, particularly those that are toxic or abuse-prone, and take 

additional measures (e.g., a medication lock box) if a member of the household is at high risk for 

suicide. (Objective 6.1) 

Strategic Direction 3: 

Treatment and Support Services

Individuals at high risk for suicide require clinical evaluation and care to identify and treat mental 

health and medical conditions, and to specifically address suicide risk. In the past, it was believed that 

appropriately treating underlying conditions (e.g., mood disorders, substance abuse) would remove the 

risk for suicide. However, this is not always the case. A growing body of evidence suggests that suicide 

prevention is enhanced when specific treatments for underlying conditions are combined with strategies 

that directly address suicide risk. 

Evidence-based and promising approaches for caring for high-risk patients include safety planning 

(i.e., working collaboratively with each patient to develop an action plan for times of crises) and specific 

forms of psychotherapy that can be used to support treatment for underlying mental health conditions. 

Addressing suicide risk may be particularly important when treating individuals who have survived a 

suicide attempt. There is now substantial evidence that interventions such as dialectical behavior therapy 

(DBT) and cognitive behavior therapy for suicide prevention (CBT-SP) can help reduce suicidal behaviors 

among these patients. In addition, clozapine has been found to be effective in reducing suicidal behaviors 

among patients with schizophrenia86 and lithium shows promise in patients with mood disorders.87 

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Principles that should guide care for individuals with high suicide risk include the following: 

Provision of evidence-based treatment as soon as possible after suicide risk is identified; 

Person- and relationship-centered care, which includes improving patient-provider communication, 
 

involving individuals with suicide risk in the development of safety plans, and providing care that is 
 

matched to the person’s level of risk, needs, and preferences;
 


Culturally competent care that addresses the needs of diverse groups of patients, including linguistic, 
 

racial/ethnic, sexual, and gender minorities;
 


Multiple points of access to appropriate treatment and a focus on providing support in the least 
 

restrictive environment;
 


Integration of care across various systems and settings (via several possible models, from
 


communication and collaboration to full integration) and shared reporting of client outcomes;
 


Continuity of care for individuals with suicide risk with a particular focus on immediate (if possible, 

within 48 hours) and continuous followup after a suicide attempt following discharge from a hospital, 

ED, or other inpatient facility; 

Appropriate empowerment of families and significant others in treatment, peer support, and 
 

post-discharge followup;
 


Use of systems-level strategies, such as establishing the organizational goal of eliminating deaths by 

suicide, tracking and investigating suicide deaths, and using other continuous quality improvement 

efforts; and 

Recovery-oriented services that are based on the following understanding: recovery emerges from 

hope, is person-driven, occurs through many pathways, is holistic, is supported by peers and allies, 

is supported through relationships and social networks, is culturally based, is grounded in respect, is 

supported by addressing trauma, and involves the individual, family, and community.88 

Goal 8. Promote suicide prevention as a core component of health 

care services. 

The use of comprehensive, systems-level strategies that make suicide prevention a core goal has 

been shown to improve outcomes for patients with suicide risk. A 2011 report by the Clinical Care 

and Intervention Task Force of the Action Alliance identified several of these programs.89 Of these 

interventions, the most thoroughly researched is the U.S. Air Force Suicide Prevention Program, which has 

been found to reduce death by suicide by one-third.16 

The integration of suicide prevention into the delivery of mental health services has also been found 

to help prevent suicides in the United Kingdom. A study that examined data from 91 mental health 

service organizations in England and Wales found that the implementation of key suicide prevention 

recommendations was associated with a reduction in suicide rates among patients.50 Providing 24-hour 

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crisis care was associated with the greatest reduction in suicide rates. Other recommendations included: 

assertive, proactive outreach; followup within 7 days of inpatient discharge; training of clinical staff in the 

management of suicide risk every 3 years; a dual diagnosis policy for those with both mental disorders and 

substance abuse; and multidisciplinary review and information sharing with families following a suicide. 

VA and its health system, the Veteran’s Health Administration (VHA), also have adopted a comprehensive 

approach in which suicide prevention is a core component of mental health and substance abuse services. 

As part of this approach, a suicide prevention coordinator is placed at every VA medical center in the 

country. Preliminary data suggest that the implementation of these programs has been associated with 

a reduction in suicide among important high-risk subgroups of those receiving health care through the 

VHA, including men in midlife.90, 91 

Other programs that have garnered attention for their comprehensive approaches and that report 

promising preliminary data include the Henry Ford Health System’s (HFHS) “Perfect Depression Care”49 

and the Central Arizona Programmatic Suicide Deterrent Project.89 Although more research is needed, 

initial findings suggest that progress can be made when health systems or other organizations focus on 

making suicide prevention a core priority by obtaining leadership support, changing the organizational 

culture around suicide prevention, and engaging each component of a system to assume its legitimate role 

in suicide prevention. 

While providers of mental health and substance abuse services have a special responsibility for addressing 

suicide risk, suicide prevention should not be viewed as an area of specialization that applies only to 

these professionals or to a single setting, such as inpatient psychiatry. Suicide prevention requires the 

active engagement of health and social services, as well as the coordination of care across multiple 

settings, thereby ensuring continuity of care and promoting patient safety. Services addressing mental and 

substance use disorders, as well as suicide prevention, can be provided in numerous settings, including 

crisis centers, health centers, clinics, other locations serving particular groups (e.g., older adults), and in 

the home (e.g., visiting nurse services, home psychotherapy, or hospice care). 

There is substantial evidence that discontinuities in treatment and fragmentation of care can increase the 

risk for suicide. Death by suicide in the period after discharge from inpatient psychiatric units is more 

frequent than at any other time during treatment.92 Similarly, the time following ED discharge also is 

a period of high risk for suicide.93 There is also reason for substantial concern in the period following 

discharge from residential addiction treatment.94 Proactive followup and active engagement strategies 

following discharge have been found to help reduce death by suicide and suicide attempts.65, 95 

Increasing collaboration among providers is also a promising, viable, and efficient way to increase access to 

suicide prevention and treatment services. This approach can help minimize prejudice and discrimination, 

while increasing opportunities to improve overall health outcomes. Even in cases when full integration 

may not be feasible, increased coordination of services and continuity of care can greatly improve care and 

lead to better patient outcomes. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Objective 8.1: Promote the adoption of “zero suicides” as an aspirational goal 

by health care and community support systems that provide services and support 

to defined patient populations. 

In recent years, a small number of health care and community support systems that provide health 

care services to defined populations (also referred to as “boundaried” systems) have adopted a “zero 

suicides” goal for the population under their care. Within these types of health care systems, the goal of 

eliminating suicide can help set into place system-wide changes that enhance service access and quality 

through continuous improvement. Managing a system of care to achieve the goal of zero suicides requires 

organizations to evaluate performance rigorously and use adverse events as opportunities to improve their 

capacity to save lives. It also requires putting into place mechanisms to support clinicians in the aftermath 

of a patient’s death by suicide. 

Historically, there have been varied responses to providers who have lost patients to suicide. These have 

ranged from the sense that some deaths are inevitable in severe cases of mental illness, just as they are 

in cases of advanced cancer or heart failure, to the view that each death must reflect a failure or lapse 

in treatment. Although neither of these perspectives is universal, it is clear that each death represents 

an opportunity for systems and providers to evaluate the care they have delivered and to consider 

opportunities for improvement. Part of the zero suicides strategy may be for health systems to conduct a 

root cause analysis (a structured process used to determine the causes of an event) of suicide attempts and 

deaths, and to use findings to try to continuously improve service quality by focusing on systems issues 

rather than individual blame. The HFHS Perfect Depression Care program provides an example of this 

promising approach.49, 96 

Objective 8.2: Develop and implement protocols for delivering services for 

individuals with suicide risk in the most collaborative, responsive, and least 

restrictive settings. 

Trusting therapeutic relationships are fundamental to reducing suicide risk and promoting recovery and 

wellness. These relationships are most productive when the patient is actively engaged in making choices 

that will keep him or her safe. There is a need to promote culturally appropriate strategies that will foster 

therapeutic alliances between patients and providers. The personal needs, wishes, and resources of the 

patient should be the foundation for developing a plan for continuing care and safety. This plan should be 

developed through direct and open communication and should engage and empower the patient. Where 

appropriate and practical, families and significant others should be engaged and empowered as well. 

Psychiatric hospitalization, voluntary or involuntary, may be an effective mechanism for preventing suicide 

over the short term. However, the decision to hospitalize could be a barrier to the development of a longterm therapeutic alliance between the patient and his or her mental health providers. Short-term gains in 

safety may be neutralized or even outweighed by longer-term increases in risk if patients are reluctant to 

disclose suicidal thoughts because they perceive a lack of acceptance or sensitivity to cultural values, or if 

they are afraid of losing their autonomy or being forced into treatment. One way to address this trade-off 

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is to ensure that inpatient psychiatric units are recovery-oriented and prepared to ensure continuity of care 

at the point of discharge. Another strategy is to develop alternatives to hospitalization for persons who are 

not at imminent risk. 

There is also a need to identify alternatives to coercion, restraint, and involuntary treatment as ways to 

ensure the safety of patients in crisis. Because past trauma or abuse increases the risk for suicide, confining 

people against their will can retraumatize patients. It may also make these patients reluctant to seek help in 

the future for fear of being discriminated against, traumatized, or imprisoned. There is a need to develop 

and implement protocols for delivering services in the least restrictive settings consistent with safety. 

Protocols should be developed and implemented for delivering services to persons with high suicide risk 

that promote collaboration and responsiveness. At a minimum, these protocols would instill attitudes and 

beliefs on the value of shared responsibility and collaborative care and promote effective communication 

with patients, families, and significant others. 

Objective 8.3: Promote timely access to assessment, intervention, and effective 

care for individuals with a heightened risk for suicide. 

Timely access to care is critically important to individuals in crisis. Crisis hotlines, online crisis chat/ 

intervention services, self-help tools, crisis outreach teams, and other services play an important role in 

providing timely care to patients with high suicide risk. Virtual or remote care, such as telephone calls to 

crisis hotlines, and counseling by telephone, texting, or the Internet allow individuals in crisis to access 

help 24 hours a day, 7 days a week. This type of care typically is available at low or no cost to individuals 

in crisis and provides immediate access, convenience, and a higher level of anonymity than face-to-face 

therapy arrangements. 

Providing detailed instructions about how to access care 24 hours a day, 7 days a week is a critical part 

of safety planning for providers working with patients at high risk. It is unrealistic to expect individual 

providers to be available at all hours. There may be limitations to the coverage that provider organizations 

can offer. Providing patients with information about how and when to access care in an ED may be 

necessary but not sufficient. Access to virtual or remote care is critical for augmenting the care provided 

at clinics and private practices, which usually have limited hours of operation, and also can be useful for 

reaching rural and underserved populations. 

Objective 8.4: Promote continuity of care and the safety and well-being of all 

patients treated for suicide risk in emergency departments or hospital inpatient 

units. 

Patients leaving the ED or hospital inpatient unit after a suicide attempt, or otherwise at a high risk for 

suicide, require rapid, proactive followup. Having survived a suicide attempt is one of the most significant 

risk factors for later death by suicide. The risk is particularly high in the weeks and months following the 

attempt, including the period after discharge from acute care settings such as EDs and inpatient psychiatric 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

units.97, 98 Among patients with high suicide risk, particularly those who have attempted suicide, immediate 

followup and continuity of care are crucial to promoting positive outcomes.43 

When patients with high suicide risk come to an ED, they may receive limited mental health services,99

may not receive adequate treatment for underlying mental health or substance use disorders, and 

frequently do not receive any followup care.100, 101 All patients who present to the ED for a suicide attempt 

or who are at risk for suicide require mental health evaluations. Should they not require acute inpatient 

care, they should be informed about risks during the discharge period and be referred for mental health 

services before discharge from the ED. However, although referral is necessary, it may not be sufficient. 

There is increasing evidence that specific outreach programs can be highly effective in increasing the 

proportion of patients who engage in mental health care after hospitalization.102 

For patients who are transferred from the ED to medical-surgical services for the treatment of injuries 

related to a suicide attempt, followup mental health evaluations should be conducted before discharge to 

decide between transfer to a mental health inpatient unit or referral to outpatient care. These evaluations 

should consider the support available from family and friends and the patient’s clinical status. Before a 

decision to discharge is made, followup appointments for mental health care should be made and patients 

(and families or friends) should be coached about the importance of continuity in care. 

All patients who are admitted to an inpatient mental health unit require followup mental health services 

after discharge, as well as connections to community-based supports. Health care systems should seek 

to dramatically shorten the time between inpatient discharge and followup outpatient treatment. For 

example, EDs and others providing services to these patients could set a goal of ensuring that followup 

occurs within 48 hours or, at most, within a week of discharge. 

Continuity of care following a suicide attempt should represent a collaborative approach between patient 

and provider that gives the patient a feeling of connectedness. Strategies may include telephone reminders 

of appointments, providing a “crisis card” with emergency phone numbers and safety measures, and/or 

sending a letter of support.103 Many types of motivational counseling and case management can also be 

used to promote adherence to the recommended treatment. 

Objective 8.5: Encourage health care delivery systems to incorporate suicide 

prevention and appropriate responses to suicide attempts as indicators of 

continuous quality improvement efforts. 

Health care delivery systems should evaluate performance rigorously and incorporate suicide prevention 

and appropriate responses to suicide attempts in continuous quality improvement efforts, as a way to 

improve their capacity to save lives at risk. Such efforts could include formal root cause analyses of suicide 

attempts and deaths by suicide, supervisory reviews, reviews of aggregate data for trends, or focused 

quality assurance studies on issues related to suicide risk. Health care systems should consider whether 

the implementation of lessons learned can be part of a strategy aimed at eliminating suicides and part of 

overall quality improvement. Such reviews should focus on identifying systemic issues where improvement 

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holds promise for increasing the quality of care, and should not focus on attributing blame to providers or 

to individuals in crisis. 

Objective 8.6: Establish linkages between providers of mental health and 

substance abuse services and community-based programs, including peer 

support programs. 

To be effective in suicide prevention, providers of mental health and substance abuse services must 

coordinate services with each other and with other service providers in the community. It is generally 

recognized that mental health and substance abuse services can have a greater impact when community 

gatekeepers refer at-risk patients to these specialized providers. The effects of mental and substance use 

services can also be enhanced when specialized providers refer patients to community programs that can 

augment care. 

Timely and effective cooperation, collaboration, and communication between mental health and substance 

use providers and sources of support in the community are critical to promote patient safety and recovery. 

Mental health and substance abuse providers should develop linkages with community-based supports 

such as community agencies for suicide prevention, mental health advocacy organizations, aging services 

organizations, veterans support organizations, and programs providing peer support services. These 

programs can help foster a sense of connection and belonging and provide critically needed services 

including employment and vocational help, housing assistance, social interactions that are not focused on 

illness, and peer support. 

Objective 8.7: Coordinate services among suicide prevention and intervention 

programs, health care systems, and accredited local crisis centers. 

Increased collaboration and coordination among suicide prevention programs, health care systems 

addressing mental health and substance abuse, and local crisis centers can help provide a continuum of 

care for individuals at risk for suicide. Health care providers and organizations that conduct assessments of 

suicide risk must have access to mental health and substance abuse services for patients with high suicide 

risk. Such support can be obtained from local mental health providers or can be provided remotely (e.g., 

telephone, online) by crisis service organizations. 

A growing network of crisis services organizations can serve an effective option for continuous care. Many, 

including the certified crisis centers in the National Suicide Prevention Lifeline (800–273–TALK/8255) 

network, offer trained personnel who can conduct remote assessments, coordinate linkage for care, and 

provide followup for persons at risk. A prototype for integrating crisis and clinical services is the VA crisis 

line and its relationship with the National Suicide Prevention Lifeline. In the VA system, call responders 

regularly interact with providers at the medical center nearest to the patient to arrange and facilitate 

followup. 

The Massachusetts Statewide Advocacy for Veterans’ Empowerment (SAVE) program provides another 

example of the benefits of coordinating services.104 The program works to prevent suicide and mental 

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health distress by serving as a liaison with the various agencies within the federal and state governments, 

thereby ensuring access to benefits and services that address these issues and contribute to a positive 

transition to civilian life. 

Objective 8.8: Develop collaborations between emergency departments and 

other health care providers to provide alternatives to emergency department 

care and hospitalization when appropriate, and to promote rapid followup after 

discharge. 

Patients with high suicide risk often are treated at EDs, and may be hospitalized as a way to prevent a 

suicide attempt. Although this can be an effective strategy and is necessary as a safety measure, there is a 

need to develop alternatives. Research has shown that the proportion of individuals attempting suicide 

who are discharged directly from the ED to the community has been increasing.105 Discharge from the 

ED may be clinically appropriate, but it requires that adequate supports and followup be in place. In 

addition, not every ED has the capacity to provide suicide risk assessment.99 One strategy is for primary 

care, mental health, and substance use programs to establish mechanisms to facilitate rapid access to their 

services when patients are in crisis. Another is to develop alternative services that can be accessed through 

EDs. For example, a crisis line could arrange for appointments with providers in the community while the 

patient is in the ED. 

Collaborations among EDs and community providers, such as health and mental health centers, crisis 

centers, hotlines, and outreach teams, can improve the quality and continuity of care for these high-risk 

patients. These collaborations can help expand alternatives to EDs, such as the same day scheduling for 

mental health services and in-home crisis care, and secure rapid and continuous followup after discharge. 

Plans for discharge from the ED must incorporate linkages to other necessary levels of care (e.g., intensive 

outpatient, private therapist, pharmacological therapy). Organizations must recognize, accept, and 

implement shared service responsibilities among various clinical staff within the organization and among 

providers in the larger community. 

Goal 9. Promote and implement effective clinical and professional 

practices for assessing and treating those identified as being at risk 

for suicidal behaviors. 

Primary care physicians play an important role in the assessment and management of suicide risk. It is 

estimated that 75 percent of individuals who die by suicide are in contact with a primary care physician in 

the year before their death, and that 45 percent do so within one month of their death.106 In contrast, only 

20 percent of these patients saw a mental health professional in the preceding month. 

Effective clinical and professional practices in the assessment and treatment of individuals with high 

suicide risk can help prevent these individuals from acting on their despair and distress in self-destructive 

ways. These practices should be grounded in evidence-based care or in best practices, in cases where 

promising approaches have been identified but more research is needed. 

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Suicide risk assessment programs often target patients with known risk factors for suicide, including 

those who have previously expressed suicidal thoughts or made a suicide attempt and persons with 

mood or substance use disorders. Treatment of patients with suicide risk often includes medication 

(e.g., antidepressants) and psychosocial approaches such as cognitive-behavioral therapy and supportive 

counseling. Because suicide attempts are known to be a strong predictor of future attempts and deaths by 

suicide, continuity of care is critical for these patients. Effective clinical care should include monitoring 

patients for a suicide attempt after an ED visit or hospitalization and providing outreach, mental health 

followup, therapy, and case management. 

Objective 9.1: Adopt, disseminate, and implement guidelines for the assessment 

of suicide risk among persons receiving care in all settings. 

The assessment of suicide risk is critical to identifying high-risk individuals and providing needed 

services and supports. Assessment of suicide risk should be an integral part of primary care, hospital care 

(particularly ED care), care for mental and substance use disorders, crisis response (e.g., help lines, mobile 

teams, first responders, crisis chat services), and of the care provided in skilled nursing facilities. Any 

person identified as being at a possible risk for suicide should be formally assessed for suicidal thoughts, 

plans, intent, access to lethal means, a history of previous attempts, the presence of acute risk factors 

(including problems in the family and other social relationships, work or school, finances, and the legal 

system), and level of risk. Persons identified as being at risk for suicide should have immediate access to 

needed clinical care and support. 

Tools and methods to help detect risk, conduct assessments, intervene for safety, and deliver quality 

treatment and support are available but not widely used. Research has not yet identified a simple, easily 

administered scale leading to a score that can provide a quantifiable substitute for clinical decisionmaking and judgment. However, reliable and valid instruments do exist and can be a useful component 

of a full evaluation. Guidelines for risk assessment, along with appropriate tools and protocols, must be 

disseminated among all settings that provide care for individuals with suicide risk. 

Strategies for assessing suicide risk should be tailored to the individual and context. For individuals 

in primary care without known risk factors, a staged approach may be useful, where evaluations for 

suicide risk are conducted when patients have a positive screen or show evidence of a mental health or 

substance use disorder or a chronic pain syndrome. In these cases, evaluations for the risk of suicide 

should be conducted at the initial diagnostic and treatment planning evaluation and when there are 

significant changes in symptoms and treatments. For individuals who have previously been at high risk, 

evaluations should be conducted on a frequent, regularly scheduled basis, when there are significant 

changes in symptoms or treatments, and when a person experiences stressful events. Guidelines for suicide 

risk assessment should be meaningfully related to the training objectives listed in Objective 7.2 of this 

National Strategy. 

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Objective 9.2: Develop, disseminate, and implement guidelines for clinical 

practice and continuity of care for providers who treat persons with suicide risk. 

Disjointed service delivery, lack of effective communication among caregivers, and clinician concerns 

associated with the possible loss of a patient to suicide are barriers to effective clinical care for persons 

with suicide risk. These barriers can create an environment where a person with suicide risk may feel 

reluctant to disclose suicidal thoughts and feelings to a helping professional because he or she senses 

discomfort and is afraid of being automatically referred to inpatient care. Unprepared caregivers, acting in 

isolation, are more likely to experience heightened anxiety than trained caregivers empowered to share the 

responsibility for managing suicide risk. 

Guidelines on the treatment of specific mental health conditions are necessary, but they are not sufficient. 

There is a need for guidelines for clinical practice that address the care indicated for individuals identified 

as being at risk for suicide. These guidelines should reflect the latest evidence and best practices in care 

for patients with suicide risk. They should indicate how care should be modified to address the needs of 

patients at risk for suicide and specify what services and interventions should be provided to supplement 

care directed toward the underlying condition(s). At a minimum, these guidelines should address: 

Patient-centered care;
 


Recovery-oriented mental health services;
 


Building protection and resilience;
 


Suicide prevention specific intervention planning and review;
 


Safety planning;
 


Effective therapeutic alliances;
 


Communication among providers;
 


Alignment of clinical approaches with needs (e.g., underlying psychiatric and/or substance use 
 

disorders, trauma support, complicated grief); 

Immediate access to crisis services; 

Continuity of care, including immediate followup after discharge from an inpatient unit following a 

suicide attempt; and 

Appropriate empowerment of families and significant others in treatment, peer support, and postdischarge followup. 

Objective 9.3: Promote the safe disclosure of suicidal thoughts and behaviors by 

all patients. 

Settings that provide care to patients with suicide risk must be nonjudgmental and psychologically safe 

places in which to receive services. Patients who have thoughts of suicide may feel embarrassed, guilty, and 

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fearful of disclosing their thoughts and feelings to others. These patients may also fear losing autonomy or 

the ability to make their own treatment decisions. To address these barriers to treatment, collaborative and 

non-coercive approaches should be used whenever possible. Health care providers and other caregivers 

must have the skills required to promote disclosure. Individuals contacting a potential helper must feel 

comfortable to disclose their desire or intent to die and their thoughts of suicide. They must feel confident 

that the potential caregiver will be accepting and in a position to offer nonjudgmental help. 

Anxiety about asking suicide-related questions may also be a barrier to identifying individuals at risk. 

Education, training, and rehearsal of ways to address the disclosure of suicide risk can help ease these 

concerns. System-based approaches that give providers access to resources that can help them manage 

someone who is suicidal also can help reduce provider anxiety regarding the disclosure of suicide-related 

thoughts and behaviors. For example, VA places a suicide prevention coordinator at each medical center, 

as a resource for providers who need to make difficult clinical judgments. 

Objective 9.4: Adopt and implement guidelines to effectively engage families 

and concerned others, when appropriate, throughout entire episodes of care for 

persons with suicide risk. 

Family members, significant others, and close friends can play an important role in enhancing the safety of 

patients with suicide risk. These individuals should be trained to understand, monitor, and intervene with 

loved ones who are at risk for suicide. 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 be knowledgeable 

about risk factors and about how to help protect an individual from suicide. These individuals (family 

members/support network) should know when to contact treatment providers or emergency services and 

how to take reasonable precautions to reduce access to lethal means. Family members need to feel able to 

ask directly about suicidal thoughts, but should not be placed in the position of providing around-theclock “suicide watches.” 

Involving the patient’s family and/or close friends is an important way to help ensure patients leaving the 

ED after a suicide attempt or those being discharged after inpatient care keep their followup appointments. 

These individuals also can help support patient adherence to important treatment decisions and followup 

arrangements. 

Contact and collaboration between providers and patients’ family members or friends usually requires 

consent from the patient. Engaging the patient in arranging such contact and collaboration is important 

as a matter of both autonomy and effectiveness. However, in the context of suicide prevention, limited 

exceptions to these principles may be necessary. 

Guidelines should be developed and implemented to help providers balance respecting autonomy versus 

ensuring safety in their work with patients with high suicide risk and their families. As an example, the 

American Association of Suicidology has developed a set of recommendations for inpatient and residential 

patients at high risk for suicide.107 The recommendations seek to enhance the provision of care in inpatient 

and residential facilities and to promote, when possible, the involvement of families as meaningful 

members of the treatment team. 

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Objective 9.5: Adopt and implement policies and procedures to assess suicide 

risk and intervene to promote safety and reduce suicidal behaviors among 

patients receiving care for mental and/or substance use disorders. 

Strategies for monitoring patients and identifying those at risk in a number of contexts are also needed. 

Monitoring should be more frequent and more focused for those people known to have risk factors such 

as mental or substance use disorders, chronic pain, or disability. Monitoring should be more intensive for 

those identified as being at high risk for suicidal behaviors. Clinical care for individuals at a high risk for 

suicide, including those who have survived a suicide attempt, should recognize and support recovery and 

should also be based on the understanding that individuals remain at risk for extended periods of time. 

Regularly scheduled monitoring should focus on evaluating changes in symptoms of medical and mental 

health conditions, changes in protective factors such as social networks, the occurrence and impact of 

stressful events, and the recurrence of suicidal ideation, plans, or intent. 

Specialty centers that provide care for mental and substance use disorders should have in place policies, 

procedures, and programs designed to identify the level of suicide risk and intervene to prevent suicide 

among their patients. Evaluation of these policies and procedures over time can contribute to the more 

effective and efficient delivery of health care to patients with high suicide risk. 

Although assessment and intervention are different processes, policies and procedures in these two areas 

must be coordinated. Put simply, a lack of knowledge and resources to respond to patients found to be 

at high risk for suicide could represent a barrier to case identification. Policies and procedures should 

recognize that managing a patient at a high risk for suicide can take more time than a standard encounter 

and may require the involvement of more than one provider. 

As noted earlier, interventions for patients at risk for suicide should combine care for underlying 

conditions with strategies that directly address suicide risk. At the same time, it is important to reevaluate 

treatments for mental health and substance use disorders to ensure that they are appropriate, and that they 

address both the management of symptoms and recovery. For those with a serious mental illness, ensuring 

that the treatment plan is recovery oriented can be lifesaving. 

Collaborative safety planning has been found to be a component of effective treatment of suicidal risk. 

Health systems such as VA have begun to require safety planning as an intervention within their systems 

for patients at high risk. 

Objective 9.6: Develop standardized protocols for use within emergency 

departments based on common clinical presentation to allow for more 

differentiated responses based on risk profiles and assessed clinical needs. 

EDs are key settings for providing services to persons with high suicide risk, particularly those who have 

attempted suicide. In 2009, 374,486 people were treated in EDs for self-inflicted injuries.1 

Standardized protocols should be developed for use within EDs that allow for differentiated responses 

based on risk profiles and assessed clinical needs (e.g., intoxicated and suicidal, chronically suicidal, 

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suicidal with active psychosis). These protocols should emphasize patient-centered and stepped 

approaches that allow relative suicide risk to be assessed and matched with a continuum of services. For 

example, individuals who are identified as being at a high risk for suicide may require intensive outpatient 

suicide-specific mental health treatment. Those who are intoxicated and suicidal will, in general, have to 

be evaluated after they have become sober before they can be discharged. Seriously ill patients with high 

suicide risk may require partial hospitalization or short-term psychiatric inpatient stays. 

Objective 9.7: Develop guidelines on the documentation of assessment and 

treatment of suicide risk and establish a training and technical assistance 

capacity to assist providers with implementation. 

The proper documentation of assessment and treatment can improve the care of patients with high suicide 

risk and, at the same time, protect providers from allegations of malpractice. A proper assessment should 

identify the severity of a patient’s risk for suicide, allowing for the development of critical treatment 

plan determinations. Decisions such as whether to hospitalize or whether a patient can be treated on an 

outpatient basis depend on the foreseeable risk of suicide and the patient’s ability to work collaboratively 

to stay safe. The type of treatment that is recommended should be appropriate for the patient’s level of 

risk, needs, and preferences. These issues require careful documentation. Training materials on evidencebased psychotherapies for suicide prevention and safety planning should include tools to support these 

interventions, such as chart templates used to document their delivery. 

Goal 10. Provide care and support to individuals affected by suicide 

deaths and attempts to promote healing and implement community 

strategies to help prevent further suicides. 

The mental health and medical communities often fail to provide needed services to individuals who have 

attempted suicide and to those who have been affected by a suicide attempt or death. Individuals who have 

made a suicide attempt may receive insufficient care in the community. Those who have been bereaved by 

suicide may receive little or no guidance or support for the traumatic impact of this occurrence. 

While most individuals bereaved by suicide recover from the trauma, many people may suffer alone and 

experience harmful effects that can be devastating and sometimes long lasting. For these reasons, it is 

crucial to pay attention to the needs of these potentially vulnerable but underserved groups. In addition, 

deaths by suicide can affect whole organizations and communities, leading to concerns regarding suicide 

contagion, particularly among youth. 

Objective 10.1: Develop guidelines for effective comprehensive support programs 

for individuals bereaved by suicide and promote the full implementation of these 

guidelines at the state/territorial, tribal, and community levels. 

Guidelines for providing care and support to individuals bereaved by suicide are needed. Communities 

vary tremendously in the extent to which they provide these types of support services. Individuals 

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bereaved by suicide often have difficulty finding the services they need when they are ready to access them. 

Developing comprehensive national guidelines for effective support will provide a “roadmap” for the kinds 

of services that communities can work to provide for these groups. This support can include, but is not 

limited to, outreach teams of professionals and trained individuals who have been bereaved by suicide, 

face-to-face and online support groups, memorial services, and other opportunities for those who have 

been bereaved by suicide to interact with each other and find positive and culturally appropriate ways to 

deal with their grief. 

The Action Alliance’s Task Force on Survivors of Suicide Loss is working toward the development of 

consensus guidelines for the creation and implementation of effective, comprehensive support programs 

for individuals affected by a suicide loss. The Task Force will review existing evidence regarding model 

services and programs, draft consensus guidelines incorporating input from various groups, and submit 

the guidelines for inclusion in the Best Practices Registry for Suicide Prevention. 

Objective 10.2: Provide appropriate clinical care to individuals affected by a 

suicide attempt or bereaved by suicide, including trauma treatment and care for 

complicated grief. 

Exposure to a suicide attempt or death, particularly of someone who is psychologically close, can have 

harmful effects on individuals and families, including increasing the risk for suicide in the person 

exposed.39 Family and friends of individuals who attempt suicide can have similar reactions. The actual or 

threatened loss of a loved one by suicide is often shocking, painful, and unexpected. The reactions can be 

intense, complex, and long lasting, and may be accompanied by powerful emotions such as denial, anger, 

guilt, and shame. Each person will experience this grief in a unique way. 

Because of the prejudice attached to suicide, family members and friends may not know how to help 

someone who has been affected by a suicide loss or attempt. Shame and embarrassment may prevent 

the person from reaching out for help. While support groups can be very helpful, individuals affected by 

suicide must also have access to knowledgeable professional services and supports. 

Objective 10.3: Engage suicide attempt survivors in suicide prevention planning, 

including support services, treatment, community suicide prevention education, 

and the development of guidelines and protocols for suicide attempt survivor 

support groups. 

Making a suicide attempt is a risk factor for later death by suicide.11 Promoting the positive engagement 

of those who have attempted suicide in their own care is likely crucial in successfully reducing risk for 

suicide. In addition, these individuals can be powerful agents for challenging prejudice and activating hope 

for others. 

Most successful suicide prevention strategies have used multiple components, but one underutilized 

intervention in suicide prevention has been peer support. Appropriate peer support plays an important 

role in the treatment of mental and substance use disorders and holds a similar potential for helping those 

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at risk for suicide. Guidelines and protocols are needed to support the development of such services for 

those who have attempted suicide, as well as technical assistance to assist with the dissemination and 

implementation of these tools. 

Objective 10.4: Adopt, disseminate, implement, and evaluate guidelines for 

communities to respond effectively to suicide clusters and contagion within 

their cultural context, and support implementation with education, training, and 

consultation. 

The 2001 National Strategy described the phenomena of “suicide contagion” and “suicide clusters.” 

Contagion has been described as the process by which exposure to suicidal behaviors from interpersonal 

contacts or the media can lead to an increase in suicidal behaviors, particularly among adolescents and 

young adults. A suicide cluster has been defined as a group of suicides or suicide attempts, or both, that 

occur closer together in time and space than would normally be expected in a given community.67 

CDC has estimated that cluster suicides may account for 1 to 5 percent of suicides among adolescents 

and young adults.67 In 1988, CDC issued recommendations for communities to use in the prevention 

and containment of suicide clusters.67 These recommendations provide an important foundation 

for community suicide prevention efforts but have not been routinely implemented in communities 

experiencing clusters. In addition, the effect of differing cultural contexts (e.g., in American Indian/ 

Alaska Native communities), has not been systematically analyzed, nor has the effectiveness of the 

recommendations been evaluated. 

Objective 10.5: Provide health care providers, first responders, and others with 

care and support when a patient under their care dies by suicide. 

Clinicians, first responders, emergency personnel, and other medical professionals who lose a patient to 

suicide should be provided with support to deal with the emotional aftermath of this traumatic event. 

Such support should address trauma and grief reactions and potential suicide risk among caregivers. 

Mechanisms for review of such deaths should avoid blaming the caregiver. Instead, the goal should be to 

respond to the caregiver’s need for support and help the provider respond to patients who may be at risk 

for suicide in the future. 

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What You Can Do to Advance the Goals and Objectives in Strategic 

Direction 3 of the National Strategy for Suicide Prevention 

The Federal Government Can: 

Promote access to high-quality mental health services and facilitate the integration of mental health 

services into a range of settings (e.g., Federally Qualified Health Centers, Bureau of Prisons, Indian 

Health Service, and VA facilities). (Objectives 8.3 and 8.6) 

Update and revise federal publications addressing the appropriate response after a suicide. 
 

(Objective 10.4)



State, Territorial, Tribal, and Local Governments Can: 

Disseminate information about the National Suicide Prevention Lifeline and other local or regional 

crisis lines. (Objective 8.3) 

Promote the availability of online support services and crisis outreach teams. (Objective 8.3) 

Develop protocols and improve collaboration among crisis centers, law enforcement, mobile 
 

crisis teams, and social services to ensure timely access to care for individuals with suicide risk. 
 

(Objective 8.3)



Businesses and Employers Can: 

Ensure that counselors in an employee assistance program (EAP) are well equipped to assess and 

manage suicide risk. (Objective 9.1) 

Ensure that mental health services offered to employees include grief counseling for individuals 

bereaved by suicide. (Objective 10.1) 

Health Care Systems, Insurers, and Clinicians Can: 

Implement patient-informed alternatives to hospitalization for individuals with suicide risk. 

(Objective 8.2) 

Develop alternatives to treatment in an emergency department, such as same-day scheduling for 

mental health services and in-home crisis care. (Objective 8.8) 

Develop and implement protocols to ensure immediate and continuous followup after discharge from 

an ED or inpatient unit. (Objective 8.4) 

Educate family members and significant others about appropriate steps they can take to support 
 

individuals at suicide risk during treatment and/or after discharge from an ED or inpatient unit. 
 

(Objective 9.4)



Schools, Colleges, and Universities Can: 

Educate students who are in training to become mental health, social service, or health care 

providers on the identification and treatment of individuals at high risk for suicide. (Objective 9.2) 

Nonprofit, Community-, and Faith-Based Organizations Can: 

Coordinate the services of community-based and peer-support programs with the support available 

from local providers of mental health and substance abuse services to better serve individuals at risk 

for suicide. (Objective 8.6) 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


Individuals and Families Can: 

Provide appropriate followup support to family members of individuals who have been discharged 

from an ED or inpatient unit, including reminders about appointments, and information on 

compliance with treatment plans and on ways to reduce access to lethal means. (Objective 9.4) 

Learn when to contact treatment providers or emergency services for loved ones who are at risk for 

suicide. (Objective 9.4) 

Strategic Direction 4: 
 

Surveillance, Research, and Evaluation



The National Strategy’s fourth strategic direction addresses suicide prevention surveillance, research, and 

evaluation activities, which are closely linked to the goals and objectives in the other three areas. Public 

health surveillance refers to the ongoing, systematic collection, analysis, interpretation, and timely use of 

data for public health action to reduce morbidity and mortality. In contrast, research and evaluation are 

activities that assess the effectiveness of particular interventions, thereby adding to the knowledge base in 

the area of suicide prevention. 

The past decade has seen substantial improvements in suicide-related surveillance, research, and 

evaluation. However, additional efforts are needed to inform and guide suicide prevention efforts 

nationwide. The collection and integration of surveillance data should be expanded and improved. In 

addition, although some evidence is available regarding the effectiveness of particular interventions and 

approaches, there is a need to assess the effectiveness of new and promising practices. 

Goal 11. Increase the timeliness and usefulness of national 

surveillance systems relevant to suicide prevention and improve the 

ability to collect, analyze, and use this information for action. 

The regular collection and rapid dissemination of suicide-related data are needed to guide appropriate 

public health action. The time between when an event takes place and when the data are ready for 

dissemination must be shortened. This is no simple task, as it involves collecting information on several 

behaviors (e.g., suicidal thoughts, attempts, deaths) that may be available at many levels (e.g., local, 

state, national). The information may come from several different sources, including vital statistics, 

EDs, inpatient hospital records, and urgent care centers, and may not be linked. In addition, there are 

continuing concerns and constraints regarding the accumulation of potentially identifiable data. 

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Examples of existing nationally representative data sources containing information regarding suicidal 

behaviors include: 

CDC’s National Vital Statistics System: annual data on all suicide deaths occurring in the U.S.; 
 

available from WISQARS (www.cdc.gov/injury/wisqars);



CDC’s NVDRS: annual data on suicide deaths from 18 states; available from
 


WISQARS (www.cdc.gov/injury/wisqars/nvdrs.html);



CDC’s Youth Risk Behavior Surveillance System: data released every 2 years on suicide ideation and 
 

attempts among high school students (www.cdc.gov/healthyyouth/yrbs/index.htm); and
 

SAMHSA’s National Survey on Drug Use and Health: annual survey that, since 2008, has included 
 

questions on suicidal thoughts and behaviors among adults (www.oas.samhsa.gov/nsduh.htm).


It is important to strengthen systems and to improve the quality of the data collected for surveillance 

purposes. It is equally necessary to enhance the ability of jurisdictions to use available information for 

strategic planning aimed at preventing suicidal behaviors. 

Objective 11.1: Improve the timeliness of reporting vital records data. 

Timeliness of reporting of national statistics on suicide mortality is a core issue. Although several states are 

able to rapidly provide information about suicide-related deaths, many others experience delays certifying 

and reporting these deaths. As a result, there is a two-year gap between the close of the calendar year and 

when the national data for that year become available. For example, data for 2009—the most recent final 

data available—were released in December of 2011. This makes it difficult to know when national suicide 

rates climb as a result of contextual factors, such as an economic crisis, as well as to plan interventions or 

to know if suicide prevention efforts are having an effect in reducing deaths by suicide. Efforts should be 

made to gradually reduce this gap with an ultimate target of 12 months. 

Objective 11.2: Improve the usefulness and quality of suicide-related data. 

Consistent suicide-related data can help public health practitioners better understand the scope of the 

problem, identify high-risk groups, and monitor the effects of suicide prevention programs. However, 

existing data regarding suicide and suicidal behavior continue to have many limitations. Deaths from 

suicide may be misclassified as homicides, accidents, or even as death from natural causes. Information 

available from death certificates is limited and provides an incomplete picture of the risk factors for 

suicide. For example, death data regarding sexual orientation and gender identity are generally not 

collected, so it is not possible to calculate a reliable suicide rate for LGBT people. 

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 these data. There is a need to improve the quality and accuracy of death scene investigations 

by providing training to these responders. 

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Data on fatal and nonfatal self-directed violence often are not standardized. To address this issue, in 2011, 

CDC published the report Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data 

Elements.

108 The definitions and data elements were developed in collaboration with the VA and have been 

adopted by the Department of Defense. 

Lack of external cause-of-injury coding in administrative datasets (e.g., ED, hospital discharge) greatly 

reduces the utility of these datasets. The CDC has developed an action agenda for improving external cause 

coding that could be a useful framework for addressing this issue within these administrative datasets.109 

Efforts to link and analyze information coming from separate data systems, such as law enforcement, 

emergency medical services, and hospitals, are also needed. 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 morbidity and mortality. 

Objective 11.3: Improve and expand state/territorial, tribal, and local public 

health capacity to routinely collect, analyze, report, and use suicide-related data 

to implement prevention efforts and inform policy decisions. 

The surveillance of suicidal behaviors and related issues (e.g., mental and substance use disorders) has 

improved over the years, but additional advances are needed. In particular, there is a need to increase 

the number of states and territories that are funded to integrate data sets as a part of NVDRS and to 

improve relevant data sets and facilitate access to them. In addition, staff members in states/territories, 

tribes, and local governments require training on how to analyze and interpret data for policy and 

prevention purposes. 

Although national data provide an overall view of the problem, local data are key to effective prevention 

efforts. State/territorial, tribal, and local suicide rates vary considerably from national rates. There is a need 

to promote the development of local reports on suicide and suicide attempts, and to integrate data from 

multiple data management systems. These reports should describe the magnitude of the suicide problem 

and how suicide differentially affects particular groups. In addition, the reports should also address the 

use of mental health and substance use services. These publications would be useful in tracking trends in 

suicide rates over time, identifying changes in groups at risk and methods used, and evaluating suicide 

prevention efforts. At the local level, they could serve as a resource for developing timely and targeted 

interventions to prevent suicidal behaviors. State epidemiologists and suicide prevention coordinators 

could play an important role in supporting and providing assistance for these local efforts. 

Objective 11.4: Increase the number of nationally representative surveys and 

other data collection instruments that include questions on suicidal behaviors, 

related risk factors, and exposure to suicide. 

Existing sources of data on suicidal behaviors underestimate the burden that suicide-related problems 

place on our society. There is a need to increase the number of nationally representative surveys and other 

data collection instruments that include questions on suicidal behaviors and related risk and protective 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

factors. Questions about suicide attempts should identify the person’s age at the time of the attempt and 

whether medical attention was required. Data collection tools also should include questions that better 

identify vulnerable populations, such as items addressing sexual orientation and gender identity. 

Exposure to suicide, particularly of someone emotionally close to the bereaved, can increase the risk for 

depression, complicated grief and trauma reactions, and suicide. Yet little is known about the number 

of people who have been exposed to suicide and about those who have been adversely affected by that 

exposure. Nationally representative surveys and other data collection instruments and systems should 

include questions on exposure to suicide and its links with suicidal thoughts and behaviors, mental and 

substance use disorders, and violence. Obtaining this data would help greatly in planning support services 

for those who have been bereaved by suicide. 

There also is a need to collect suicide data on deaths among those who are currently receiving active 

inpatient or outpatient care (e.g., outpatient mental health care, inpatient cancer treatment). Although 

these events may be particularly amenable to prevention, there is currently no national system that can 

provide this information. 

Goal 12. Promote and support research on suicide prevention. 

Research on suicide prevention, and on the treatment of mental and substance use disorders, has increased 

considerably during the past 20 years. Findings have contributed to the development of assessment 

tools, resiliency-building interventions, and treatment and symptom-monitoring techniques. Continued 

advancements will lead to the development of better assessment tools, treatments, and preventive 

interventions. It also will lead to more effective and efficient therapeutic interventions for individuals who 

engage in suicidal behaviors. 

Objective 12.1: Develop a national suicide prevention research agenda with 

comprehensive input from multiple stakeholders. 

Everyone has a stake in the development and implementation of a national suicide research agenda that 

can ultimately be measured in terms of knowledge gained and measurable declines in suicide attempts and 

deaths. This agenda should build on existing knowledge of suicide prevention and surveillance findings to 

identify priority research areas. Topics could include: groups with increased suicide risk, gender and ethnic 

differences, social and economic factors, genetic contributions, protective factors, promising interventions 

for suicide prevention and treatment, and interventions for individuals who have been affected by suicide. 

The Research Prioritization Task Force, launched under the Action Alliance, has developed a prioritization 

process that includes a stakeholder survey, portfolio analyses, and input by experts. The research 

summaries published in the 2002 IOM report Reducing Suicide: A National Imperative9

 can serve as a 

starting point for updating the state of the science and research infrastructure needs. 

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Objective 12.2: Disseminate the national suicide prevention research agenda. 

After the research agenda is developed, it should be disseminated to researchers and program planners at 

the local, regional, and national levels, so that it can inform the development of new suicide prevention 

interventions and programs. The research agenda will also be useful to the various groups that fund 

suicide prevention research in identifying knowledge gaps and areas of need. 

As part of the prioritization process discussed in Objective 12.1, an inventory of currently funded suicide 

research will be created. Funders, both public and private, will be asked to provide annual updates of 

currently funded research to a web-based system that can be inventoried and queried. This effort will 

help facilitate funding coordination and serve as a way to disseminate to funders and program planners 

information on research that is currently in progress. 

Moving forward, the research agenda should be updated on a regular basis, with input from its various 

users, to ensure that it remains relevant. Expanded surveillance efforts, discussed under Goal 11, will help 

enhance the ability of researchers and program planners to develop and evaluate interventions targeting 

specific groups. Updating the agenda to address new questions posed by program planners, agencies, and 

organizations will help ensure that it remains a living document that helps save lives. 

Objective 12.3: Promote the timely dissemination of suicide prevention 

research findings. 

Emerging suicide prevention research findings must be translated into recommendations and suggestions 

for practical application in multiple settings. Researchers should be encouraged to publish their findings 

so that practitioners can incorporate them into the development of new interventions targeting particular 

groups. There is also a need to disseminate these findings more widely via communication efforts targeting 

specific groups, such as health care providers, public health officials, providers of aging services, school 

officials, and others. 

Objective 12.4: Develop and support a repository of research resources to help 

increase the amount and quality of research on suicide prevention and care in 

the aftermath of suicidal behaviors. 

Conducting research on suicide prevention involves many challenges. Although the absolute number of 

suicides in a population may be cumulatively quite large, the risk of suicide to any given individual, even 

those with multiple risk factors, is relatively small. Suicide is a relatively rare outcome, which makes it 

difficult to conduct randomized controlled trials (RCTs) that evaluate the impact of an intervention in 

preventing suicide. 

Researchers would benefit from information on the most appropriate research designs for rare events, and 

on appropriate outcomes that are suitable to answer well-defined research questions. Although RCTs are 

expensive, they could be done more economically by including only patients with high suicide risk, such 

as individuals who have recently attempted suicide. Suicide attempts, particularly medically serious suicide 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

attempts, may serve as a sufficiently powerful proxy (i.e., substitute) measure to address some specific 
 

research questions. 
 

A national repository of research methods would be a useful resource for suicide prevention researchers. 
 

The repository could include a link to national databases (e.g., CDC, national, state/territorial, tribal, 
 

and local) that can be used as research tools. Other contents could include information on appropriate 
 

and rigorous study designs, common measures that should be used in research studies, successful 
 

implementation efforts and adaptations, and safety and ethical considerations. 
 

Goal 13. Evaluate the impact and effectiveness of suicide prevention 

interventions and systems and synthesize and disseminate findings. 

Program evaluation is a driving force for planning effective suicide prevention strategies, improving 

existing programs, informing and supporting policy, and demonstrating the results of resource 

investments. Suicide prevention interventions should be guided by specific testable hypotheses and 

implemented among groups of sufficient size to yield reliable results. Given the state of the field, 

program evaluations should emphasize measurable behavioral outcomes, in addition to other outcomes 

(e.g., changes in knowledge or attitudes) and process measures (e.g., number of people attending 

program sessions). 

Programs that share risk factors with suicide should be encouraged to incorporate suicide prevention 

components and related measures in their program design and evaluation plans. For example, suicide 

shares risk and protective factors with other forms of violence, including interpersonal violence among 

youth. These factors include problem-solving and coping skills and characteristics of school and 

community environments, such as bullying, intolerance, and prejudice.128 Violence prevention approaches 

that address these types of shared factors, such as by promoting coping skills and family functioning, are 

likely to also contribute to suicide prevention. The evaluation of these interventions should incorporate 

suicide-related outcome measures as a way of assessing the potential effect of such programs on preventing 

suicidal behaviors. 

Objective 13.1: Evaluate the effectiveness of suicide prevention interventions. 

A broad range of interventions can be used for suicide prevention. Examples include: education and 

awareness programs, life skills development, the use of media reporting guidelines for suicide, schoolbased and other community programs, clinical provider training, screening for individuals at high risk, 

the use of crisis lines, medications, psychotherapy, and followup care for suicide attempts.72, 73, 110 Program 

evaluations and other studies must evaluate the effectiveness of these interventions and their impact on 

the prevention of suicide attempts and deaths. In particular, there is a need to implement and evaluate 

the effectiveness of interventions for individuals who have been bereaved by suicide, as few studies have 

focused specifically on this population. 

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Objective 13.2: Assess, synthesize, and disseminate the evidence in support of 

suicide prevention interventions.

Although the number of evaluated suicide prevention programs has increased over the years, findings 

from individual studies must be assessed and synthesized in order to understand the strength of the 

evidence in support of particular interventions. Systematic reviews serve an important role in the 

assessment and synthesis of research findings. These reviews can help identify effective interventions and 

provide recommendations for future programs and research. 

Findings from a review of studies conducted in the United States and abroad suggest that interventions 

can be effective for preventing suicide including for example, physician education and the training 

of gatekeepers in institutional settings (e.g., the U.S. Air Force).72 Another umbrella review examined 

findings from six systematic reviews of multilevel suicide prevention interventions.73 These interventions 

were defined as having multiple components and targeting different populations or several levels within 

a health care system and/or having more than one area of focus, such as combining medications with 

psychotherapy. The review found support for physician education and means restriction and improving 

access to care for individuals with suicide risk. 

Although the umbrella review focused on interventions delivered in health care systems, multilevel suicide 

prevention interventions can also be conducted in other settings. As an example, a multilevel intervention 

could combine the following components: building life skills among high school students, training 

school staff as gatekeepers, ensuring the school has appropriate crisis protocols and has strong links to 

community referral resources, and other activities conducted in the community. These activities could 

include promoting the Lifeline (800–273–TALK/8255) to the general public and distributing gunlocks. 

More research is needed to better understand the strength of the evidence in support of suicide 

prevention interventions. After findings are synthesized, they should be disseminated to promote the 

broader implementation of the specific types of interventions that have been found to be effective in 

preventing suicide. 

Objective 13.3: Examine how suicide prevention efforts are implemented in 

different states, territories, tribes, and communities to identify the types of 

delivery structures that may be most efficient and effective. 

Suicide prevention efforts are implemented differently across states/territories, tribes, and local 

communities. There is a need to evaluate the delivery structure of suicide prevention systems to identify 

these differences, and to assess the effectiveness of different system designs for the delivery of suicide 

prevention services. Findings from these assessments could be used to generate recommendations 

regarding the types of delivery structures that appear to be most efficient and effective. 

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Objective 13.4: Evaluate the impact and effectiveness of the National Strategy 

for Suicide Prevention in reducing suicide morbidity and mortality. 

The National Strategy represents a comprehensive, long-term approach to suicide prevention. As discussed 

in the Introduction section (under “Looking Ahead”), the goals and objectives are broad in scope and 

encompass a wide range of activities. 

The National Strategy represents a roadmap that, when followed, will lead to the vision of a nation 

free from the tragic experience of suicide. Different groups (e.g., associations, government agencies, 

educational institutions, health systems) may find it useful to review the goals and objectives in the 

National Strategy and identify their own priority areas for action. 

As an example, the Action Alliance has identified four priority areas for 2012–14 and will monitor 

progress toward their achievement. Several considerations helped guide the development of this action 

agenda, including the potential impact on suicide-related morbidity and mortality and the availability of 

organizations, agencies, or other groups that may be willing to take on different roles in implementing 

activities and evaluating progress. 

What You Can Do to Advance the Goals and Objectives in Strategic 

Direction 4 of the National Strategy for Suicide Prevention 

The Federal Government Can: 

Assist states in the transition to electronic death certificates through enhanced technical support. 

(Objectives 11.1 and 11.2) 

Promote the increased utilization of the National Violent Death Reporting System. (Objectives 11.2, 

11.3, and 11.5) 

Develop a standardized module of suicide-related questions that can be used in different surveys 

and data systems. (Objective 11.4) 

Support suicide-related research, including research on the risk and protective factors for suicide 

among different groups. (Objective 12.1) 

Promote the evaluation of suicide prevention programs and practices and the synthesis and 

dissemination of findings. (Objectives 13.1 and 13.2) 

State, Territorial, Tribal, and Local Governments Can: 

Analyze and identify strategies to increase the efficiency of state-based processes for certifying, 

amending, and reporting vital records related to suicide deaths. (Objective 11.1) 

Implement CDC’s action plan for improving external cause of injury coding. (Objectives 11.2 

and 11.3) 

Adopt recommended self-directed violence uniform definitions and data elements developed by CDC 

and VA. (Objective 11.2) 

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Improve data linkage across agencies and organizations, including hospitals, psychiatric and other 

medical institutions, and police departments, to better capture information on suicide attempts. 

(Objective 11.5) 

Businesses and Employers Can: 

Evaluate the effectiveness of workplace wellness programs in reducing suicide risk. (Objective 13.1) 

Health Care Systems, Insurers, and Clinicians Can: 

Implement the recommendations for health care providers in CDC’s action plan for improving 
 

external cause of injury coding within administrative data, such as emergency department and 
 

hospital discharge systems. (Objective 11.2)



Routinely document suicide-related information (e.g., alcohol use, drug use, description of intent) in 

emergency department charts. (Objective 11.5) 

Initiate continuous quality improvement studies to determine the effectiveness of policies and 

procedures intended to rapidly connect individuals at risk for suicide with services. (Objective 13.1) 

Schools, Colleges, and Universities Can: 

Conduct research to identify new, effective policy and program interventions to reduce suicide and 

suicidal behavior. (Objective 12.1) 

Share suicide-related research findings with state and local suicide prevention coalitions, health care 

providers, and other relevant practitioners. (Objective 12.3) 

Nonprofit, Community-, and Faith-Based Organizations Can: 

Work with a local university to evaluate your suicide prevention program. (Objective 13.1) 

Individuals and Families Can: 

Participate in surveys and other data collection efforts addressing suicide and related behaviors. 
 

(Objective 11.4)



Support evaluation of suicide prevention programs. (Objective 13.1)



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Appendix A: National Strategy for 

Suicide Prevention Goals and Objectives 

for Action Summary List 

Strategic Direction 1: Healthy and Empowered Individuals, Families, 

and Communities 

GOAL 1. Integrate and coordinate suicide prevention activities across multiple 

sectors and settings. 

Objective 1.1: Integrate suicide prevention into the values, culture, leadership, and 

work of a broad range of organizations and programs with a role to support suicide 

prevention activities. 

Objective 1.2: Establish effective, sustainable, and collaborative suicide prevention 

programming at the state/territorial, tribal, and local levels. 

Objective 1.3: Sustain and strengthen collaborations across federal agencies to 

advance suicide prevention. 

Objective 1.4: Develop and sustain public-private partnerships to advance 

suicide prevention. 

Objective 1.5: Integrate suicide prevention into all relevant health care reform efforts. 

GOAL 2. Implement research-informed communication efforts designed to prevent 

suicide by changing knowledge, attitudes, and behaviors. 

Objective 2.1: Develop, implement, and evaluate communication efforts designed to 

reach defined segments of the population. 

Objective 2.2: Reach policymakers with dedicated communication efforts. 

Objective 2.3: Increase communication efforts conducted online that promote positive 

messages and support safe crisis intervention strategies. 

Objective 2.4: Increase knowledge of the warning signs for suicide and of how to 

connect individuals in crisis with assistance and care. 

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GOAL 3. Increase knowledge of the factors that offer protection from suicidal 

behaviors and that promote wellness and recovery. 

Objective 3.1: Promote effective programs and practices that increase protection from 

suicide risk. 

Objective 3.2: Reduce the prejudice and discrimination associated with suicidal 

behaviors and mental and substance use disorders. 

Objective 3.3: Promote the understanding that recovery from mental and substance 

use disorders is possible for all. 

GOAL 4. Promote responsible media reporting of suicide, accurate portrayals 

of suicide and mental illnesses in the entertainment industry, and the safety of 

online content related to suicide. 

Objective 4.1: Encourage and recognize news organizations that develop and 

implement policies and practices addressing the safe and responsible reporting of 

suicide and other related behaviors. 

Objective 4.2: Encourage and recognize members of the entertainment industry who 

follow recommendations regarding the accurate and responsible portrayals of suicide 

and other related behaviors. 

Objective 4.3: Develop, implement, monitor, and update guidelines on the safety of 

online content for new and emerging communication technologies and applications. 

Objective 4.4: Develop and disseminate guidance for journalism and mass 

communication schools regarding how to address consistent and safe messaging on 

suicide and related behaviors in their curricula. 

Strategic Direction 2: Clinical and Community Preventive Services 

GOAL 5. Develop, implement, and monitor effective programs that promote 

wellness and prevent suicide and related behaviors. 

Objective 5.1: Strengthen the coordination, implementation, and evaluation of 

comprehensive state/territorial, tribal, and local suicide prevention programming. 

Objective 5.2: Encourage community-based settings to implement effective 

programs and provide education that promote wellness and prevent suicide and 

related behaviors. 

Objective 5.3: Intervene to reduce suicidal thoughts and behaviors in populations 

with suicide risk. 

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Objective 5.4: Strengthen efforts to increase access to and delivery of effective 

programs and services for mental and substance use disorders. 

GOAL 6. Promote efforts to reduce access to lethal means of suicide among 

individuals with identified suicide risk. 

Objective 6.1: Encourage providers who interact with individuals at risk for suicide to 

routinely assess for access to lethal means. 

Objective 6.2: Partner with firearm dealers and gun owners to incorporate suicide 

awareness as a basic tenet of firearm safety and responsible firearm ownership. 

Objective 6.3: Develop and implement new safety technologies to reduce access to 

lethal means. 

GOAL 7. Provide training to community and clinical service providers on the 

prevention of suicide and related behaviors. 

Objective 7.1: Provide training on suicide prevention to community groups that have a 

role in the prevention of suicide and related behaviors. 

Objective 7.2: Provide training to mental health and substance abuse providers on 

the recognition, assessment, and management of at-risk behavior, and the delivery of 

effective clinical care for people with suicide risk. 

Objective 7.3: Develop and promote the adoption of core education and training 

guidelines on the prevention of suicide and related behaviors by all health 

professions, including graduate and continuing education. 

Objective 7.4: Promote the adoption of core education and training guidelines on the 

prevention of suicide and related behaviors by credentialing and accreditation bodies. 

Objective 7.5: Develop and implement protocols and programs for clinicians and 

clinical supervisors, first responders, crisis staff, and others on how to implement 

effective strategies for communicating and collaboratively managing suicide risk. 

Strategic Direction 3: Treatment and Support Services 

GOAL 8. Promote suicide prevention as a core component of health care 

services. 

Objective 8.1: Promote the adoption of “zero suicides” as an aspirational goal by 

health care and community support systems that provide services and support to 

defined patient populations. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Objective 8.2: Develop and implement protocols for delivering services for individuals 

with suicide risk in the most collaborative, responsive, and least restrictive settings. 

Objective 8.3: Promote timely access to assessment, intervention, and effective care 

for individuals with a heightened risk for suicide. 

Objective 8.4: Promote continuity of care and the safety and well-being of all patients 

treated for suicide risk in emergency departments or hospital inpatient units. 

Objective 8.5: Encourage health care delivery systems to incorporate suicide 

prevention and appropriate responses to suicide attempts as indicators of continuous 

quality improvement efforts. 

Objective 8.6: Establish linkages between providers of mental health and substance 

abuse services and community-based programs, including peer support programs. 

Objective 8.7: Coordinate services among suicide prevention and intervention 

programs, health care systems, and accredited local crisis centers. 

Objective 8.8: Develop collaborations between emergency departments and other 

health care providers to provide alternatives to emergency department care and 

hospitalization when appropriate, and to promote rapid followup after discharge. 

GOAL 9. Promote and implement effective clinical and professional practices for 

assessing and treating those identified as being at risk for suicidal behaviors. 

Objective 9.1: Adopt, disseminate, and implement guidelines for the assessment of 

suicide risk among persons receiving care in all settings. 

Objective 9.2: Develop, disseminate, and implement guidelines for clinical practice 

and continuity of care for providers who treat persons with suicide risk. 

Objective 9.3: Promote the safe disclosure of suicidal thoughts and behaviors by 

all patients. 

Objective 9.4: Adopt and implement guidelines to effectively engage families and 

concerned others, when appropriate, throughout entire episodes of care for persons 

with suicide risk. 

Objective 9.5: Adopt and implement policies and procedures to assess suicide 

risk and intervene to promote safety and reduce suicidal behaviors among patients 

receiving care for mental health and/or substance use disorders. 

Objective 9.6: Develop standardized protocols for use within emergency departments 

based on common clinical presentation to allow for more differentiated responses 

based on risk profiles and assessed clinical needs. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Objective 9.7: Develop guidelines on the documentation of assessment and treatment 

of suicide risk and establish a training and technical assistance capacity to assist 

providers with implementation. 

GOAL 10. Provide care and support to individuals affected by suicide deaths and 

attempts to promote healing and implement community strategies to help prevent 

further suicides. 

Objective 10.1: Develop guidelines for effective comprehensive support programs 

for individuals bereaved by suicide, and promote the full implementation of these 

guidelines at the state/territorial, tribal, and community levels. 

Objective 10.2: Provide appropriate clinical care to individuals affected by a 

suicide attempt or bereaved by suicide, including trauma treatment and care for 

complicated grief. 

Objective 10.3: Engage suicide attempt survivors in suicide prevention planning, 

including support services, treatment, community suicide prevention education, 

and the development of guidelines and protocols for suicide attempt survivor 

support groups. 

Objective 10.4: Adopt, disseminate, implement, and evaluate guidelines for 

communities to respond effectively to suicide clusters and contagion within 

their cultural context, and support implementation with education, training, 

and consultation. 

Objective 10.5: Provide health care providers, first responders, and others with care 

and support when a patient under their care dies by suicide. 

Strategic Direction 4: Surveillance, Research, and Evaluation 

GOAL 11. Increase the timeliness and usefulness of national surveillance 

systems relevant to suicide prevention and improve the ability to collect, 

analyze, and use this information for action. 

Objective 11.1: Improve the timeliness of reporting vital records data. 

Objective 11.2: Improve the usefulness and quality of suicide-related data. 

Objective 11.3: Improve and expand state/territorial, tribal, and local public 

health capacity to routinely collect, analyze, report, and use suicide-related data to 

implement prevention efforts and inform policy decisions. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Objective 11.4: Increase the number of nationally representative surveys and other 

data collection instruments that include questions on suicidal behaviors, related risk 

factors, and exposure to suicide. 

GOAL 12. Promote and support research on suicide prevention. 

Objective 12.1: Develop a national suicide prevention research agenda with 

comprehensive input from multiple stakeholders. 

Objective 12.2: Disseminate the national suicide prevention research agenda. 

Objective 12.3: Promote the timely dissemination of suicide prevention 

research findings. 

Objective 12.4: Develop and support a repository of research resources to help 

increase the amount and quality of research on suicide prevention and care in the 

aftermath of suicidal behaviors. 

GOAL 13. Evaluate the impact and effectiveness of suicide prevention 

interventions and systems and synthesize and disseminate findings. 

Objective 13.1: Evaluate the effectiveness of suicide prevention interventions. 

Objective 13.2: Assess, synthesize, and disseminate the evidence in support of 

suicide prevention interventions. 

Objective 13.3: Examine how suicide prevention efforts are implemented in different 

states/territories, tribes, and communities to identify the types of delivery structures 

that may be most efficient and effective. 

Objective 13.4: Evaluate the impact and effectiveness of the National Strategy for 

Suicide Prevention in reducing suicide morbidity and mortality. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Appendix B: Crosswalk of Goals and 

Objectives From 2001 to 2012 

This appendix describes how the goals and objectives included in the 2001 National Strategy for Suicide 

Prevention (National Strategy) are addressed in the 2012 National Strategy. As noted in the Introduction, 

the goals and objectives have been updated, revised, and, in some cases, replaced to reflect advances in 

knowledge and areas where the proposed actions have been completed. For more information on the 

organization of the 2012 goals and objectives, see the Introduction section. For a list of the 2012 goals and 

objectives, see Appendix A. 

GOAL OR OBJECTIVE 

Notes 

2001 2012 

Goal 1 Increase awareness that suicide 

is a public health problem that is 

preventable. 

Goal 2 The goal was expanded to address a 

broad range of communication efforts 

targeting various audiences. 

1.1 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. 

2.1 and 

2.4 

The objective was expanded to focus on 

changing the knowledge, attitudes, and 

behaviors of various audiences. 

1.2 Establish regular national congresses 

on suicide prevention designed to foster 

collaboration with stakeholders on 

prevention strategies across disciplines 

and with the public. 

1.1 The objective was revised to encourage 

the integration of suicide prevention 

into the values, culture, leadership, and 

work of a wide range of organizations 

and programs. 

1.3 Convene national forums on issues 

likely to strongly influence effectiveness 

of suicide prevention messages. 

N/A Several organizations dedicated to 

suicide prevention conduct national 

meetings on a regular basis. 

1.4 Increase the number of public 

and private institutions active in 

suicide prevention that are involved 

in collaborative dissemination of 

information on the World Wide Web. 

2.3 and 

4.3 

The objective was modified to support 

an increase in all types of online 

communication efforts. The related 

Objective 4.3 focuses on guidelines 

addressing the safety of online content. 

Goal 2 Develop broad-based support for suicide 

prevention. 

Goal 1 The wording was revised: “Integrate and 

coordinate suicide prevention activities 

across multiple sectors and settings.” 

2.1 Expand Federal Steering Group (FSG) 

to improve federal coordination, help 

implement the NSSP, and coordinate 

future revisions. 

Achieved 

and 1.3 

The FSG was expanded and is now 

called the Federal Working Group. 

The objective was revised to focus on 

sustaining and strengthening federal 

collaborations. 

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GOAL OR OBJECTIVE 

2001 2012 

Notes 

2.2 By 2002, establish public-private 

partnerships to advance and coordinate 

implementation of NSSP. 

Achieved 

at 

national 

level and 

1.4 

The partnership was formed as the 

National Action Alliance for Suicide 

Prevention. The objective was expanded 

to support similar efforts at the state/ 

territorial, tribal, and local levels. 

2.3 Increase the number of national 1.1 The objective now addresses the 

professional, voluntary, and other integration of suicide prevention into 

groups that integrate suicide prevention the values, culture, leadership, and 

into ongoing programs and activities. work of a wide range of organizations 

and programs with a role to support 

suicide prevention activities. 

2.4 Increase the number of nationally 1.1 (see above) 

organized faith communities adopting 

institutional policies promoting suicide 

prevention. 

Goal 3 Goal 3: Develop and implement Goal 3 The focus of the goal was broadened 

strategies to reduce the stigma and 3.2 to promote greater knowledge of 

associated with being a consumer of protective factors and of factors 

mental health, substance abuse, and that promote wellness and recovery. 

suicide prevention services. Reducing prejudice and discrimination 

is addressed in Objective 3.2. 

3.1 By 2005, increase the proportion of the 3.2 Addressed in Objective 3.2, which 

public that views mental and physical focuses on reducing the prejudice and 

health as equal and inseparable discrimination associated with suicide 

components of overall health. and suicide-related behaviors. 

3.2 By 2005, increase the proportion of the 3.2 and (see above) Also addressed in Objective 

3.3, which focuses on promoting the 

understanding that recovery from mental 

and substance use disorders is possible. 

public that views mental disorders as 3.3 

real illnesses that respond to specific 

treatments. 

3.3 By 2005, increase the proportion of 3.2 and (see above) 

the public that views consumers of 3.3 

mental health, substance abuse, and 

suicide prevention services as pursuing 

fundamental care and treatment for 

overall health. 

3.4 By 2005, increase the proportion of 8.3 The new Objective 8.3 promotes timely 

those suicidal persons with underlying access to assessment, intervention, 

disorders who receive appropriate and effective care for individuals with a 

mental health treatment. heightened risk for suicide. 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


GOAL OR OBJECTIVE 

Notes 

The revised goal addresses the 

development, implementation, and 

monitoring of programs that promote 

wellness and prevent suicide and 

related behaviors. 

2001 2012 

Goal 4 Develop and implement communitybased suicide prevention programs. Goal 5 

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 their communities. 

5.1 Nearly all states have a suicide 

prevention plan, but there is much 

variation among plans. Objective 5.1 

supports improvements to the plans. 

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. 

5.2 The new Objective 5.2 includes 

programs conducted in various settings, 

including schools, which were previously 

addressed in separate objectives. 

4.3 By 2005, increase the proportion of 

colleges and universities with evidencebased programs designed to address 

serious young adult distress and prevent 

suicide. 

5.2 (see above) 

4.4 By 2005, increase the proportion of 

employers that ensure the availability of 

evidence-based prevention strategies for 

suicide. 

5.2 (see above) 

4.5 By 2005, increase the proportion of 

correctional institutions, jails, and 

detention centers housing either adult 

or juvenile offenders with evidencebased suicide prevention programs. 

5.2 (see above) 

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. 

5.2 (see above) 

4.7 By 2005, increase the proportion of 

family, youth, and community service 

providers and organizations with 

evidence-based suicide prevention 

programs. 

5.2 (see above) 

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2001 2012 

Notes 

4.8 By 2005, develop one or more training Achieved The Suicide Prevention Resource Center 

and technical resource centers to build was established in 2002. 

capacity for states and communities 

to implement and evaluate suicide 

prevention programs. 

Goal 5 Promote efforts to reduce access to Goal 6 The goal was revised to focus on 

lethal means and methods of self-harm. reducing access to lethal means and 

methods among individuals with suicide 

risk. 

5.1 By 2005, increase the proportion of 6.1 The wording was revised: “Encourage 

primary care clinicians, other health providers who interact with individuals 

care providers, and health and safety at risk for suicide to routinely assess for 

officials who routinely assess the access to lethal means.” 

presence of lethal means (including 

firearms, drugs, and poisons) in the 

home and educate about actions to 

reduce associated risks. 

5.2 By 2005, expose a proportion of 2.1 Public information campaigns and other 

households to public information communications efforts, including those 

campaign(s) designed to reduce the addressing lethal means, are discussed 

accessibility of lethal means, including in Objective 2.1. 

firearms, in the home. 

5.3 By 2005, increase the proportion of 3.2 and This is now addressed in Objective 3.2, 

the public that views consumers of 

mental health, substance abuse, and 

suicide prevention services as pursuing 

fundamental care and treatment for 

overall health. 

3.3 which focuses on reducing prejudice 

and discrimination associated with 

behavioral health disorders, and in 

Objective 3.3, which focuses on 

promoting the understanding that 

recovery is possible. 

5.4 By 2005, develop guidelines for safer 

dispensing of medications for individuals

at heightened risk of suicide. 

7.3 The objective is covered in Objective 

7.3, which promotes the development 

and adoption of training guidelines for 

all health professions. 

5.5 By 2005, improve automobile design to 

impede carbon monoxide-mediated suicide. 

6.3 The objective was broadened to address 

all types of safety technologies. 

5.6 By 2005, institute incentives for the 6.3 (see above) 

discovery of new technologies to prevent 

suicide. 

GOAL OR OBJECTIVE 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


GOAL OR OBJECTIVE 

Notes 

The wording was revised: “Provide 

training to community and clinical 

service providers on the prevention of 

suicide and related behaviors.” 

2001 2012 

Goal 6 Implement training for recognition of 

at-risk behavior and delivery of effective 

treatment. 

Goal 7 

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. 

7.3 The objective was broadened to address 

the education and training in all health 

professions and to include graduate and 

continuing education. 

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. 

7.3 (see above) 

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. 

7.3 (see above) 

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. 

7.1 The new Objective 7.1 addresses the 

training of all community providers. 

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. 

7.1 (see above) 

6.6 By 2005, increase the proportion of 

correctional workers who have received 

training on identifying and responding 

to persons at risk for suicide. 

7.1 (see above) 

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2001 2012 

Notes 

6.7 By 2005, increase the proportion of 7.1 (see above) 

divorce and family law and criminal 

defense attorneys who have received 

training in identifying and responding to 

persons at risk for suicide. 

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. 

7.1 (see above) 

6.9 By 2005, increase the number of 7.4 The objective was revised to promote 

recertification or licensing programs the adoption of core education and 

in relevant professions that require or training guidelines on the prevention 

promote competencies in depression of suicidal self-directed violence and 

assessment and management and related behaviors by credentialing and 

suicide prevention. accreditation bodies. 

Goal 7 Develop and promote effective clinical Goal 8 The goal was revised to promote suicide 

and professional practices. prevention as a core component of 

health care services. 

7.1 By 2005, increase the proportion of 8.4 The objective was revised to promote 

patients treated for self-destructive continuity of care and the safety and 

behavior in hospital emergency well-being of all patients treated for 

departments that pursue the proposed suicide risk in emergency departments 

mental health follow-up plan. or hospital inpatient units. 

7.2 By 2005, develop guidelines for 9.1 The objective was broadened to 

assessment of suicidal risk among address the adoption of guidelines for 

persons receiving care in primary health the assessment of suicide risk among 

care settings, emergency departments, persons receiving care in all settings. 

and specialty mental health and 

substance abuse treatment centers. 

7.3 By 2005, increase the proportion of 9.5 The wording was revised: “Adopt and 

specialty mental health and substance implement policies and procedures 

abuse treatment centers that have to assess suicide risk and intervene 

policies, procedures, and evaluation to promote safety and reduce suicidal 

programs designed to assess suicide behaviors among patients receiving 

risk and intervene to reduce suicidal care for mental and/or substance use 

behaviors among their patients. disorders.” 

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. 

9.2 The objective was broadened to address 

guidelines for clinical practice and 

continuity of care for all providers who 

treat persons with suicide risk. 

GOAL OR OBJECTIVE 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


GOAL OR OBJECTIVE 

Notes 

The objective was slightly revised: 

“Provide health care providers, first 

responders, and others with care and 

support when a patient under their care 

dies by suicide.” 

2001 2012 

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. 

10.5 

7.6 By 2005, increase the proportion of 

patients with mood disorders who 

complete a course of treatment or 

continue maintenance treatment as 

recommended. 

8.3 Addressed in Objective 8.3, which 

focuses on promoting timely access to 

assessment, intervention, and effective 

care for individuals with a heightened 

risk for suicide. 

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. 

8.3 (see above) 

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. 

9.4 The wording was revised: “Adopt and 

implement guidelines to effectively 

engage families and concerned others, 

when appropriate, throughout entire 

episodes of care for persons with 

suicide risk.” 

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 

health care programs (e.g., Medicaid, 

CHAMPUS/TRICARE, CHIP, Medicare). 

N/A Screening for depression and alcohol 

misuse have now been endorsed 

by the United States Preventative 

Services Task Force (USPSTF) and are 

now covered as preventative services 

under Medicare. The PHQ-9 has been 

incorporated into the CMS Minimum 

Data Set for nursing home assessment. 

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. 

N/A Screening for depression and alcohol 

misuse have now been endorsed by 

the USPSTF and are now covered as 

preventative services under Medicare. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


GOAL OR OBJECTIVE 

Notes 

2001 2012 

Goal 8 Improve access to and community 

linkages with mental health and 

substance abuse services. 

8.6, 8.7, 

and 8.8 

Objective 8.6 addresses linkages 

between behavioral health service 

providers and community-based 

programs. Objective 8.7 addresses 

coordination between behavioral health 

systems and local crisis centers. 

Objective 8.8 addresses collaborations 

between emergency departments and 

other health care providers. 

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. 

5.4 and 

1.5 

Parity laws are addressed in Objective 

5.4, which supports efforts to increase 

access to and delivery of effective 

programs and services for mental and 

substance use disorders. Objective 1.5 

promotes the integration of suicide 

prevention into all relevant health care 

reform efforts. 

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. 

8.3 Covered in Objective 8.3, which 

promotes timely access to assessment, 

intervention, and effective care for 

individuals with a heightened risk for 

suicide. 

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. 

N/A The revised objectives are broad and 

not focused on specific settings or 

populations. 

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. 

N/A (see above) 

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. 

N/A (see above) 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


GOAL OR OBJECTIVE 

Notes 

(see above) 

2001 2012 

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. 

N/A 

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. 

10.1 The wording was revised: “Develop 

guidelines for effective comprehensive 

support programs for individuals 

bereaved by suicide and promote the 

full implementation of these guidelines 

at the state/territorial, tribal, and 

community levels.” 

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. 

Goal 8, 

8.5 

The incorporation of suicide prevention 

into continuous quality improvement 

efforts is an important theme in Goal 8 

and is addressed in Objective 8.5. 

Goal 9 Improve reporting and portrayals of 

suicidal behavior, mental illness, and 

substance abuse in the entertainment 

and news media. 

Goal 4 Reworded to include online content: 

“Promote responsible media reporting 

of suicide, accurate portrayals of 

suicide and mental illnesses in the 

entertainment industry, and the safety 

of online content related to suicide.” 

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. 

4.2 Recommendations regarding accurate 

and responsible depictions have been 

developed. The objective was revised to 

encourage and recognize members of 

the entertainment media who follow the 

recommendations. 

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. 

4.2 (see above) 

9.3 By 2005, increase the proportion of 

news reports on suicide that observe 

consensus reporting recommendations. 

4.1 Recommendations regarding reporting 

have been developed. The objective was 

revised to encourage their use. 

PAGE 89 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

2001 

GOAL OR OBJECTIVE 

2012 

Notes 

9.4 By 2005, increase the number of 4.4 The objective was broadened to include 

journalism schools that include in their mass communication schools. 

curricula guidance on the portrayal and 

reporting of mental illness, suicide, and 

suicidal behaviors. 

Goal 10 Promote and support research on Goal 12 Promote and support research on 

suicide and suicide prevention. suicide prevention. 

10.1 By 2002, develop a national suicide 12.1 and The Action Alliance’s Research 

Prioritization Task Force is developing 

a national research agenda. The 

new Objective 12.2 addresses the 

dissemination and use of the research 

agenda. 

research agenda with input from 12.2 

survivors, practitioners, researchers, 

and advocates. 

10.2 By 2005, increase funding (public and 13.1 and Objective 13.1 supports the 

private) for suicide prevention research, 13.2 evaluation of suicide prevention 

for research on translating scientific interventions. Objective 13.2 promotes 

knowledge into practice, and for the assessment, synthesis, and 

training of researchers in suicidology. dissemination of the evidence obtained 

via these evaluations. 

10.3 By 2005, establish and maintain a 12.3 and A best practices registry has 

registry of prevention activities with 12.4 been established by the Suicide 

demonstrated effectiveness for suicide Prevention Resource Center. The new 

or suicidal behaviors. Objective 12.3 focuses on the timely 

dissemination of suicide prevention 

research findings. The new Objective 

12.4 focuses on the development of a 

repository of research resources. 

10.4 By 2005, perform scientific evaluation 13.1 and Objective 13.1 supports the 

studies of new or existing suicide 13.2 evaluation of suicide prevention 

prevention interventions. interventions. Objective 13.2 promotes 

the assessment, synthesis, and 

dissemination of the evidence obtained 

via these evaluations. 

Goal 11 Improve and expand surveillance Goal 11 The wording was revised: “Increase 

systems. the timeliness and usefulness of 

national surveillance systems relevant 

to suicide prevention, and improve the 

ability to collect, analyze, and use this 

information for action.” 

11.1 By 2005, develop and refine 11.2 Addressed in Objective 11.2, focuses 

standardized protocols for death scene on improving the usefulness and quality 

investigations and implement these of suicide-related data. 

protocols in counties (or comparable 

jurisdictions). 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


GOAL OR OBJECTIVE 

Notes 

(see above) 

2001 2012 

11.2 By 2005, increase the proportion of 

jurisdictions that regularly collect and 

provide information for follow-back 

studies on suicides. 

11.2 

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. 

11.2 (see above) 

11.4 By 2005, implement a National Violent 

Death Reporting System (NVDRS) 

that includes suicides and collects 

information not currently available from 

death certificates. 

11.3 NVDRS, a state-based surveillance 

system that collects facts from different 

sources about the same incident, has 

been established by the Centers for 

Disease Control and Prevention, and 

currently operates in several states. The 

expansion of NVDRS is referenced in 

Objective 11.3. 

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. 

11.3 The objective was broadened to promote 

the improvement and expansion of 

state/territorial, tribal, and local public 

health capacity to routinely collect, 

analyze, report, and use suicide-related 

data to implement prevention efforts 

and inform policy decisions. 

11.6 By 2005, increase the number of 

nationally representative surveys that 

include questions on suicidal behavior. 

11.4 The objective was broadened to address 

other data collection instruments and 

systems, and to include questions on 

risk factors and exposure to suicide. 

11.7 By 2005, implement pilot projects in 

several states that link and analyze 

information related to self-destructive 

behavior derived from separate data 

systems, including law enforcement 

agencies, emergency medical services, 

and hospitals. 

11.3 Addressed in Objective 11.3, which 

seeks to expand the capacity to 

collect, analyze, report, and use 

suicide-related data. 

PAGE 91 
New objectives added in 2012: 

Objective 1.2: Establish effective, sustainable, and collaborative suicide prevention programming at 

the state/territorial, tribal, and local levels. 

Objective 2.2: Reach policymakers with dedicated communication efforts. 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Objective 3.1: Promote effective programs and practices that increase protection from suicide risk. 

Objective 5.3: Intervene to reduce suicidal thoughts and behaviors in populations with suicide risk. 

Objective 7.2: Provide training to mental health and substance abuse providers on the recognition, 

assessment, and management of at-risk behavior and the delivery of effective clinical care for people 

Objective 8.1: Promote the adoption of “zero suicides” as an aspirational goal by health care and 

community support systems that provide services and support to defined patient populations. 

Objective 8.2: Develop and implement protocols for delivering services for individuals with suicide 

risk in the most collaborative, responsive, and least restrictive settings. 

Objective 8.5: Encourage health care delivery systems to incorporate suicide prevention and 

appropriate responses to suicide attempts as indicators of continuous quality improvement efforts. 

Objective 9.3: Promote the safe disclosure of suicidal thoughts and behaviors by all patients. 

Objective 9.6: Develop standardized protocols for use within emergency departments based on 

common clinical presentation to allow for more differentiated responses based on risk profiles and 

assessed clinical needs. 

with suicide risk. 


PAGE 92 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Objective 9.7: Develop guidelines on the documentation of assessment and treatment of suicide risk, 
 

and establish a training and technical assistance capacity to assist providers with implementation. 
 

Objective 10.2: Provide appropriate clinical care to individuals affected by a suicide attempt or
 


bereaved by suicide, including trauma treatment and care for complicated grief. 
 

Objective 10.3: Engage suicide attempt survivors in suicide prevention planning, including support 
 

services, treatment, community suicide prevention education, and the development of guidelines and 
 

protocols for suicide attempt survivor support groups. 
 

Objective 10.4: Adopt, disseminate, implement, and evaluate guidelines for communities to
 


respond effectively to suicide clusters and contagion within their cultural context, and support 
 

implementation with education, training, and consultation. 
 

Objective 12.2: Disseminate the national suicide prevention research agenda. 

Objective 13.3: Examine how suicide prevention efforts are implemented in different states/
 


territories, tribes, and communities to identify the types of delivery structures that may be most 
 

efficient and effective.
 


Objective 13.4: Evaluate the impact and effectiveness of the National Strategy for Suicide Prevention 

in reducing suicide morbidity and mortality. 

PAGE 93 
 

Appendix C: Brief History of Suicide Prevention 

in the United States 

NATIONAL MILESTONES IN SUICIDE PREVENTION 

1958: First 

suicide prevention 

center opens in 

Los Angeles, 

California. 

1960: International 

Association for 

Suicide Prevention 

founded.



1967: National 

Institute of Mental 

Health (NIMH) 

establishes Center 

for Studies of 

Suicide Prevention. 

1968: First national

conference on

suicidology held in

Chicago, Illinois.

1968: American 
 

Association of 
 

Suicidology (AAS) 
 

founded.



1971: The 

journal Suicide 

and Life 

Threatening 

Behavior 

publishes its 

first issue. 

1973: NIMH publishes 

Suicide Prevention in 

the 70s. 

1976: AAS establishes 

crisis center certification 

program and certifies its 

first crisis center. 

1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 19

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

1987: American 

Foundation for 

Suicide Prevention 

(AFSP) founded.

1989: Suicide Awareness 

Voices of Education 

(SAVE) holds its first 

national suicide 

awareness memorial in 

St. Paul, Minnesota. 

1989: U.S. 

Department of Health 

and Human Services 

(HHS) publishes 

Report of the 

Secretary’s Task Force 

on Youth Suicide. 

1989: AAS holds its 

first “Healing After 

Suicide” conference. 

1990: SAVE is 

incorporated. 

Suicide prevention efforts in the United States started in the 1950s, through the pioneering efforts of 

a small group of dedicated clinicians interested in better understanding suicide and its prevention. 

These early efforts were expanded upon in the 1980s with the support and passion of individuals who 

had been bereaved by a suicide loss. With limited funding and formal organization, these individuals 

and their grassroots organizations set out to place suicide on the national agenda. Their combined 

efforts over time culminated with the release of the 2001 National Strategy for Suicide Prevention. 

These dedicated advocates, organizations, and communities have remained at the forefront of suicide 

prevention activities nationwide. 

PAGE 94 
 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

1992: Centers for 

Disease Control 

and Prevention 

(CDC) publishes 

Youth Suicide 

Prevention 

Programs: A 

Resource Guide. 

1994: Yellow 

Ribbon Suicide 

Prevention 

Program founded. 

1995: Lifekeeper 

Foundation 

founded. 

1996: Suicide 

Prevention Advocacy 

Network USA (SPAN 

USA) founded. 

1996: World Health 

Organization and 1996: CDC publishes United Nations 

report on suicide publish Prevention 

among Native of Suicide: 

Americans. Guidelines for the 

Formulation and 1996: U.S. Air Force 

Implementation of suicide prevention 

National Strategies. initiative launched. 

1997: The Jason 

Foundation, Inc. 

is founded. 

1997: Congress 

passes S. Res. 84 

and H. Res. 212 

recognizing suicide 

as a national 

problem; CDC 

establishes 

National Center for 

Injury Prevention 

and Control. 

1997: Organization 

for Attempters and 

Survivors of Suicide 

in Interfaith Services 

(OASSIS) founded. 

1998: The Trevor 

Project founded. 

1998: National 

Organization for 

People of Color 

Against Suicide 

founded. 

1998: SPAN USA 

and CDC partner to 

host the Reno 

Consensus 

Development 

Conference. 

1998: CDC funds 

Suicide Prevention 

Research Center at 

University of 

Nevada. 

1999: First National 

Survivors of Suicide 

Day held. 

1999: National 

Hopeline Network 

(1–800–SUICIDE) 

launched. 

1999: HHS 

publishes The 

Surgeon General’s 

Call to Action to 

Prevent Suicide. 

1999: National 

Council for Suicide 

Prevention 

established. 

2000: The Jed 

Foundation 

founded. 

2000: OASSIS 

sponsors first 

National 

Interfaith 

Conference on 

Religion and 

Suicide. 

2001: Substance Abuse and Mental 

Health Services Administration 

(SAMHSA) funds national crisis line. 

2001: HHS publishes National 

Strategy for Suicide Prevention. 

2002: SAMHSA 

establishes national 

Suicide Prevention 

Resource Center 

(SPRC). 

2002: Institute of 

Medicine releases 

Reducing Suicide: A 

National Imperative. 

2002: The first Out 

of the Darkness 

Overnight walk held. 

2003: President’s 

New Freedom 

Commission on 

Mental Health 

publishes Achieving 

the Promise: 

Transforming Mental 

Health Care in 

America. 

2005: SAMHSA 

launches National 

Suicide Prevention 

Lifeline (800–273– 

TALK/8255). 

2004: Garrett 

Lee Smith 

Memorial Act 

signed into law 

creating the 

state, tribal, and 

campus suicide 

prevention grant 

programs. 

2006: Federal

Working Group

on Suicide 

Prevention 

formed. 

2007: Joshua Omvig 

Veterans Suicide 

Prevention Act signed 

into law. 

2007: The Veterans 

Suicide Prevention 

Hotline founded. 

2007: Joint Commission 

publishes Patient Safety 

Goals on Suicide, making 

suicide prevention one of 

its standards for 

accreditation. 

2008: Mental 

Health Parity and 

Addiction Equity Act 

signed into law. 

2009: U.S. 

Department of 

Defense (DoD) 

establishes Task 

Force on the 

Prevention of 

Suicide by 

Members of the 

Armed Forces. 

2010: National Action 

Alliance for Suicide 

Prevention established. 

2010: SPRC and SPAN 

USA/AFSP publish 

Charting the Future of 

Suicide Prevention: A 

2010 Progress Review of 

the National Strategy and 

Recommendations for the 

Decade Ahead. 

2011: The 

Department of 

Defense 

establishes the 

Defense Suicide 

Prevention office 

(DSPO). 

2012: National 

Strategy for Suicide 

Prevention revised. 

85 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

PAGE 95
 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

First Steps 

In 1958, the first suicide prevention center in the United States opened in Los Angeles, California, with 

funding from the U.S. Public Health Service. Other crisis intervention centers followed. In 1966, the 

Center for Studies of Suicide Prevention (later the Suicide Research Unit) was established at the National 

Institute of Mental Health (NIMH) of the National Institutes of Health (NIH). This was followed by the 

creation of national nonprofit organizations dedicated to the cause of suicide prevention. 

In 1970, NIMH convened a task force in Phoenix, Arizona, to discuss the status of suicide prevention in 

the United States. NIMH presented the findings in the 1973 report Suicide Prevention in the 70s, which 

also identified future directions and priorities.111 In 1983, the Centers for Disease Control and Prevention 

(CDC) established a violence prevention unit that brought public attention to a disturbing increase in 

youth suicide rates. In response, the Secretary of the U.S. Department of Health and Human Services 

(HHS) established a Task Force on Youth Suicide, which reviewed the existing evidence and issued 

recommendations in 1989.112 

The Push for a National Strategy 

Suicide became a central issue in the United States in the mid-1990s, when survivors of suicide loss saw 

the need to mobilize attention and the political will to prevent suicide in the nation. Using the United 

Nations (U.N.) guidelines for the creation and implementation of national strategies published in 

1996,53 these grassroots groups launched a citizen-initiated campaign to encourage the development of a 

national strategy in the United States. These efforts resulted in two 

Congressional Resolutions—S. Res. 84 and H. Res. 212 of the 105th 

Congress—recognizing suicide as a national problem and suicide 

prevention as a national priority. 

As recommended in the U.N. guidelines, these groups set out to 

establish a public and private partnership that would be responsible 

for promoting suicide prevention in the United States. This 

innovative public-private partnership jointly sponsored a national 

consensus conference on suicide prevention in Reno, Nevada, which 

developed a list of 81 recommendations. 

The Reno conference is viewed as the founding event of the modern 

suicide prevention movement. Informed by its findings, in 1999, 

Surgeon General David Satcher issued his Call to Action to Prevent 

Suicide, which emphasized suicide as a serious public health problem requiring attention and action.5 

This document introduced a blueprint for addressing suicide prevention through a number of efforts 

organized under the framework of “Awareness, Intervention, and Methodology” (AIM). It included 15 

broad recommendations consistent with a public health approach to suicide prevention, along with goal 

statements and broad objectives. 

PAGE 96 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 

Key Points From Reno, Nevada, Conference 

1. 	 Suicide prevention must recognize and affirm the value, dignity, and importance of 
 

each person.



2. 	 Suicide is not solely the result of illness or inner conditions. The feelings of 

hopelessness that contribute to suicide can stem from societal conditions and attitudes. 

Therefore, everyone concerned with suicide prevention shares a responsibility to help 

change attitudes and eliminate the conditions of oppression, racism, homophobia, 

discrimination, and prejudice. 

3. 	 Some groups are disproportionately affected by these societal conditions, and some are 

at greater risk for suicide. 

4. 	 Individuals, communities, organizations, and leaders at all levels should collaborate to 

promote suicide prevention. 

5. 	 The success of this strategy ultimately rests with individuals and communities across the 

United States. 

A year later, the HHS Secretary formed a Federal Steering Group to coordinate efforts and ensure 

resources for the development of the national strategy. The group brought together individuals and 

organizations from the public and private sectors to collaborate in this effort and sought input through 

four strategically located national public hearings. These efforts culminated with the release of the National 

Strategy for Suicide Prevention in 2001.6 

The National Strategy for Suicide Prevention (National Strategy) set forth an ambitious agenda, consisting 

of 11 goals and 68 objectives, organized under the AIM framework described in the Surgeon General’s Call 

to Action. The document was meant to serve as a wide-ranging “catalyst for social change, with the power 

to transform attitudes, policies, and services (p. 27).”6

 For the broader suicide prevention community, the 

National Strategy provided a common point of reference and a resource for advocacy at the state and local 

levels, while directing more attention to the needs of those affected by suicide. 

PAGE 97 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Key Developments and Accomplishments 

In the years that followed, several other key developments helped advance suicide prevention in the 

nation. Among these was the 2002 report Reducing Suicide: A National Imperative, which summarized the 

state of the science base, gaps in knowledge, strategies for prevention, and research designs for the study of 

suicide.9

 This landmark report presented findings from a 13-member committee formed by the Institute of 

Medicine in 2000, at the request of several federal agencies. 

Another important document was the 2003 report Achieving the Promise: Transforming Mental Health 

Care in America, prepared by the New Freedom Commission on Mental Health.113 Assembled by President 

George W. Bush in 2002, the commission was asked to study the mental health service delivery system, 

and to make recommendations that would enable adults with serious mental illnesses and children with 

serious emotional disturbances to live, work, learn, and participate fully in their communities. After 1 year 

of study, and after reviewing research and testimony, the group issued its final report, which identified six 

goals and corresponding recommendations. 

Activity in the field of suicide prevention has grown dramatically since the National Strategy was issued 

in 2001. Government agencies at all levels, schools, nonprofit organizations, and businesses have started 

programs to address suicide prevention. Charting the Future of Suicide Prevention, a progress report 

commissioned by the Substance Abuse and Mental Health Services Administration (SAMHSA) and 

released in October 2010, discusses many of these accomplishments.7 

Federal Policy Initiatives 

Enacted in 2004, the Garrett Lee Smith Memorial Act (GLSMA) is the most important legislative 

accomplishment in the field of youth suicide prevention in the past decade. The act was named for Sen. 

Gordon Smith’s (R-OR) son, a college student who died by suicide in late 2003. The GLSMA created 

the first significant federal grant program directed specifically at suicide prevention. Administered by 

SAMHSA, the program provides grants to states, tribes, territories, and institutions of higher education 

for the implementation of youth and college suicide prevention efforts. More than 300 GLSMA suicide 

prevention grants have been funded since the program’s inception, including 27 grants funded through the 

Prevention and Public Health Fund created by the Affordable Care Act. 

Another federal law, the Joshua Omvig Veterans Suicide Prevention Act (JOVSPA) of 2007, has supported 

the development of a comprehensive program to reduce the incidence of suicide among veterans. Named 

for a veteran of Operation Iraqi Freedom who died by suicide in 2005, the act directed the Secretary of 

the U.S. Department of Veterans Affairs (VA) to implement a comprehensive suicide prevention program 

for veterans. Components include staff education, mental health assessments as part of overall health 

assessments, a suicide prevention coordinator at each VA medical facility, research efforts, 24-hour mental 

health care, a toll-free crisis line, and outreach to and education for veterans and their families. In the 

summer of 2009, VA added a one-to-one “chat service” for veterans who prefer to reach out for assistance 

using the Internet. 

PAGE 98 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Program Initiatives 

In 2001, SAMHSA established the country’s first program with the mission of effectively reaching 

and serving all persons at risk of suicide in the United States through a national network of local, 

certified crisis call centers. This program, now called the National Suicide Prevention Lifeline (800– 

273–TALK/8255) serves as a central switchboard, seamlessly connecting callers to a crisis center 

geographically nearest the caller from among a national network of more than 150 crisis centers in 49 

states. It provides services in English and Spanish, 24 hours a day, 7 days a week. It also includes a feature 

allowing callers to press “1” and be connected to a VA crisis center. The Lifeline also operates a website 

(www.suicidepreventionlifeline.org) and works closely with social networking websites. In October 2011, 

the Lifeline answered its 3 millionth call. 

The Lifeline used evaluation results to introduce best practice standards used across the network. To 

improve service quality, SAMHSA funded two evaluations of network crisis center practices in 2003–04. 

These evaluations culminated in groundbreaking findings for the field, released in 2005 and published in 

2007.114, 115 These findings demonstrated both effective crisis center practices (e.g., significant reductions 

in caller distress and suicidal risk) and needs for improvement (e.g., better risk assessment, more uniform 

approaches for callers at imminent risk of suicide, a need to monitor calls and more follow up with callers). 

The creation of the first national resource center on suicide prevention was another important 

accomplishment. Established by SAMHSA in 2002, the Suicide Prevention Resource Center (SPRC) 

conducts a broad range of activities intended to improve the development, implementation, and evaluation 

of suicide prevention programs and practices. The center disseminates information, products, and services 

to various audiences through its website (www.sprc.org), online and face-to-face training programs, 

webinars, and direct consultation and support from its expert staff. SPRC also maintains an online library 

and clearinghouse of suicide prevention information and a registry of evidence-based programs and best 

practice recommendations. 

The 2001 National Strategy specifically called for the creation of a national violent death reporting system 

to gather information from several data sources that were not otherwise linked. In Fiscal Year 2002, 

Congress appropriated funds for the development and implementation of the National Violent Death 

Reporting System (NVDRS). Originally implemented in six states, the system was extended to a total of 

18 states in Fiscal Year 2009, via a congressional appropriation of $3.5 million. The system collects data on 

violent deaths from four primary sources: death certificates, police reports, medical examiner and coroner 

reports, and crime laboratories. Data are available for public use through the Web-Based Injury Statistics 

Query and Reporting System (WISQARS, at www.cdc.gov/injury/wisqars/index.html). 

The 2001 National Strategy also called for the development of comprehensive state suicide prevention 

plans that would coordinate across government agencies; involve the private sector; and support plan 

development, implementation, and evaluation in communities. Today, nearly all states have a suicide 

prevention plan in place and some have formed public-private partnerships to advance their plans. 

Although these suicide prevention plans vary in terms of the groups they serve, involvement of the private 

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sector, and resources available for services, their development represents an important first step and 

achievement in the field of suicide prevention. 

Recent Developments 

Recent milestones in the history of suicide prevention in the United States include the formation of the 

National Action Alliance for Suicide Prevention, in 2010, and the revision of the National Strategy in 2012. 

These milestones represent continuing progress toward the prevention of suicide in this country. For more 

on these recent developments, see the Introduction section. 

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Appendix D: Groups With Increased Suicide Risk 

As noted in the Introduction, many factors make it difficult to identify the subgroups of the population 

that may have an increased risk for suicidal behaviors. Risk and protective factors are varied, interact in 

different ways, and may change over time. Some risk and protective factors may be more important to 

one group than to another. The types of suicidal behaviors that are most common also vary across groups. 

For example, suicide rates may be particularly high in some groups, but suicide attempts may be more 

common in others. In addition, limitations associated with the collection of suicide-related data can also 

make it difficult to obtain prevalence estimates for specific groups. 

This appendix provides information on suicide risk among the following groups, which have been 

identified as being at a higher risk for suicidal behaviors than the general population: 

American Indians/Alaska Natives; 

Individuals bereaved by suicide; 

Individuals in justice and child welfare settings; 

Individuals who engage in nonsuicidal self-injury (NSSI); 

Individuals who have attempted suicide; 

Individuals with medical conditions; 

Individuals with mental and/or substance use disorders; 

Lesbian, gay, bisexual, and transgender (LGBT) populations; 

Members of the Armed Forces and veterans; 

Men in midlife; and 

Older men. 

Additional information on these groups is available from the Suicide Prevention Resource Center’s 

(SPRC) online library (www.sprc.org/search/library). For evidence-based and best practices programs 

and guidelines, please visit the National Registry of Evidence-Based Programs and Practices 

(www.nrepp.samhsa.gov), and the Best Practices Registry for Suicide Prevention (www.sprc.org/bpr). 

General resources on suicide prevention are listed in Appendix E. 

American Indians/Alaska Natives 

In 2009, the suicide rate among American Indians/Alaska Natives (AI/AN) was 11.91 per 100,000, which is 

similar to the overall U.S. rate of 11.77.1

 However, suicide rates are much higher among AI/AN youth than 

among youth overall. In 2009, the rate of suicide among AI/AN youth aged 10 to 18 years was 10.37 per 

100,000, compared with an overall rate of 3.95 per 100,000.1

 Suicide is the second leading cause of death 

among AI/AN youth aged 10 to 34 years, with young Native men aged 20 to 24 having the highest rate of 

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suicide in the AI/AN population: 40.79 deaths per 100,000.1 Although suicide rates vary widely among 

individual tribes, it is estimated that 14 to 27 percent of AI/AN adolescents have attempted suicide.21-23 

Research indicates that cultural continuity,116 high levels of cultural spiritual orientation,117 and 

connectedness to family and friends21 are protective factors for suicidal behaviors among AI/AN 

populations. Specific risk factors particular to this group include alcohol and other substance use,118 

discrimination,119, 120 limited mental health services access and use,121, 122 and historical trauma.123, 124 

Findings from the Adverse Childhood Experiences (ACE) study suggest that there is a strong and positive 

correlation between the number of adverse events in a child’s life and the probability for negative outcomes 

during adulthood.125 In reservation settings, AI/AN youth have considerable exposure to suicide and 

may be at particular risk for contagion.126 Much of the research available on AI/AN racial and ethnic 

disparities does not include urban (non-reservation) areas, where a majority (78 percent) of Native people 

in the United States live.127 Compared with other racial and ethnic groups, few resources are devoted to 

the health needs of the urban AI/AN population,128 and many have experienced losses of community, 

language, and ethnic identity.129 

Several federal initiatives, such as the Substance Abuse and Mental Health Services Administration 

(SAMHSA) Garrett Lee Smith and Native Aspirations programs and the Indian Health Service (IHS) 

Methamphetamine and Suicide Prevention Initiative, support suicide prevention efforts among AI/ 

AN populations. AI/AN communities have implemented a range of culturally specific prevention and 

intervention approaches to address the holistic needs of families and individuals affected by suicide 

and other health disparities. These efforts include reducing risk behaviors (e.g., substance use, bullying, 

violence) and promoting protective factors (e.g., cultural practices, community connectedness and 

healing, improved access to appropriate services, skills enhancement). Recent efforts have included the 

development of crisis response protocols aimed at ensuring that available services and traditional supports 

are interconnected. Many tribes have also adapted mainstream suicide prevention programs, including 

trainings, crisis lines, mentoring, and school-based programs, for use in local AI/AN communities. 

Many efforts are underway to better document the effectiveness of these holistic approaches in Native 

communities. A comprehensive, public health-based prevention program in a southwestern tribal 

community showed significant reduction in suicidal acts among youth.64 The American Indian Life Skills 

Development program, a school-based curriculum for AI/AN youth aged 14 to 19, showed reductions in 

feelings of hopelessness and increases in problem-solving skills.130 Positive youth development programs, 

such as Project Venture, while recognized as an evidence-based approach for substance use prevention, 

also showed positive results in terms of suicide prevention. Many of the specific tactics that suicide 

prevention research points to as effective (e.g., increased social integration, connection building) have 

been a part of Project Venture for 20 years.131 

Community-based surveillance systems, such as the one developed by the White Mountain Apache, 

demonstrate that tribal-specific surveillance can identify unique risk and protective factors for particular 

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populations to guide local suicide prevention programs.132, 133 Practice-based evidence also plays an 

important role and complements evidence-based practices in addressing suicide and other health issues 

among AI/AN populations. 

Resources 

Adolescent Suicide Prevention Program Manual: A Public Health Model for Native American 

Communities, 2011 

SPRC 

www.sprc.org/library/AdolescentSP_ProgramManuaPH_ModelNA_Communities.pdf 

The Adolescent Suicide Prevention Program (1989–2005) significantly lowered youth suicide rates in 

a Native community in the Southwest United States. This manual outlines methods for community 

involvement, culturally framed public health approaches, outreach efforts, behavioral health programs, 

program evaluation, and sustainability. 

AI/AN National Suicide Prevention Strategic Plan (2011–2015), August 2011 

IHS, U.S. Department of Health and Human Services (HHS) 

www.ihs.gov/MedicalPrograms/Behavioral/documents/AIANNationalSPStrategicPlan.pdf 

This strategic plan provides a comprehensive and integrated approach to reducing the loss and suffering 

that result from suicidal behaviors among the AI/AN population. 

Ensuring the Seventh Generation: A Youth Suicide Prevention Toolkit for Tribal Child Welfare 

Programs, 2009 

National Indian Child Welfare Association (NICWA) 

www.nicwa.org/YouthSuicidePreventionToolkit/YSPToolkit.pdf 

This toolkit for tribal child welfare workers and care providers discusses risk factors, warning signs, 

prevention and intervention strategies that can be applied in child welfare agencies, and mobilization of 

support networks for particular children. 

Indian Health Service American Indian/Alaska Native Suicide Prevention Website 

www.ihs.gov/NonMedicalPrograms/nspn 

This website provides AI/AN communities with culturally appropriate information about best and 

promising practices, training opportunities, tools for adapting mainstream programs to tribal needs, 

ongoing activities, potential partnerships, and other information regarding suicide prevention and 

intervention. 

SPRC American Indian/Alaska Native Suicide Prevention Pages 

www.sprc.org/aian 

These web pages offer information on suicide prevention in AI/AN communities, including local and 

promising practices, sustaining efforts, resources, publications, and data sources. 

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To Live To See the Great Day That Dawns: Preventing Suicide by American Indian and Alaska Native 

Youth and Young Adults, 2010 

SAMHSA, HHS 

www.sprc.org/library/Suicide_Prevention_Guide.pdf 

This guide supports AI/AN communities in developing effective, culturally appropriate, and 

comprehensive suicide prevention planning and postvention responses for youth and young adults. 

Individuals Bereaved by Suicide 

The impact of suicide can be profound and sometimes devastating for those who are left behind. Each 

year, more than 13 million people in the United States report that they have known someone who died 

by suicide that year.134 Conservative estimates suggest that there are typically at least five or six family 

members who are affected when a family member takes his or her life, and perhaps as many as 30 to 60 

people in the larger social network who also may be affected.135 Moreover, exposure to suicide carries 

risks for elevated rates of guilt, depression, and other psychiatric symptoms, complicated grief, and social 

isolation. Alarmingly, there is also compelling evidence that individuals bereaved by suicide (also referred 

to as “survivors of suicide loss”) may have an increased risk for suicide completion themselves.39 Therefore, 

to paraphrase Edwin Shneidman, helping those who have been bereaved by suicide is a direct form of 

suicide prevention with a population known to be at risk. 

In the years since the National Strategy was released, the movement to support individuals bereaved by 

suicide has intensified significantly. Innovative grassroots community programs have formed outreach 

teams who visit the newly bereaved at home, face-to-face, and through online support groups, annual 

memorial services, survivor conferences, and other types of innovative support services. National 

organizations such as the American Foundation for Suicide Prevention (AFSP), Suicide Awareness Voices 

of Education (SAVE), and the American Association of Suicidology (AAS) have also increased their 

efforts to provide help and comfort to those bereaved by suicide. Examples include AFSP’s International 

Survivors of Suicide Day gatherings around the country and the Survivor Conference within the AAS 

annual meeting. 

Despite these commendable efforts, research suggests that many individuals who have been bereaved 

by suicide experience difficulty mobilizing themselves to seek help, knowing where to find services in 

their communities, and knowing how to cope when the services are inadequate to meet their diverse and 

complicated needs.136 The lack of services may include an absence of information about where to find 

resources, a scarcity of peer-to-peer opportunities to interact with other survivors in a safe and facilitated 

setting, and a dearth of mental health professionals who have the training and experience to work 

effectively with the special needs of this population. 

As has happened in other nations, coordinated leadership at the national, state/territorial, tribal, and local 

levels will be needed to build a support infrastructure for people bereaved by suicide. Several goals for 

services can be identified. Every person bereaved by suicide should receive compassionate care from first 

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responders (e.g., police, emergency medical professionals, clergy, funeral professionals) and should receive 

information about where to get additional help if and when he or she is ready to seek it. As different people 

will use different types of resources, often at different points in their grieving process, a second goal should 

encompass the development of a variety of support services within local communities. These include, but 

are not limited to, educational and self-help literature about grief after suicide, survivor outreach teams, 

face-to-face and online support groups, and referral assistance in finding clinicians who understand grief, 

trauma, and the special problems of those who have been bereaved by suicide. Increased education about 

the impact of suicide and the needs of the bereaved by suicide should be included in the training of first 

responders and mental health and substance use professionals. And lastly, the national suicide research 

agenda should include studies that will expand knowledge of the impact of suicide on those left behind, 

and of interventions that will be effective in helping a diverse range of people who are exposed to the 

sometimes overwhelming impact of suicide.39 

Resources 

American Association of Suicidology (AAS) 

www.suicidology.org/web/guest/suicide-loss-survivors 

The survivor pages on the AAS website include the e-newsletter Surviving Suicide, a directory of survivor 

support groups, a resource list, and materials for clinicians who have lost a patient and/or family member 

to suicide. AAS has also produced the SOS Handbook, a quick reference booklet for suicide survivors. 

American Foundation for Suicide Prevention (AFSP) 

www.afsp.org/index.cfm?fuseaction=home.viewPage&page_id=742A015C-D811-979AAB84379C813F8D93 

AFSP reaches out to those who have been bereaved by suicide to offer support and to provide 

opportunities for them to get involved in educational, outreach, awareness, advocacy, and fundraising 

programs. It sponsors International Survivors of Suicide Day, a global observance where individual 

communities host awareness events. It also offers peer support resources, such as an e-network, a support 

groups directory, and the Survivor Outreach Program. 

Lifeline Gallery: Stories of Hope and Recovery 

www.lifeline-gallery.org 

This website, which is part of the National Suicide Prevention Lifeline (800–273–TALK/8255), includes a 

section where those who have been bereaved by suicide can share with others their experiences of how the 

death by suicide of a loved one affected them, their family, and their community. 

Suicide Awareness Voices of Education (SAVE) 

http://www.save.org/index.cfm?fuseaction=home.viewPage&page_id=EB883CA2-7E90-9BD4­

C5E35440BC7761EE 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

SAVE’s website survivor section provides information on coping with suicide loss, talking with children 

resources such as a survivor groups directory and the Bereavement Caregiver Blog. Its print materials 

include the booklet Suicide: Coping With the Loss of a Friend or Loved One and the book Suicide Survivors: 

A Guide For Those Left Behind. 

The Link Counseling Center 

www.thelink.org 

The Link provides services and support to those who have lost a loved one to suicide, including workshops, 

resource materials, telephone counseling, information and referrals, and trainings for survivors and 

professionals on creating and facilitating support groups for survivors. 

Individuals in Justice and Child Welfare Settings 

Suicide is often the single most common cause of death in secure justice settings.32 More than 400 suicides 

occur annually in local jails at a rate three times greater than among the general population, and suicide 

is the third leading cause of death in prisons.33-35 Youth involved in the juvenile justice and child welfare 

systems have a high prevalence of many risk factors for suicide. Although statistics on prevalence are 

unavailable, juveniles in confinement have life histories that put them at higher suicide risk, including 

experiences such as mental disorders and substance abuse; physical, sexual, and emotional abuse; and 

current and prior self-injurious behavior. 137 Youth in foster care share many of these traumatic experiences. 

In one study, children in foster care were almost three times more likely to have considered suicide and 

almost four times more likely to have attempted suicide than those who had never been in foster care.37 

Suicide among youth in contact with the juvenile justice system occurs at a rate about four times greater 

than the rate among youth in the general population.138-143 Research suggests that youth engage in more 

than 17,000 incidents each year in juvenile facilities, that more than half of all detained youth reported 

current suicidal ideation, and that one-third also had a history of suicidal behaviors.144, 145 

Risk factors for suicide among both juvenile and adult inmates include: a history of or existing mental 

illness and substance abuse; a history of suicidal behaviors; lack of mental health care; a history of abuse 

(e.g., emotional, physical, sexual); family discord/abuse; impulsive aggression; a history of interpersonal 

conflict; prior involvement in special education; legal/disciplinary problems; family history of suicide; 

poor family support; prior offenses; referral to juvenile court; and coming from a single-parent home.139­

143, 146 Protective factors against suicide among juvenile and adult inmates include: a sense of control over 

one’s own destiny; problem-solving and conflict resolution skills; adaptable temperament; support from 

and connections to family and community; positive school or employment experience; specific plans for 

the future; religious/spiritual/cultural beliefs that protect against suicide; housing that is “suicide-resistant” 

(i.e., free of protruding objects and means/methods for suicide) and that is proximal to staff and peers; and 

availability of mental health services that are provided consistently by qualified, trained, and supportive 

staff who provide strong community linkages and referrals and ensure continuity of care.21, 143, 147 

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Experts theorize that jail suicides may have two primary causes: (1) jail environments are conducive 

to suicidal behaviors; and (2) the inmate faces a crisis situation.148 Studies conducted by the National 

Center on Institutions and Alternatives and commissioned by the U.S. Department of Justice (DoJ) 

recommend that all sites develop and implement comprehensive policies and programming addressing 

suicide prevention, intervention, and care in the aftermath of a suicide death or attempt. These policies 

and programs should include: initial and annual training for all direct care, medical, and mental health 

personnel; initial intake and ongoing assessment of incarcerated persons; enhanced communication 

along the continuum of justice system; levels of supervision for persons at risk of self-harm and 

suicide; appropriate suicide-resistant housing; intervention; reporting; mortality/morbidity incident 

review; and critical incident stress debriefing.146 Because inmates can be at risk for suicide at any point 

during confinement, the biggest challenge for those who work in the justice system is to view the issue 

as requiring a continuum of comprehensive suicide prevention services aimed at the collaborative 

identification, continued assessment, and safe management of individuals at risk for suicidal behaviors. 

A dramatic reduction in the rate of suicide within county jails throughout the United States in the past 20 years 

has been attributed to increased staff training, better identification of inmates who may be at risk for suicidal 

behaviors, and the implementation of comprehensive programming.32 Recent efforts for suicide prevention 

for youth involved in the juvenile justice system include: targeting state-level juvenile justice agency directors/ 

administrators with training developed to encourage comprehensive policy development; training direct care 

staff working in juvenile facilities; improving data collection and research within the population; increasing 

collaboration between mental health and juvenile justice systems; and improving policy and programming.149 

Resources 

Endangered Youth: A Report on Suicide Among Adolescents Involved with the Child Welfare and 

Juvenile Justice Systems, 2006 

Connecticut Center for Effective Practices 

www.chdi.org/endangeredyouth 

This report offers an interdisciplinary framework that addresses the suicide risk for children, youth, 

and their families involved in the child welfare and juvenile justice systems. Case studies illustrate the 

challenges confronting families, communities, and professionals, while offering opportunities for learning 

and development of effective service delivery. 

Ensuring the Seventh Generation: A Youth Suicide Prevention Toolkit for Tribal Child Welfare 

Programs, 2009 

NICWA 

www.nicwa.org/YouthSuicidePreventionToolkit/YSPToolkit.pdf 

Intended for tribal child welfare workers and care providers, this toolkit discusses suicide risk factors 

associated with children in child welfare; warning signs caseworkers and care providers should watch 

for; suicide prevention and intervention strategies that can be applied in child welfare agencies; and 

mobilization of support networks around particular children. 

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Juvenile Suicide in Confinement: A National Survey, 2009 

National Center on Institutions and Alternatives 

Office of Juvenile Justice and Delinquency Prevention 

www.ncjrs.gov/pdffiles1/ojjdp/213691.pdf 

This report presents findings from the first national survey of juvenile suicides in confinement and offers 

recommendations for preventing suicide in juvenile facilities. 

National Study of Jail Suicide: 20 Years Later, 2010 

National Center on Institutions and Alternatives and the National Institute of Corrections, DoJ 

static.nicic.gov/Library/024308.pdf 

This study presents the most comprehensive information on inmate suicides throughout the United States. 

It challenges jail and health care officials and their staffs to remain diligent in identifying and managing 

people at highest risk. 

Preventing Suicide in Jails and Prisons, 2007 

World Health Organization (WHO) and International Association for Suicide Prevention 

www.who.int/mental_health/prevention/suicide/resource_jails_prisons.pdf 

This article is aimed at correctional administrators who develop or implement mental health programs 

and correctional officers responsible for the safety and custody of suicidal inmates. It provides general 

background on suicide and identifies a number of key prevention components. 

Suicide Prevention in Custody 

National Center on Institutions and Alternatives (NCIA) 

www.ncianet.org/services/suicide-prevention-in-custody 

This section of NCIA’s website contains links to a number of resources on suicide prevention in jails and 

prisons, including Guiding Principles to Suicide Prevention in Correctional Facilities, 2011. 

Suicide Prevention in Juvenile Correctional Facilities 

SPRC 

www.sprc.org/training-institute/juvenile-correctional-curriculum 

This section of SPRC’s website contains links to resources on suicide prevention among youth in contact 

with the juvenile justice system, a two-part webinar, and a packet of handouts on suicide prevention in 

juvenile correctional facilities. 

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Individuals Who Engage in Nonsuicidal Self-Injury 

NSSI has been defined as the direct and intentional destruction of one’s own body tissue in the absence of 

any intent to die.150 NSSI includes behaviors such as cutting the skin with a sharp instrument and can also 

involve hitting, scratching, or burning the skin. These acts can lead to serious injury requiring medical 

treatment, infection, permanent scarring, and accidental death. They also have been linked to an increased 

risk of future suicidal thoughts, attempts, or death by suicide.30 

Research studies have often combined individuals who engage in self-injury with or without suicidal 

intent. Intentional self-injury, regardless of motivation or degree of suicidal intent, is often referred to 

as deliberate self-harm (DSH).151 This definition thus includes both suicide attempts and acts with other 

motives or intentions. 

Research of NSSI and DSH populations shows a relatively strong relationship between self-injury and 

suicidal behaviors. An Australian study found that approximately 30 percent of patients presenting with 

self-poisoning to an emergency department (ED) reported previous episodes of self-harm.152 Of patients 

who presented to the ED on more than one occasion, 3 percent died by suicide within 5 years and 4 

percent within 10 years. In a followup study of deliberate self-harm conducted in the United Kingdom, 

death by suicide was 17 times more frequent than expected in those who had previously presented to a 

general hospital with deliberate self-harm.31 In another U.K. followup study of deliberate self-harm, there 

was an approximately 30-fold increase in risk of suicide compared with the general population. Suicide 

rates were highest within the first 6 months after the first self-harm episode. A systematic review of the 

international literature on fatal and nonfatal repetition of self-harm found that after 1 year, nonfatal 

repetition of self-harm behaviors was approximately 15 percent.153 The review found that suicide risk was 

hundreds of times higher among self-harm patients than in the general population. 

Researchers see NSSI as falling along a continuum of self-harmful behavior that has suicide at the 

endpoint. Self-injuring adolescents who attempt suicide have greater suicidal ideation and depressive 

symptoms than adolescents who only engage in self-injury.154 Regardless of whether an individual who 

engaged in self-injury reports having suicidal intent (DSH) or not (NSSI), research indicates that these 

individuals are at increased risk for repetition of these behaviors as well as of dying by suicide within 

10 years.31 

Resources 

Cornell Research Program on Self-Injurious Behavior in Adolescents and Young Adults 

www.crpsib.com 

This program conducts research on self-injury in adolescents and young adults and translates the 

knowledge gained into resources and tools for understanding and treating self-injury. The website 

summarizes the program’s work and provides links and resources with information on preventing, 

detecting, and treating self-injurious behavior. 

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Self-Injury Outreach & Support (SiOS) 

www.sioutreach.org 

SiOS is an international nonprofit outreach organization that provides resources and guides for both 

people who self-injure and those who can help them recover, including families and friends and school, 

mental health, and medical professionals. It offers research-informed coping strategies and a page where 

individuals can share their stories of recovery. 

Signs of Self-Injury Prevention Program 

Screening for Mental Health 

www.mentalhealthscreening.org/programs/youth-prevention-programs/sosi 

This education program is for high school students in a classroom setting. It teaches students about 

the signs and symptoms of self-injury, appropriate peer responses to a friend who self-injures, and the 

importance of adult intervention. Students determine their personal risk for self-injurious behaviors and 

develop coping skills for overcoming thoughts of self-injury. 

Understanding Nonsuicidal Self-Injury in Suicide Prevention 

SPRC 

www.sprc.org/training-institute/r2p-webinars/understanding-nonsuicidal-self-injury-suicide-prevention 

This webinar reviews a NSSI high school prevention program that has been shown to be effective. It uses 

this program as an example in demonstrating how to differentiate NSSI from suicide, understand how 

NSSI is a risk factor for suicide, learn the components of a self-injury prevention program for high schools, 

and understand outcome data related to an evaluation of the program. 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Individuals Who Have Attempted Suicide 

A previous suicide attempt is a known predictor of suicide death.11 A study of individuals who had 

survived a serious suicide attempt, conducted in New Zealand, found that almost half made another 

attempt or subsequently died by suicide within 5 years.155 Many individuals do not receive ongoing 

treatment or mental health care after an attempt, although they may continue to experience suicidal 

thoughts.156 In addition, a study conducted in the United Kingdom found that many people who die by 

suicide do so within 30 days of having been discharged from a hospital for a previous attempt, often before 

an appointment for services.98 

The vast majority of these deaths are preventable. A developing literature base on the role of protective 

and social factors and landmark projects designed to learn from the experience of individuals who have 

attempted suicide provide insight regarding new strategies for reducing reattempts, including approaches 

focused on challenging the prejudice, shame, and silence that surround suicide attempts. 

Even after a positive experience in a primary care or psychiatric program, recent attempt survivors can 

struggle with reintegrating into their homes, schools, and workplaces.157 Feelings of shame and self-doubt 

and fear of biased reactions are just some of the experiences they describe. Within many communities, 

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silence, prejudice, and misunderstanding about the subject of suicide create barriers to open discussion. 

This culture of “don’t ask, don’t tell” can foster rejection, social isolation, and even discrimination if the 

suicide attempt is known. Spouses, parents, and others need help adjusting, as well as tools, evidence-based 

information, and programs for supporting people who survive an attempt. 

Research suggests that even simple efforts to challenge isolation and provide follow-up support to people 

living in the community after an attempt can have a powerful impact and reduce future attempts.158 

A program that used hand-written postcards with brief personal messages showed remarkable results 

in reducing reattempt hospital admissions, revealing that a small amount of effort in the area of social 

support may be very powerful.159 In addition, a growing number of programs that provide suicide attempt 

survivors with self-help tools and social support show great promise in reducing isolation and empowering 

people to manage their own suicide risk and mental health. 

In the last 15 years, several organized efforts have emerged to learn from and serve the needs of people 

who have attempted suicide outside the traditional clinical services sector. In October 2005, the first 

National Conference for Survivors of Suicide Attempts, Health care Professionals, Clergy, and Laity was 

held in Memphis, Tennessee. The summary report of that conference is one of the first documents to 

articulate the perspectives of individuals who have attempted suicide.160 Two years later, in July 2007, the 

National Suicide Prevention Lifeline (800–273–TALK/8255) sponsored a project that provided even more 

specific and rich information to better serve the needs of this population.161 

Simultaneously, across the nation and internationally, there has been a significant increase in the number 

and variety of mental health consumer peer support and peer specialist services that may provide 

meaningful ongoing supports for people who have survived suicide attempts. These programs, which 

have been recognized as evidence-based practices by SAMHSA, provide social support that is not framed 

in terms of crisis and that can be an important resource for personal mental health maintenance and 

recovery.162 Such initiatives can empower and motivate people after an attempt, while at the same time 

challenge prejudice and shame in the area of suicide. These efforts can also increase social support for 

suicide reduction and contribute to increased funding and resources for preventing recurring attempts. 

Although many communities are initiating programs and supports that can prevent people from 

reattempting, more and better strategies are needed. Technical assistance efforts, combined with the 

broad dissemination of resources and information to communities across America, have great potential 

to reduce suicide death. Resources for attempt survivors, such as Stories of Hope and Recovery, developed 

by SAMHSA and the National Suicide Prevention Lifeline (800–273–TALK/8255), hold promise for 

reducing prejudice and for promoting collaborative approaches for treatment engagement with attempt 

survivors. The After an Attempt brochure, distributed by SAMHSA, provides basic information for attempt 

survivors, family, and providers in English and Spanish for distribution in hospitals. Increased resources, 

peer support groups, web-based supports, informational DVDs, and trainings for health care providers 

are needed to ensure that individuals who have attempted suicide, along with their families and friends, 

receive the support, advice, and information they need to find the most direct path to recovery. 

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Resources 

American Association of Suicidology 

www.suicidology.org/web/guest/suicide-attempt-survivors 

AAS has a collection of resources for those who have survived a suicide attempt and are looking for 

support and information. They include pamphlets, stories of others who have attempted suicide, and links 

to research about attempt survivors. 

Continuity of Care for Suicide Prevention and Research: Suicide Attempts and Suicide Deaths 

Subsequent to Discharge from the Emergency Department or Psychiatry Inpatient Unit, 2010 

SPRC 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

www.sprc.org/library/continuityofcare.pdf 

This is a comprehensive report offering recommendations for the ongoing care of patients at risk for 

suicide who have been treated in EDs and hospitals. It discusses 10 principles for improved continuity of 

care and provides examples of seven integrated systems of care in the United States and Europe. 

Individuals With Medical Conditions 

Several physical illnesses are associated with an increased risk for suicidal behaviors.29 The factors that may 

help explain this increased risk vary by medical condition but can include chronic pain, cognitive changes 

that make it difficult to make decisions and solve problems, and the challenges and emotional toll that can 

be associated with long-term conditions and limitations. 

Cancers 

Cancer is one of the most common physical illnesses associated with elevated suicide risk. The National 

Cancer Institute has identified cancers of the mouth, throat, and lung as risk factors for suicidal 

behaviors.163 While suicide risk tends to be highest in the first few months after diagnosis, risk remains 

elevated in the first 5 years.164 Fear associated with how the disease is perceived and managed, rather 

than the fear of death itself, is a frequent precipitator of suicidal behaviors.165 The consequences or side 

effects of treatment can also result in psychological problems.166 Fatigue and/or exhaustion, some of the 

most frequently reported side effects of cancer treatments, can be a risk factor for suicidal behaviors.167 In 

addition, depression and anxiety are common in cancer patients. About 63 to 85 percent of individuals 

with cancer who die by suicide meet criteria for severe depression, anxiety, and thought disorder.168 

It is not always clear whether these types of mental disorders are triggered by the disease, occur as a 

consequence of the disease, or are an adverse effect of the treatment itself.165 

Degenerative Diseases of the Central Nervous System 

Huntington Disease: The prevalence of suicide is believed to be two to four times greater in individuals 

with Huntington disease than among the general population.169 The lifetime history of suicide attempts 

ranges from 4.8 to 17.7 percent.170 Major depressive disorder may be present in up to half of patients with 

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Huntington’s disease and is thought to be a consequence of the disease itself, rather than a psychological 

reaction to having a serious illness.170 In addition, anxiety disorders, obsessive-compulsive disorders, 

psychosis, mania, aggression, irritability, impulsivity, and personality changes have all been reported in 

patients with the disease. 

Multiple Sclerosis: Studies confirm an increased risk of suicide among patients with multiple sclerosis.171 

Lifetime prevalence rates of depression range from 37 to 54 percent, and the prevalence rate of depression 

is almost three times the lifetime prevalence reported in the general population.172 Generalized anxiety 

disorder, panic disorder, and bipolar affective disorder (manic episodes) are also present more frequently 

in these patients. 

Parkinson’s Disease: Parkinson’s disease is often associated with one or more psychiatric or cognitive 

disorders, such as depression, psychosis, and dementia.173 Most of the observations support the hypothesis 

that depression is a primary consequence of brain dysfunction, although situational factors may contribute 

to mood changes to some extent.174 Suicide and suicide attempts are uncommon despite the fact that 

the rates of suicidal ideation are elevated. Depression seems to be the most important predictor of 

suicide ideation. 

Traumatic Injuries of the Central Nervous System 

Spinal Cord Injury: Suicide and suicide attempts occur more frequently in those with spinal cord injuries 

(SCI) than in the general population.175, 176 People with SCI are five times as likely to experience depression 

compared with the general population, and the rates of depression following a traumatic spinal cord injury 

may be as high as 45 percent. Others have found that 10 to 13 percent of SCI patients suffer from anxiety239 

and high levels of post-traumatic stress disorder.177 

Traumatic Brain Injury: People with moderate to severe traumatic brain injury (TBI) may have 

widespread cognitive impairment that can affect attention, memory, executive functioning, language and 

communication, visual-spatial skills, and processing speed.178 TBI survivors may also have perceptual 

deficits and motor deficits. Executive brain dysfunction is a contributing factor related to suicidal 

behaviors.179 A review of the literature found that on the whole, there is an increased risk of death by 

suicide (three to four times greater for those with severe TBI), a higher frequency of attempts, and 

clinically significant suicidal ideation in 21 to 22 percent of the TBI population.180 

Other Disorders of the Central Nervous System 

Epilepsy: Suicide rates in patients with epilepsy vary from 0 to 25 percent.181 Factors that can affect the 

rate of suicide include psychological stressors associated with epilepsy, seizure type and frequency, psychic 

auras, and the presence of associated psychopathology.182 Some studies suggest that suppression of seizures 

in longstanding epilepsy may be associated with suicide risk,183 and that suicide does not occur among 

patients with severe epilepsy.184 The WHO states that increased suicidal behavior in epilepsy is linked to 

increased impulsivity, aggression, and chronic disability often seen in persons with the illness, and that 

alcohol and drug abuse also contribute to a greater risk of suicide among these patients.185 

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Migraine: In general, patients with migraine are two to four times more likely to develop depression, two 

to six times more likely to develop general anxiety disorder, five times more likely to develop obsessivecompulsive disorder, and up to seven times more likely to develop panic disorder than the general 

population. Furthermore, depressed patients are about three times more likely to develop migraine in their 

lifetime. Migraine with an aura is believed to have a stronger association with psychiatric conditions than 

migraine without an aura. The relationship between migraine and depression and anxiety appears to be 

bidirectional, with each increasing the risk of the other condition. The risk of suicide ideation and attempts 

is higher among migraine patients, especially in those who have migraine with aura.186 

HIV/AIDS 

Most studies among individuals living with HIV report lifetime prevalence of suicide attempts that range 

from 22 to 50 percent.187 Individuals with AIDS were 44 times more likely to attempt suicide than those 

without AIDS.188 

While most studies report that persons living with HIV/AIDS have much higher suicide rates than the 

general population or those with other life-threatening illnesses, studies have reported no significant 

differences in suicide rates between HIV-infected individuals and other groups at risk for suicide, such 

as injection drug users and psychiatric patients.189, 190 Hence, HIV status may not be the most relevant 

factor related to suicide, but rather that other suicide risk factors that are common among HIV-infected 

individuals play a more important role.191 Studies have shown that suicide attempts and suicide ideation 

among people with HIV occur most often in those who have a previous psychiatric history and other 

social and environmental risk factors for suicide.192 Mood, anxiety, substance abuse, and personality 

disorders are prevalent among those with HIV.187 

Chronic Kidney Disease 

The following psychiatric disorders have been frequently observed in patients with severe end-stage kidney 

disease who require hemodialysis: affective disorders, dementia and delirium, drug-related disorders (e.g., 

alcohol dependence), schizophrenia and other psychoses, and personality disorders.193 The prevalence of 

depressive disorders in hemodialysis patients is estimated at 20 to 30 percent, with a rate of 10 percent 

for major depression.194 Hemodialysis patients with major depressive disorder commonly demonstrate a 

sense of hopelessness, as well as lack of pleasure and energy, and other depressive symptoms. This subset of 

patients has been noted to be the most likely to request withdrawal from hemodialysis. 

Arthritis 

Arthritic disorders often co-occur with other physical conditions, especially chronic pain conditions 

including back pain, migraine, and other chronic headaches.195 The association between arthritis and 

problems such as anxiety, substance use, and personality disorders has been demonstrated in large, 

population-based studies.196, 197 The relationship between arthritis and suicidal behavior may be largely 

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explained by comorbid mental health disorders alone or in combination with other factors such as level of 

pain and/or disability that are associated with a lower quality of life.198 

Asthma 

Adolescents with asthma are more likely to report depressive symptoms, panic attacks, suicide ideation 

and behavior, and substance abuse when compared with those without asthma.199-201 It is not clear whether 

the association between asthma and depressive and anxiety disorders, as well as with suicidal ideation and 

behavior, results from a shared underlying process or from shared risk factors. 

Resources 

Medical Conditions Associated With Suicide Risk, Edited by A.L. Berman & M. Pompili, 2011 

American Association of Suicidology 

www.suicidology.org/web/guest/store 

This book summarizes research on 25 medical conditions that are associated with suicide risk, such as 

cancer, TBI, and HIV and AIDS. It outlines risk factors to assess patients and provides recommendations 

for clinicians. 

Individuals With Mental and/or Substance Use Disorders 

Mental and substance use disorders are widely recognized as important risk factors for suicidal behaviors 

in all age groups. Having a substance use disorder along with as a mood disorder may be particularly likely 

to increase suicide risk.28 Information on suicide risk and specific mental and substance use disorders is 

provided next, along with appropriate resources. 

Mental Disorders 

MOOD DISORDERS 

Mood disorders are among the most common and may be the most life-threatening psychiatric illnesses.202 

Major depressive disorder, also called major depression or unipolar disorder, is characterized by a 

combination of symptoms, such as sadness and loss of interest or pleasure in once-pleasurable activities, 

which interfere with everyday life. It has been estimated that 12 to 17 percent of individuals will experience 

a major depressive episode within their lifetime.203 Although a person may experience only a single 

episode, more often he or she may have several episodes throughout his or her life. 

Bipolar disorders, also called manic-depressive illness, is characterized by dramatic mood swings, going 

from an overly energetic “high” (mania) to sadness and hopelessness (depression). People with bipolar 

disorders type I have had at least one manic episode along with periods of major depression. Those with 

bipolar disorders type II have periods of high energy levels and impulsiveness that are not as extreme as 

mania and also alternate with episodes of major depression. The estimated lifetime prevalence of bipolar 

disorders is 1.3 to 5 percent.203 

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More than 60 percent of suicidal deaths occur among individuals with mood disorders. Suicide risk is 

particularly high among individuals with bipolar disorders, which is strongly associated with suicide 

thoughts and behaviors. Over their lifetime, the vast majority (80 percent) of patients with bipolar 

disorders have either suicidal ideation or ideation plus suicide attempts.24 In clinical samples, 14 to 59 

percent of the patients have suicide ideation, and 25 to 56 percent attempt suicide at least once in their 

lifetime.204 Approximately 15 to 19 percent of patients with bipolar disorders die from suicide. The suicide 

rate among patients with bipolar disorders is estimated to be more than 25 times higher than the rate in 

the general population.25

Several factors can increase the risk for suicide among patients who have mood disorders. These factors 

include a recent suicide attempt and a severe major depressive episode, often accompanied by feelings of 

hopelessness and guilt, a belief that that are few reasons for living, thoughts of suicide, agitation, insomnia, 

appetite and weight loss, and psychotic features.205 Suicidal behaviors among mood disorder patients occur 

almost exclusively during an acute, severe, major depressive episode.205 

Among patients with major depressive disorder, risk factors for suicide include other comorbid psychiatric 

conditions, such as post-traumatic stress disorder (PTSD), dependent personality disorder, borderline 

personality disorder, and substance use disorders.206 Among those with bipolar disorders, risk factors 

include a family history of suicide, early onset of bipolar disorders, increasing severity of affective 

disorders, presence of mixed affective states, and abuse of alcohol or drugs.207 

Major depressive disorder often fails to be recognized, diagnosed, or treated.203 It is believed that many 

men in midlife who have the disorder do not seek treatment for their symptoms, and even when they do, 

they often drop out of treatment before they reach remission.208 Evidence is mounting that individuals who 

have had a stroke or heart attack and/or have chronic diabetes are likely to develop depression related to 

their physical illnesses. Older individuals are particularly likely to do so. 

Studies have shown that educating primary care providers in the assessment, treatment, and management 

of depression leads to reductions in suicide. Appropriate acute and long-term treatment of depressive 

disorders, including both pharmacological and nonpharmacological methods (especially cognitive 

behavioral therapy), greatly reduces the risk of suicide and attempted suicide in this high-risk 

population.205 Large-scale, long-term, European observational studies of former inpatients with bipolar 

disorders show that long-term use of mood stabilizers reduces the risk of suicide, compared to patients 

who stop taking medication. There is also some evidence that psychotherapies can improve compliance 

and increase the effectiveness of pharmacotherapy, thereby possibly providing more protection against 

suicide risk.205 

ANXIETY DISORDERS 

Anxiety disorders affect about 40 million American adults aged 18 and older (about 18 percent) in a given 

year.209 Unlike the relatively mild, brief anxiety caused by a stressful event like speaking in public, anxiety 

disorders last at least 6 months and can become worse if not treated. These disorders include the following: 

social phobia, simple phobia, generalized anxiety disorder, panic disorder, agoraphobia, PTSD, and 

obsessive-compulsive disorder (OCD). 

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The presence of any anxiety disorder is significantly associated with suicidal ideation and suicide attempts. 

Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or 

substance abuse, which may mask anxiety symptoms or make them worse. The presence of any anxiety 

disorder in combination with a mood disorder is associated with a higher likelihood of suicide attempts in 

comparison with a mood disorder alone.210 Among adults in the general population (i.e., not in the Armed 

Forces or veterans), panic disorder and PTSD have been found to be more strongly associated with suicide 

attempts when there is a co-occurring personality disorder.211 

BORDERLINE PERSONALITY DISORDER 

Borderline personality disorder (BPD) is an emotional disorder characterized by a pervasive pattern of 

instability in interpersonal relationships, self-image, and emotions. Defining features of this disorder 

include an unstable mood, serious problems with emotion regulation, a wide range of impulsive behaviors, 

unstable interpersonal relationships, suicide, and chronic suicidal ideation.212 

It has been estimated that between 3 and 10 percent of patients with BPD die by suicide.213 Recurrent 

suicide attempts, self-injury, and impulsive aggressive acts are often associated with BPD and often result 

in emergency and inpatient treatment. Suicides in BPD often occur late in the course of the illness and 

follow long courses of unsuccessful treatment.214 

The last few years have been marked by new data on the effectiveness of psychotherapies specifically 

designed for patients with BPD.215 Research has shown that Dialectical Behavior Therapy (DBT) is effective 

in reducing the self-injurious behaviors associated with BPD.41 DBT specifically aims to modify the 

regulation of negative emotion. The main outcomes of DBT are reduced overdoses, ED visits for suicidal 

behaviors, frequency of self-directed violence, and hospital admissions. The efficacy of medications for 

BPD is not firmly established. 

SCHIZOPHRENIA 

Schizophrenia is a severe, chronic disorder characterized by disturbances in perception, thought, language, 

and social function. The risk for suicide in individuals suffering from schizophrenia is particularly high in 

the early stages of the illness (first 3–5 years of onset). A meta-analysis of more than 60 studies found that 

almost 5 percent of schizophrenic patients will die by suicide during their lifetimes, usually near the onset 

of the illness.26 Surviving the initial period of heightened risk results in a lesser, although still considerable, 

risk of death by suicide.26 

The greatest indicator of suicide risk among people with schizophrenia is active psychotic illness (e.g., 

delusions) combined with symptoms of depression. Greater insight into the psychotic illness itself, the 

need for treatment, and the consequences of the disorder are strongly related to suicide risk.216 Increased 

risk for suicide is also associated with higher levels of education and higher socioeconomic status. Alcohol 

abuse has been reported in studies examining suicide attempts. 

Newer nonpharmacological therapies, such as cognitive enhancement therapy, may have great potential for 

improving the individual’s social and occupational functioning.217 Findings from a recent review suggest 

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that an integrated psychosocial and pharmacological approach may be useful, and that treating depressive 

symptoms in patients with schizophrenia is an important component of suicide risk reduction.87 

Resources 

Continuity of Care for Suicide Prevention and Research: Suicide Attempts and Suicide Deaths 

Subsequent to Discharge From the Emergency Department or Psychiatry Inpatient Unit, 2010 

SPRC 

www.sprc.org/library/continuityofcare.pdf 

This is a comprehensive report offering recommendations for the ongoing care of patients at risk for 

suicide who have been treated in EDs and hospitals. It discusses 10 principles for improved continuity of 

care and provides examples of seven integrated systems of care in the United States and Europe. 

Mental Health America 

www.mentalhealthamerica.net/ 

Mental Health America (MHA, formerly the National Mental Health Association) is an advocacy 

organization addressing all mental and substance use conditions nationwide and advocates for quality 

mental health and substance abuse services. It is a coproducer of Safeguarding Your Students Against 

Suicide, proceedings from an expert panel on preventing suicide on college campuses. Its web page 

includes suicide warning signs, how individuals can intervene to help, and links to resources. MHA also 

has local affiliates across the United States. 

National Alliance on Mental Illness 

www.nami.org 

National Alliance on Mental Illness (NAMI) is a membership organization dedicated to building better 

lives for Americans affected by mental illness. NAMI advocates for access to services, treatment, supports, 

and research. It sponsors awareness events, provides training about mental illness, and sponsors the NAMI 

Helpline—a phone crisis line. NAMI has state organizations and local affiliates across the United States. 

National Institute of Mental Health, NIH, HHS 

www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml 

The National Institute of Mental Health (NIMH) website section on suicide prevention includes 

information and resources useful for a variety of audiences, including researchers, health care 

professionals, and consumers. NIMH also conducts research on suicide and suicide prevention. Research 

updates can be found through “News From the Field: Research Findings of NIMH-funded Investigators at 

EurekAlert!” at: http://search.eurekalert.org/e3/query.html?qt=youth+suicide+prevention&charset=iso8859-1&qc=ev3rel&rf=1&col=ev3rel. 

Substance Abuse and Mental Health Services Administration, HHS 

www.samhsa.gov 

SAMHSA funds and supports the National Lifeline and SPRC and manages the Garrett Lee Smith grant 

program, which funds state, territorial, and tribal programs to prevent suicide among youth. It has 

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developed the National Registry of Evidence-Based Programs and Practices (NREPP), which reviews 

evidence of effectiveness for prevention programs on topics related to mental and substance use disorders, 

including suicide. SAMHSA also sponsors several prevention campaigns. 

Suicide Prevention Efforts for Individuals With Serious Mental Illness: Roles for the State Mental 

Health Authority, 2008 

National Association of State Mental Health Program Directors (NASMHPD) 

www.sprc.org/library/SeriousMI.pdf 

This report outlines the State Mental Health Authority’s (SMHA) leadership role in preventing suicide 

among people with serious mental illness. It suggests ways in which SMHAs can increase collaboration, 

raise awareness of the signs of suicide, and intervene to save lives. 

Substance Use Disorders 

Alcohol and drug abuse are second only to depression and other mood disorders as the most frequent risk 

factors for suicide.218 According to data from the National Violent Death Reporting System (NVDRS), in 

2008 alcohol was a factor in approximately one-third of suicides reported in 16 states.27 Opiates, including 

heroin and prescription painkillers, were present in 25.5 percent of suicide deaths, antidepressants in 20.2 

percent, cocaine in 10.5 percent, marijuana in 11.3 percent, and amphetamines in 3.4 percent. 

Suicide is a leading cause of death among people with substance use disorders (SUDs). Substance use 

may increase the risk for suicide by intensifying depressive thoughts or feelings of hopelessness while at 

the same time reducing inhibitions to hurting oneself.219 Alcohol and some drugs can cause a “transient 

depression,” heighten impulsivity, and cloud judgment about long-term consequences of one’s actions. 

About 8.5 percent of U.S. adults are estimated to have an alcohol use disorder, which includes alcohol 

dependence and alcohol abuse.13 About one-fourth of all the suicides in the United States are estimated to 

occur among individuals with alcohol use disorders.9

 Acute (e.g., binge drinking episodes) and chronic 

use of alcohol are associated with suicidal behaviors.220-222 Among individuals with alcohol use disorders, 

suicide frequently takes place within the context of a major depression and interpersonal stressors. 

Aggression, impulsivity, hopelessness, and partner-relationship disruptions are also risk factors.223 Studies 

have shown that depression is present in 45 percent224 to more than 70 percent225 of those with alcohol and 

substance use disorders who die by suicide. 

Although less is known about the relationship between suicide risk and other drug use, the number of 

substances used seems to be more predictive of suicide than the types of substances used.226 Findings 

from a few initial studies suggest that treatment of drug abuse may help reduce the risk for future 

suicidal behaviors.227 

SUDs and chronic substance use can lead to consequences and losses that contribute to suicide risk 

factors. Individuals in treatment for substance use disorders and/or transitioning between levels of care 

may be especially vulnerable.228 A large number of people in treatment have co-occurring mental disorders 

that increase suicide risk, particularly mood disorders. At the time these individuals enter treatment, their 

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substance abuse may be out of control, they may be experiencing a number of life crises, and they may be 

at peaks in depressive symptoms. In addition, mental disorders associated with suicidal behaviors, such as 

mood disorders, PTSD, anxiety disorders, and some personality disorders, often co-occur among people 

who have been treated for substance use disorders. Crises that are known to increase suicide risk, such as 

relapse and treatment transitions, may occur during treatment. According to one study, compared with 

the general population, individuals treated for alcohol abuse or dependence have a 10 times greater risk of 

eventually dying by suicide.228 Among those who inject drugs, the risk is about 14 times greater than in the 

general population.228

More is known about the factors that increase the risk of suicidal behaviors among this population than 

about the factors that may be protective. SUDs share many risk factors with suicide: family history of 

suicide or child abuse; history of mental disorders, particularly mood disorders; history of or family 

history of addiction; impulsiveness; feelings of isolation; barriers to mental health and/or treatment; 

relational, social, work, or financial losses; physical illness/chronic pain; access to lethal methods; and 

prejudice associated with asking for help. 

Perceiving that there are clear reasons to live is thought to be an important protective factor in this group. 

Other protective factors may include: a child at home and/or childrearing responsibilities; an intact 

marriage; a trusting relationship with a counselor, physician, or other service provider; employment; 

religious attendance and/or belief in religious teachings against suicide; and an optimistic or positive 

outlook. Sobriety can be a protective factor, along with attendance of mutual support group meetings. 

Resources 

National Institute on Alcohol Abuse and Alcoholism, NIH, HHS 

www.niaaa.nih.gov 

National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides leadership in the national effort to 

reduce alcohol-related problems. Alcohol is a significant risk factor for suicide, and the NIAAA publishes 

studies on how alcohol use interacts with conditions such as depression and stress to contribute to suicide. 

NIAAA also provides data on alcohol involvement in suicide. 

National Institute on Drug Abuse, NIH, HHS 

www.nida.nih.gov 

National Institute on Drug Abuse (NIDA) funds and publishes studies on the effects of substance abuse 

on mental health, including suicide, and hosts Suicide Studies Lectures, which review current standards 

to define, classify, assess, and treat suicide-related disorders that sometimes play a role in drug abuse and 

addiction. NIDA also sponsored a landmark workshop, Drug Abuse and Suicidal Behavior. 

Substance Abuse and Mental Health Services Administration, HHS 

www.samhsa.gov 

SAMHSA funds and supports the National Lifeline and SPRC and manages the Garrett Lee Smith 

grant program, which funds state, territorial, and tribal programs to prevent suicide among youth. 

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It has developed NREPP, which reviews evidence of effectiveness for prevention programs on topics 

related to mental and substance use disorders, including suicide. SAMHSA also sponsors several 

prevention campaigns. 

Substance Abuse and Suicide Prevention: Evidence and Implications—A White Paper, 2008 

Center for Substance Abuse Treatment (CSAT), SAMHSA, HHS 

www.samhsa.gov/matrix2/508SuicidePreventionPaperFinal.pdf 

This white paper provides an overview of the advances made over the past decade in substance abuse 

prevention and treatment and suicide prevention. It addresses the epidemiology of suicide, provides an 

overview of what we know about the impact of substance abuse on suicide risk, and explores suicide 

prevention in the context of behavioral health promotion and illness prevention. 

TIP 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment, 2009 

www.kap.samhsa.gov/products/manuals/tips/pdf/TIP50.pdf 

Video companion: 

www.store.samhsa.gov/product/Addressing-Suicidal-Thoughts-and-Behaviors-in-Substance-AbuseTreatment/VA10-TIP50 

TIP 50 provides counselors with tools to use in treatment and agency administrators with ways to ensure 

that suicide ideation is detected and addressed early and appropriately. TIP 50 also provides insights on 

how various drugs used by clients might affect mood and addresses cultural and gender issues that could 

influence behavior. 

Lesbian, Gay, Bisexual, and Transgender Populations 

Studies over the last four decades suggest that LGBT individuals may have an elevated risk for suicide 

ideation and attempts. Attention to this disparity has been limited, in part because neither the U.S. death 

certificate nor the NVDRS identify decedents’ sexual orientation or gender identity. Thus, it is not known 

whether LGBT people die by suicide at higher rates than comparable heterosexual people. 

Across many different countries, a strong and consistent relationship between sexual orientation and 

nonfatal suicidal behavior has been observed.229 A meta-analysis of 25 international population-based 

studies found the lifetime prevalence of suicide attempts in gay and bisexual male adolescents and adults 

was four times that of comparable heterosexual males.230 Lifetime suicide attempt rates among lesbian 

and bisexual females were almost twice those of heterosexual females. Lesbian, gay, and bisexual (LGB) 

adolescents and adults were also found to be almost twice as likely as heterosexuals to report a suicide 

attempt in the past year. A later meta-analysis of adolescent studies38 concluded that LGB youth were three 

times more likely to report a lifetime suicide attempt than heterosexual youth, and four times as likely to 

make a medically serious attempt. Across studies, 12 to 19 percent of LGB adults report making a suicide 

attempt, compared with less than 5 percent of all U.S. adults; and at least 30 percent of LGB adolescents 

report attempts, compared with 8 to 10 percent of all adolescents. To date, population-based studies have 

not identified transgender participants, but numerous nonrandom surveys show high rates of suicidal 

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behavior in that population, with 41 percent of adult respondents to the 2009 National Transgender 

Discrimination Survey reporting lifetime suicide attempts.231 

Most studies have found suicide attempt rates to be higher in gay/bisexual males than in lesbian/bisexual 

women, which is the opposite of the gender pattern found in the general population. As in the overall 

population, there is some evidence that the frequency of suicide attempts may decrease as LGB adolescents 

move into adulthood,232 although patterns of suicide attempts across the lifespan of sexual minority people 

have not been conclusively studied. Within LGB samples, especially high suicide attempt rates have been 

reported among African American, Latino, Native American, and Asian American subgroups.233-235 

Suicidal behaviors in LGBT populations appear to be related to “minority stress,”236 which stems from 

the cultural and social prejudice attached to minority sexual orientation and gender identity. This stress 

includes individual experiences of prejudice or discrimination, such as family rejection, harassment, 

bullying, violence, and victimization. Increasingly recognized as an aspect of minority stress is 

“institutional discrimination” resulting from laws and public policies that create inequities or omit LGBT 

people from benefits and protections afforded others.231, 237-240 Individual and institutional discrimination 

have been found to be associated with social isolation, low self-esteem, negative sexual/gender identity, 

and depression, anxiety, and other mental disorders. These negative outcomes, rather than minority sexual 

orientation or gender identity per se, appear to be the key risk factors for LGBT suicidal ideation and 

behavior. An additional risk factor is contagion resulting from media coverage of LGBT suicide deaths that 

presents suicidal behavior as a normal, rational response to anti-LGBT bullying or other experiences of 

discrimination. Further research is needed to explore the pathways to suicidal behaviors for transgender 

individuals, including the impact of prejudice and discrimination. 

Factors that foster and promote resilience in LGBT people include family acceptance,239 connection 

to caring others and a sense of safety,66 positive sexual/gender identity, and the availability of quality, 

culturally appropriate mental health treatment.58 Strategies for preventing suicidal behaviors in LGBT 

populations include: reducing sexual orientation and gender-related prejudice and associated stressors; 

improving identification of depression, anxiety, substance abuse, and other mental disorders; increasing 

availability and access to LGBT-affirming treatments and mental health services; reducing bullying and 

other forms of victimization that contribute to vulnerability within families, schools, and workplaces; 

enhancing factors that promote resilience, including family acceptance and school safety; changing 

discriminatory laws and public policies; and reducing suicide contagion. 

Collaboration between suicide prevention and LGBT organizations is needed to ensure the development of 

culturally appropriate suicide prevention programs, services, and materials, and to facilitate access to care 

for at-risk individuals. A promising example is the development of guidelines for media in talking about 

suicide in LGBT populations241 created by a coalition of AFSP and several national LGBT organizations. 

Another critical need is closing knowledge gaps through additional research and improved surveillance. 

Efforts are underway to expand the inclusion of sexual orientation and gender identity measures in federal 

health and mental health surveys, and to develop and test procedures for postmortem identification of 

LGBT people in NVDRS. 

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Resources 

American Foundation for Suicide Prevention: LGBT Initiative 

www.afsp.org/index.cfm?page_id=6FB9BA00-7E90-9BD4-C33BD398EAAE73C0 

This initiative works on suicide prevention among the LGBT population in a number of ways, including 

producing a conference, funding research grants, working to improve how the media covers anti-gay 

bullying, helping its chapter volunteers bring understanding of suicide into their local LGBT communities, 

and creating LGBT mental health educational resources and training tools. 

Stop Bullying Website 

www.stopbullying.gov 

A website that provides information from various government agencies on what bullying is, what 

cyberbullying is, who is at risk, and how individuals can prevent and respond to bullying. 

Suicide Prevention Among LGBT Youth: A Workshop for Professionals Who Serve Youth 

SPRC 

www.sprc.org/training-institute/lgbt-youth-workshop 

This is a free workshop kit to help staff in schools, youth-serving organizations, and suicide prevention 

programs take action to reduce suicidal behavior among LGBT youth. It contains a Leader's Guide, sample 

agenda, PowerPoint presentations, sample script, and handouts. 

The Trevor Project 

www.thetrevorproject.org 

This national organization focused on crisis and suicide prevention among lesbian, gay, bisexual, 

transgender, and questioning (LGBTQ) youth provides a 24-hour, toll-free, crisis intervention phone line 

(1–866–488–7386); an online, social networking community for LGBTQ youth aged 13 to 24 and their 

friends and allies; educational programs for schools; and advocacy initiatives. 

Members of the Armed Forces and Veterans 

The suicide rate for active duty military personnel has historically been significantly lower than the 

rate for a comparable population of Americans. However, both the numbers and rates of suicide have 

been increasing over the past decade. In 2001, the U.S. Department of Defense (DoD) recorded 160 

total suicides for a rate of 10.3 per 100,000.242 Suicide rates began to increase in 2006, driven primarily 

by a steady upward trend in the number of suicides in the Army and Marine Corps. In 2009, the DoD 

identified 309 total active duty suicides, for a rate of 18.3 per 100,000. The number of suicides has been on 

the rise in the Reserve Component (RC) as well. In 2009, there were 104 suicides of service members who 

were in the RC and not on active duty at the time of the event.243 In 2010, this number increased to 180, 

with the Army National Guard having the largest increase in the total number of suicides from 48 in 2009 

to 101 in 2010. 

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For calendar year 2010, service members who were white and under the age of 25, junior enlisted (E1–E4), 

or high school educated were at increased risk for suicide relative to comparison groups in the general 

population.244 Service members most frequently used firearms as the means for suicide. Drug overdose 

was the most frequent method for suicide attempts, and the misuse of prescription medication was more 

frequent than illegal drugs. Most service members were not known to have communicated their potential 

for self-harm with others prior to suicide or attempted suicide. The majority of service members who died 

by suicide did not have a known history of a mental or substance use disorder. Finally, the overwhelming 

majority of suicides occurred in a nondeployed setting, and more than half of those who died by suicide 

did not have a history of deployment. 

The Centers for Disease Control and Prevention (CDC) estimates that veterans account for approximately 

20 percent of the deaths from suicide in America.245 There is controversy in the scientific literature about 

whether suicide rates are higher among veterans than among other Americans after controlling for 

sex, age, and minority status.246, 247 However, rates appear to be increased among two important groups: 

veterans who have recently returned from service in Afghanistan and Iraq,248 and those who receive 

health care services from the Veterans Health Administration (VHA),249 the health care system operated 

by the U.S. Department of Veterans Affairs (VA). In the most recent years for which data are available, 

suicide rates for male VHA patients were approximately 1.4 times greater than for other American men. 

For female VHA patients, rates were approximately twice as high as among American women. Both 

increases reflect the higher rates of medical and mental health conditions, disability, and other risk factors 

for suicide that occur among VHA patients. In VHA, as in DoD, firearms represented the most common 

means for suicide and overdoses represented the most common means for attempts.248 Approximately half 

of all suicides in VHA occurred among patients known to have mental health conditions.250 An increase 

in the suicide rate among returning veterans first appeared in 2006,248 and rates continue to be monitored 

closely. The rates as observed echo the increase that occurred for the first few years after veterans returned 

from service in Vietnam.251 

Efforts to identify individuals at risk and to monitor the military and veteran populations as a whole are 

currently in place in at DoD and VA. Mental health services have been enhanced in both departments, and 

an array of suicide prevention programs have been implemented. 

In DoD, the Deputy Assistant Secretary of Defense for Readiness (DASD(R)) leads a collaborative effort 

across the Department to address suicide. The Final Report of the Department of Defense Task Force on 

the Prevention of Suicide by Members of the Armed Forces251 has served as a catalyst for the Department 

to review and assess all policies and programs that relate to suicide prevention. Based on the report 

and action plans developed from it, a departmental implementation memorandum was signed by the 

Under Secretary of Defense for Personnel and Readiness in September 2011 to guide the Department’s 

ongoing efforts. 

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Established in November 2011, the Defense Suicide Prevention Office (DSPO) is part of the DoD’s 

Office of the Under Secretary of Defense for Personnel and Readiness. DSPO oversees all strategic 

development, implementation, centralization, standardization, communication, and evaluation of DoD 

suicide programs, policies, and surveillance activities. To reduce the impact of suicide on Service members 

and their families, DSPO uses a range of approaches related to policy, research, communications, and 

behavioral health. DSPO works closely with the Army, Navy, Air Force, Marine Corps, Coast Guard and 

National Guard Bureau, as well as other governmental and nongovernmental agencies, to support Service 

members and strengthen a resilient and ready force. DSPO strives to help foster a climate that encourages 

Service members to seek help for their behavioral health issues. 

VA’s current suicide prevention began with the approval of its Mental Health Strategic Plan in 2004. 

Implementation of the plan led to an increase in core mental health staff on a national level, by 50 percent; 

from about 14,000 in 2005 to about 21,000 by the end of 2010.248 Moreover, it led to developing the 

Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics,

252 a policy document that 

specifies requirements for services that must be available to all veterans with mental health conditions. 

The VA suicide prevention program is based on the principle that prevention requires ready access to highquality mental health services within the health care system, supplemented by two additional components: 

(1) public education and awareness activities promoting engagement for those who need help; and 

(2) availability of specific services addressing the needs of those at high risk. Activities have included 

creating a national office for suicide prevention, partnering with SAMHSA and its Lifeline program to 

add a veterans’ call center to its national 800–273–TALK/8255 crisis line, funding suicide prevention 

coordinators with support staff in each VA medical center, and initiating public information strategies 

focused on promoting the use of the crisis line and of VA services for those in need. 

Resources 

Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury 

www.dcoe.health.mil/SuicidePreventionWarriors.aspx 

The Defense Centers of Excellence (DCoE) suicide prevention page includes information and campaign 

materials to raise awareness and encourage help seeking and access to mental health services specific to 

service branches of the military, families, and veterans. The DCoE sponsors the Real Warriors Campaign, 

a multimedia portal with resources to promote resilience, facilitate recovery, and support reintegration of 

returning service members, veterans, and their families. 

National Guard/Reserve 

www.ng.mil/features/suicide_prevention/default.aspx 

The website for the National Guard’s suicide prevention program features a six-part film on resilience 

among National Guard personnel. Other resources include a media gallery, a list of military and 

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nonmilitary organizations with information on suicide, and news stories from National Guard leadership 

and other branches of the military. 

Tragedy Assistance Program for Survivors 

www.taps.org 

Tragedy Assistance Program for Survivors (TAPS) provides information and services to those who have 

suffered the loss of a military loved one due to any cause. It offers webinar-based courses, six of which 

concern suicide, for mental health professionals. Other resources include crisis services, online support 

groups, seminars for survivors, and the Good Grief Camp for children grieving the loss of a loved one in 

the military. 

U.S. Air Force Suicide Prevention Program 

afspp.afms.mil 

The Air Force Suicide Prevention Program (AFSPP) is listed on SAMHSA’s NREPP. The Air Force requires 

annual suicide prevention training of all active duty, reserve, guard, and civilian employees. The program’s 

website contains links to a wide range of resources. 

U.S. Army Suicide Prevention Program 

www.armyg1.army.mil/hr/suicide/default.asp 

This program uses Applied Suicide Intervention Skills Training (ASIST) to prepare designated gatekeepers 

to recognize suicide risk and intervene. All Army personnel, including civilians, are required to participate 

in Ask, Care, and Escort (ACE) suicide prevention and awareness training. The website also includes 

awareness materials, data, and tools for commanders to develop suicide prevention programs. 

U.S. Department of Defense Restoring Hope 

www.defense.gov/home/features/2010/0810_restoringhope_resources/ 

This web page is a central portal with links to a wide range of suicide prevention and other mental health 

services, self-help resources, and awareness materials for military in all branches, veterans, providers, and 

families. Most of the links go to services and resources provided by DoD or VA. 

U.S. Department of Defense Suicide Prevention Website 

www.health.mil/News_And_Multimedia/Special_Features/suicide-prevention-awareness.aspx 

This website provides information on recognizing symptoms of those at risk for suicide, links to suicide 

prevention in each branch of the military, and a list of outside organizations that can provide information 

and assistance. 

U.S. Department of Defense/U.S. Department of Veterans Affairs Suicide Outreach 

www.suicideoutreach.org 

This website is a resource collection providing access to support hotlines, self-assessments, treatment 

options, professional resources and forums, and various multimedia tools. It supports all members of the 

U.S. Armed Forces and reserve components, veterans, families, and providers. 

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U.S. Department of Veterans Affairs Mental Health Information 

www.mentalhealth.va.gov 

This web page serves as a portal for VA mental health services, resources, and programs such as the 

National Suicide Prevention Crisis Line veterans chat; information on suicide prevention and PTSD; and 

the Make the Connection Campaign, where veterans can share stories of their experience reintegrating 

into civilian life. 

U.S. Department of Veterans Affairs Suicide Prevention Website 

www.veteranscrisisline.net 

This website describes the services of the Veterans Crisis Line, a toll-free, confidential resource that 

connects veterans in crisis and their families and friends with specially trained VA responders. It also 

includes information on warning signs and awareness and campaign materials. 

U.S. Marines Suicide Prevention Program 

www.usmc-mccs.org/suicideprevent/ 

The United States Marine Corps (USMC) program Never Leave a Marine Behind is a suicide prevention 

training program with modules geared toward officers, enlisted soldiers, families, and providers. It also 

provides awareness materials, help resources, and data. 

U.S. Navy Suicide Prevention Program 

www.public.navy.mil/bupers-npc/support/suicide_prevention/Pages/default.aspx 

This program consists of four elements: Training, Intervention, Response, and Reporting. Annual suicide 

prevention training is required of active, reserve, and civilian employees. The website lists trainings 

and resources. Materials include the Navy Leaders Guide, which describes a broad range of supportive 

interventions, resources, and strategies for supporting sailors in distress. 

Men in Midlife 

While suicide rates have tended to decrease or remain stable for most age groups in the past two decades, 

suicides in middle adulthood have increased.253, 254 Men in their adult years, from their early 20s through 

their 50s, account for the bulk of suicides and the majority of years of life lost due to suicide.255 Yet there 

has been little research on this demographic group, when compared with the number of studies conducted 

with adolescents and older adults. 

Although research exploring the recent surge in suicide in midlife is lacking, existing studies suggest that 

the factors that may increase the risk for suicidal behaviors in this group are similar to those among other 

age groups and in both sexes: mental illness that can be discerned from retrospective analyses (particularly 

mood disorders), substance use disorders (particularly alcohol abuse), and access to lethal means.28, 80 

However, these factors are likely to be exacerbated by other risk-related characteristics that occur more 

frequently among males, such as the underreporting of mental health problems,256 a reluctance to seek 

help,257 engagement in interpersonal violence,258 distress from economic hardship (e.g., unemployment), 

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and dissolution of intimate relationships.259 More research is needed on the pathways and mechanisms that 

contribute to suicide among midlife men, using developmental approaches that examine the occurrence 

and timing of risk factors as they are expressed across the life course. 

Very few systematic, large-scale efforts have addressed the prevention of suicide among men in midlife. 

Although the AFSPP is an example,260, 261 it remains uncertain whether the lessons gleaned from this closed 

system can be readily generalized to broader society. Prevention efforts are especially challenging for men 

because they are less likely to show signs of depression, report suicidal ideation, or seek help or accept it 

from others, and they often hide their suicide plans or preparations. 

Several projects have focused on organizational-level components for early intervention and education.260, 

262, 263 Although studies in other countries point to the positive protective effects of means restriction,264, 

265 no such programs have been successfully implemented in the United States. In terms of changing 

individual-level trajectories toward suicide, early classroom interventions to enhance interpersonal skills 

have been shown to reduce suicidal behaviors in early adulthood.266 Additional targets for intervention 

include: preventing exposure to violence in early developmental periods, such as bullying/peer 

victimization, childhood abuse, and domestic violence; enhancing academic engagement and reducing 

school drop-out rates; mitigating or preventing persisting alcohol and drug misuse; and developing a 

diverse array of community-based programs that engage men who otherwise would not seek care in 

traditional health settings or in settings that provide care for mental or substance use disorders.254 Many of 

these efforts now are being focused on veterans. However, few data are available at this time to identify a 

particular evidence-based suicide prevention approach targeting men in midlife. 

Resources 

Although there are no resources specific to midlife adult suicide prevention, some interventions that focus 

on workplace settings and gatekeeper training may be particularly relevant to reaching people in this 

age range. 

LivingWorks 

www.livingworks.net 

LivingWorks is an organization that delivers training in suicide prevention to various groups, including 

the general public, caregivers, and professionals. Its training programs include ASIST, suicideTALK, 

safeTALK, and suicideCARE. 

QPR Institute 

www.qprinstitute.com (Under “QPR for Organizations,” click on “Business.”) 

The QPR Institute is centered on the “question, persuade, refer” strategy of suicide prevention training for 

gatekeepers. The institute offers training and information materials tailored for a variety of organizations 

and workplace settings, including businesses and corporations. 

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ValueOptions Strategic Principles for Suicide Prevention 

www.valueoptions.com/suicide_prev/html%20paged/Strategy.htm 

This website is designed to help create a comprehensive suicide prevention plan for workplaces. It includes 

materials for senior management, articles, tip sheets, posters, banner graphics, a self-scoring quiz, and 

sample e-mail messages, as well as instruction on what the prevention plan should include. 

Working Minds: Suicide Prevention in the Workplace 

www.workingminds.org 

This is a joint program by the Carson J. Spencer Foundation and the Colorado Department of Public 

Health and Environment, Office of Suicide Prevention, aimed at preventing suicide among workingaged people, particularly men. It provides informational materials and in-person trainings, and features 

a toolkit for employers to provide training to employees on what to do when facing a suicide crisis that 

impacts the workplace. 

Workplace Strategies for Mental Health 

Great-West Life Centre for Mental Health in the Workplace 

www.gwlcentreformentalhealth.com/display.asp?l1=7&l2=101&l3=116&d=116& 

This website contains a page on suicide prevention and intervention, as well as other information and tools 

for addressing mental health issues in the workplace. 

Older Men 

Older men, in particular those who are white, have disproportionately high rates of death by suicide. In 

2009, the rate of death by suicide among older white men was 30.15 per 100,000—almost three times the 

rate among the general population (11.77 per 100,000).1 

Several factors can increase the risk for suicidal behaviors among older men, including the presence of 

a mental disorder. Research suggests that older adults who die by suicide are more likely to meet criteria 

for affective disorders (especially major depressive disorder) than younger adults.267 Other important risk 

factors include physical illness and functional decline. Finally, an extensive body of literature indicates that 

social disconnection increases risk for death by suicide in older men.267 

Suicide in late life is qualitatively different than in younger adults. Older adults are more likely than 

younger adults to die by suicide as a result of their first suicide attempt, in part because older adults are 

more likely than younger adults to use highly lethal means to attempt suicide.267 Another important 

difference is that older adults are less likely than younger adults either to have reported suicidal ideation 

or to have sought mental health treatment prior to their deaths.268 Interestingly, however, research suggests 

that most older adults who die by suicide are seen by primary care physicians in the last three months 

of life.106 

Although many suicide prevention efforts have targeted youth, older adults have also become a focus of 

suicide prevention. Since 2001, many national and regional conferences have featured the topic, and many 

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states have broadened or are in the process of broadening their suicide prevention strategies to include 

older adults. Some states (e.g., Oregon and Maine) have separate plans for this age group. Mental health 

parity for Medicare is now being phased in so that seniors in the United States will have the same copay 

(20 percent) for mental health care as for physical health care. 

Several interventions appear to offer significant promise for the prevention of suicide in late life. Most of 

these interventions have focused on treating depressive symptoms.267 Because older men do not generally 

seek mental health treatment, the most effective methods of treating mood disorders in older adults may 

involve integrating evidence-based depression treatment into the work of primary care offices, social 

service agencies, and aging services organizations that focus on addressing the needs of older adults. 

Research has shown that collaborative care models that combine pharmacological and psychosocial 

treatments for depressive symptoms may be particularly useful. Finally, there is evidence that interventions 

that attempt to decrease social isolation and disconnection in late life may reduce risk for death 

by suicide.267 

Resources 

It Takes a Community: Report on the Summit on Opportunities for Mental Health Promotion and 

Suicide Prevention in Senior Living Communities, 2010 

www.sprc.org/library_resources/items/it-takes-community-report-summit-opportunities-mental-healthpromotion-and-s 

This is a report of the October 2008 “It Takes a Community” summit to advance discussion and action to 

improve the mental health and reduce the risk of suicide among residents of senior living communities 

(SLCs). It provides a framework of whole population, at-risk population, and crisis response approaches 

and includes findings from focus groups of SLC residents. 

Late Life Suicide Prevention Toolkit: Life Saving Tools for Health Care Providers, 2006 

Canadian Coalition for Seniors’ Mental Health 

www.ccsmh.ca/en/projects/suicide.cfm 

These training materials include an interactive, case-based DVD, the National Guidelines for Seniors' 

Mental Health: The Assessment of Suicide Risk and Prevention of Suicide, a clinician pocket card, a 

Facilitator's Guide, and a PowerPoint presentation. 

Promoting Emotional Health and Preventing Suicide: A Toolkit for Senior Living Communities, 2011 

SAMHSA 

www.store.samhsa.gov/product/SMA10-4515 

This toolkit contains resources to help staff in SLCs promote emotional health and prevent suicide among 

their residents. The toolkit also provides resources to help residents become active participants in mental 

health promotion and suicide prevention efforts. 

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Appendix E: General Suicide Prevention Resources 

This appendix contains selected reports, guidelines, and other key resources on general aspects 

of suicide prevention. It also includes descriptions of federal agencies and national organizations 

that focus on suicide prevention. These groups can often provide program materials, trainings, and 

other resources. For information and resources for specific groups at increased risk for suicide, see 

Appendix D. 

Suicide Prevention National Strategy Documents 

United States 

National Strategy for Suicide Prevention 

National Action Alliance for Suicide Prevention 

www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/index.html 

www.actionallianceforsuicideprevention.org/NSSP 

www.samhsa.gov/nssp 

The National Strategy for Suicide Prevention provides the framework for suicide prevention for the United 

States. First published in 2001 and then updated in 2012, the National Strategy represents the combined 

work of advocates, clinicians, researchers, survivors, and others. It lays a framework for action to prevent 

suicide and guides the development of an array of services and programs. 

Charting the Future of Suicide Prevention: A 2010 Progress Review of the National Strategy and 

Recommendations for the Decade Ahead, 2010 

Education Development Center, Inc. 

www.sprc.org/library/ChartingTheFuture_Fullbook.pdf 

This report reviews developments in the field of suicide prevention in the 9 years following the publication 

of the National Strategy for Suicide Prevention. It identifies the areas of most important progress, as well 

as crucial areas that have gone relatively unaddressed. It also explores new issues and initiatives that have 

emerged to claim attention or offer solutions. 

Reducing Suicide: A National Imperative, 2002 

Institute of Medicine 

http://www.nap.edu/openbook.php?isbn=0309083214 

This Institute of Medicine report, commissioned by several federal agencies, summarizes the state of the 

science base, gaps in knowledge, strategies for prevention, and research designs for the study of suicide. 

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Australia 

Living Is for Everyone (LIFE) Framework, 2007 

Australian Government Department of Health and Ageing Commonwealth of Australia, Canberra 

http://www.livingisforeveryone.com.au/Home.html 

England 

Consultation on Preventing Suicide in England: A Cross-Government Outcomes Strategy to Save 

Lives, 2011 

United Kingdom Department of Health 

www.dh.gov.uk/en/Consultations/Liveconsultations/DH_128065 

This document proposes a new suicide prevention strategy for England. 

Ireland 

Reach Out: Irish National Strategy for Action on Suicide Prevention 2005–2014 

National Office for Suicide Prevention, Ireland 

www.nosp.ie/reach_out.pdf 

New Zealand 

New Zealand Suicide Prevention Action Plan 2008–2012: The Evidence for Action 

Ministry of Health, Wellington, New Zealand 

www.spinz.org.nz/file/downloads/pdf/file_48.pdf 

Norway 

National Plan for Suicide Prevention 1994–1998, 1999 

Norwegian Health Board 

www.med.uio.no/klinmed/english/research/centres/nssf/articles/prevention/The_national_plan_for_ 

suicide_prevention_1994-1998.pdf 

The Norwegian Plan for Suicide Prevention Follow-up Project 2000–2002: Building on Positive 

Experiences, 2001 

Norwegian Journal Suicidologi, no. 1 

www.med.uio.no/klinmed/english/research/centres/nssf/articles/prevention/MehlumAndReinholdt.pdf 

Scotland 

Refreshing the National Strategy and Action Plan to Prevent Suicide in Scotland: Report of the 

National Suicide Prevention Working Group, 2010 

The Scottish Government 

www.scotland.gov.uk/Publications/2010/10/26112102/0 

This report describes the revised Scottish national strategy for suicide prevention. 

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Media Reporting on Suicide 

Picture This: Depression and Suicide Prevention, 2009 

www.eiconline.org/resources/publications/z_picturethis/Disorder.pdf 

This is a guide for content creators in the entertainment industry that addresses issues within the areas 

of depression and suicide prevention. These issues include those as identified by mental health experts, 

advocates, policymakers, and others working to improve public awareness about and reduce instances of 

depression and suicide. 

Recommendations for Reporting on Suicide, 2011 

Substance Abuse and Mental Health Services Administration (SAMHSA), U. S. Department of Health and 

Human Services (HHS) 

www.reportingonsuicide.org 

This website presents research-based recommendations for reporting on suicide, including suggestions for 

online media, message boards, bloggers, and “citizen journalists.” 

Evidence-Based and Best Practices for Suicide Prevention 

Best Practices Registry for Suicide Prevention 

Suicide Prevention Resource Center (SPRC) and American Foundation for Suicide Prevention (AFSP) 

www.sprc.org/bpr 

This registry contains approximately 100 suicide prevention programs, including student curricula and 

peer leader programs, gatekeeper trainings, and trainings for health and mental health professionals. The 

registry is organized into three sections. Section I: Evidence-Based Programs lists interventions that have 

undergone evaluation and demonstrated positive outcomes. Most of these are the suicide prevention 

programs in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP). Section 

II: Expert and Consensus Statements lists statements that summarize the current knowledge in the suicide 

prevention field and provide best practice recommendations to guide program and policy development. 

Section III: Adherence to Standards lists suicide prevention programs and practices whose content has been 

reviewed for accuracy, likelihood of meeting objectives, and adherence to program design standards. 

National Registry of Evidence-Based Programs and Practices 

SAMHSA, HHS 

www.nrepp.samhsa.gov 

NREPP is a searchable online registry of roughly 230 interventions supporting mental health promotion, 

substance abuse prevention, and mental health and substance abuse treatment. It includes a small 

number of interventions focused on suicide prevention and treatment. The registry connects members 

of the public to intervention developers so that they can learn how to implement these approaches in 

their communities. 

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Suicide Data and Surveillance 

National Violent Death Reporting System (NVDRS) 

Centers for Disease Control and Prevention (CDC), HHS 

www.cdc.gov/injury/wisqars/nvdrs.html 

NVDRS is a surveillance system that links data from law enforcement, coroners and medical examiners, 

vital statistics, and crime laboratories to assist each participating state in designing and implementing 

tailored prevention and intervention efforts, including for suicide. NVDRS also pools these data to better 

depict the scope and nature of violence. 

Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements, 

Version 1.0, 2011 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

National Center for Injury Prevention and Control, CDC, HHS 

www.cdc.gov/ViolencePrevention/pub/selfdirected_violence.html 

To address the current lack of a uniform definition on fatal and nonfatal self-harm, CDC developed 

this resource to improve understanding of self-directed violence and standardize data collection. The 

definitions and data elements were developed in collaboration with the U.S. Department of Veterans 

Affairs and the U.S. Department of Defense. 

Suicide Prevention Data Reports 

Office of Applied Studies, SAMHSA, HHS 

www.oas.samhsa.gov/suicide.cfm 

This website lists reports that provide surveillance data on suicidal thoughts and behaviors. 

Web-Based Injury Statistics Query and Reporting System (WISQARS) 

CDC, HHS 

www.cdc.gov/injury/wisqars 

This is an interactive database system that provides customized reports of data from a variety of sources 

on fatal and nonfatal injuries, violent deaths, and cost of injury. The system features a large amount of data 

on suicide. 

Suicidal Thoughts and Behaviors Among Adults 

www.oas.samhsa.gov/2k9/165/Suicide.htm 

This issue of The National Survey on Drug Use and Health Report examines suicidal thoughts and behaviors 

among adults aged 18 and older. Data are presented by age group, gender, and past year substance use 

disorder. All findings in the report are based on 2008 data. 

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Suicide Prevention Organizations 

For organizations that focus on specific groups with increased suicide risk, see Appendix D. 

American Association of Suicidology (AAS) 

www.suicidology.org 

AAS promotes research, public awareness programs, public education, and training for professionals and 

volunteers. It serves as a national clearinghouse for information on suicide, publishing and disseminating statistics 

and suicide prevention resources. AAS also hosts annual national conferences for professionals and survivors. 

American Foundation for Suicide Prevention (AFSP) 

www.afsp.org 

AFSP funds research and offers educational programs and resources for professionals, survivors of 

suicide loss, and the public. With SPRC, AFSP coproduces the Best Practices Registry (BPR) for Suicide 

Prevention. AFSP’s Public Policy Division, SPAN USA, promotes and keeps track of policies and 

legislation related to suicide prevention. AFSP chapters provide connections to local resources and services 

addressing suicide prevention. The chapters also organize awareness events. 

International Association for Suicide Prevention (IASP) 

www.iasp.info 

IASP is an international suicide prevention membership organization dedicated to preventing suicidal 

behavior, alleviating its effects, and providing a forum for academics, mental health professionals, crisis 

workers, volunteers, and suicide survivors. IASP sponsors World Suicide Prevention Day, congresses, task 

forces, conferences, and awards for research in suicidology. 

Jason Foundation 

www.jasonfoundation.com 

The Jason Foundation is an educational organization dedicated to the awareness and prevention of youth 

suicide. It produces educational curricula and training programs for students, educators, youth workers, 

and parents to help them identify and assist at-risk youth. 

Means Matter, Harvard School of Public Health 

www.hsph.harvard.edu/means-matter 

The mission of the Means Matter campaign is to increase the proportion of suicide prevention groups 

that promote activities that reduce a suicidal person’s access to lethal means of suicide. The website has a 

wide variety of information to help families, clinicians, suicide prevention groups, local communities, and 

colleges and universities. 

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National Council for Suicide Prevention (NCSP) 

www.ncsponline.org 

NCSP is a group of leading national suicide prevention organizations that comes together to speak as a 

collective voice on selected issues and is dedicated to advancing suicide prevention through leadership and 

advocacy. NCSP philosophy is rooted in the belief that collaboration between like organizations will help 

pool resources and strengthen member organizations’ ability to effect positive change in the field. 

National Organization for People of Color Against Suicide (NOPCAS) 

www.nopcas.org 

NOPCAS addresses suicide prevention, intervention, and postvention in communities of color. NOPCAS 

provides professional development and culturally appropriate training for lay and professional audiences 

as well as sponsoring survivor/bereavement support groups. It also provides the online crisis intervention 

network entitled “I’m Alive,” staffed by certified volunteers, and a speakers bureau. 

National Suicide Prevention Lifeline (Lifeline) 

www.suicidepreventionlifeline.org 

The Lifeline provides immediate assistance 24 hours a day, 7 days a week to individuals in suicidal crisis by 

connecting them to the nearest available suicide prevention and mental health service provider through a 

toll-free telephone number: 1–800–273–TALK (8255). The Lifeline also provides informational materials 

featuring the phone number, such as brochures, wallet cards, and posters. 

Samaritans USA 

www.samaritansusa.org 

Samaritans USA provides services to those at risk for suicide, provides support for those who have 

experienced a loss due to suicide, and educates caregivers and health providers. Crisis lines are the 

cornerstone of Samaritans USA’s services. Samaritans USA also provides suicide prevention education to 

the public and survivor support groups. 

Suicide Awareness Voices of Education (SAVE) 

www.save.org 

SAVE’s mission is to prevent suicide through public awareness and education, reduce prejudice, and serve 

as a resource for those touched by suicide. SAVE’s prevention and education programs are designed to 

increase awareness and knowledge about brain illnesses and suicide, accessing community resources, and 

understanding and use of intervention skills to help prevent suicide. 

Suicide Prevention Resource Center (SPRC) 

www.sprc.org 

SPRC is a SAMHSA-funded, national center that helps strengthen the efforts of state, tribal, community, 

and campus suicide prevention organizations and coalitions and organizations that serve populations 

with high suicide rates. It provides technical assistance, training, a variety of resource materials, a current 

awareness newsletter (The Weekly SPARK), and a searchable online library. In partnership with AFSP, 

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SPRC coproduces the BPR for Suicide Prevention. SPRC also provides organizational support for the 

National Action Alliance for Suicide Prevention. 

The Jed Foundation 

www.jedfoundation.org 

The Jed Foundation works to promote emotional health and prevent suicide among college and university 

students. The Jed Foundation’s programs include: ULifeline, an online resource that gives students access to 

campus-specific resources and allows them to take an anonymous mental health screening; the Half of Us 

campaign with mtvU, which uses online, on-air, and on campus programming to encourage help-seeking; Love 

is Louder, a movement online and in communities to build connectedness and increase resiliency; and more. 

The Link Counseling Center 

www.thelink.org 

The Link provides services and support to those who have lost a loved one to suicide, including 

workshops, resource materials, telephone counseling, information, and referrals. The Link also offers 

trainings for survivors and professionals on creating and facilitating support groups for survivors. 

Yellow Ribbon 

www.yellowribbon.org 

Yellow Ribbon is the producer of the adult gatekeeper training Be a Link!, and the youth program Ask 

4 Help! Its services include providing technical assistance to states and communities and support to 

survivors, including a list of survivor support groups across the United States. 

U.S. Government Agencies 

Information on the federal agencies that are a part of the Federal Working Group on Suicide Prevention is 

provided in Appendix G. These agencies include the National Institute of Mental Health (NIMH), within 

the National Institutes of Health (NIH). The following two other NIH institutes also address issues related 

to suicide prevention. 

National Institute on Alcohol Abuse and Alcoholism (NIAAA), NIH, HHS 

www.niaaa.nih.gov 

NIAAA provides leadership in the national effort to reduce alcohol-related problems. Alcohol is a 

significant risk factor for suicide, and NIAAA publishes studies on how alcohol use interacts with 

conditions such as depression and stress to contribute to suicide. NIAAA also provides data on alcohol 

involvement in suicide. 

National Institute on Drug Abuse (NIDA), NIH, HHS 

www.nida.nih.gov 

NIDA funds and publishes studies on the effects of substance abuse on mental health, including suicide, 

and hosts Suicide Studies Lectures, which review current standards to define, classify, assess, and treat 

suicide-related disorders that sometimes play a role in drug abuse and addiction. NIDA also sponsored the 

landmark workshop Drug Abuse and Suicidal Behavior. 

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Appendix F: Glossary 

Affected by suicide—All those who may feel the impact of suicidal behaviors, including those bereaved by 

suicide, as well as community members and others. 

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. 

Behavioral health—A state of mental/emotional being and/or choices and actions that affect wellness. 

Behavioral health problems include substance abuse or misuse, alcohol and drug addiction, serious 

psychological distress, suicide, and mental and substance use disorders. The term is also used to describe 

the service systems encompassing the promotion of emotional health; the prevention of mental and 

substance use disorders, substance use, and related problems; treatments and services for mental and 

substance use disorders; and recovery support. 

Bereaved by suicide—Family members, friends, and others affected by the suicide of a loved one (also 

referred to as survivors of suicide loss). 

Best practices—Activities or programs that are in keeping with the best available evidence regarding what 

is effective. 

Bipolar disorders—A mood disorder characterized by the presence or history of manic episodes usually, 

but not necessarily, alternating with depressive episodes. 

Bisexual—An adjective that refers to individuals whose sexual orientation or identity involves sexual, 

physical, and/or romantic attraction to both men and women. 

Boundaried system—A health care and community support system that provides behavioral and other 

health care services to a defined population (e.g., Henry Ford Health System). 

Community—A group of individuals 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 and substance 

use disorder. 

Complicated grief—Feelings of loss, following the death of a loved one, which are debilitating and do not 

improve even after time passes. These painful emotions are so long lasting and severe that those who are 

affected have trouble accepting the loss and moving on with their lives. Also referred to “traumatic grief ” 

or “prolonged grief.” 

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Connectedness—Closeness to an individual, group, or individuals within a specific organization; 

perceived caring by others; satisfaction with relationship to others; or feeling loved and wanted by others. 

Contagion—A phenomenon whereby susceptible persons are influenced toward 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, including 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. 

Deliberate self-harm—See suicidal self-directed violence. 

Depression—A constellation of emotional, cognitive, and somatic signs and symptoms, including 

sustained sad mood or lack of pleasure. 

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—Programs that have undergone scientific evaluation and have proven to be 

effective. 

Gatekeepers—Those individuals in a community who have face-to-face 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. Examples include clergy, first 

responders, pharmacists, caregivers, and those employed in institutional settings, such as schools, prisons, 

and the military. 

Gay—An adjective that refers to persons whose sexual orientation or identity involves sexual, physical, 

and/or romantic attraction to individuals of the same sex. 

Gender identity—An individual’s deeply-rooted internal sense of gender. For most individuals, the sex 

assigned to them at birth aligns with their gender identity. This is not true for some others, however, who 

identify as transgender. 

Goal—A broad and high-level statement of general purpose to guide planning on an issue; it focuses on 

the end result of the work. 

Health—The complete state of physical, mental, and social well-being, not merely the absence of disease or 

infirmity. 

Health and safety officials—Law enforcement officers, firefighters, emergency medical technicians, and 

outreach workers in community health programs. 

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Healthy People 2020—The national prevention initiative that identifies opportunities to improve the 

health of all Americans, with specific and measurable objectives to be met by 2020. 

Indicated intervention—Intervention designed for individuals at high risk for a condition or disorder or 

for those who have already exhibited the condition or disorder. 

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 disorders, educating providers about suicide 

prevention, or reducing access to lethal means among individuals with suicide risk). 

Lesbian—An adjective that refers to women whose sexual orientation or identity involves sexual, physical, 

and/or romantic attraction to other women. 

Lesbian, gay, bisexual, or transgender—A blanket term that refers to those who identify as lesbian, gay, 

bisexual, or transgender. 

Ligature points—Elements in an environment that could be used to support a noose or other 

strangulation devices (especially, for a suicide attempt). 

Means—The instrument or object used to carry out a self-destructive act (e.g., chemicals, medications, 

illicit drugs). 

Means restriction—Techniques, policies, and procedures designed to reduce access or availability to 

means and methods of deliberate self-harm. 

Methods—Actions or techniques that result in an individual inflicting self-directed injurious behavior 

(e.g., overdose). 

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 well-being, optimal development, and use of mental abilities (cognitive, affective, 

and relational). 

Mental health services—Health services that are specifically designed for the care and treatment of 

persons with mental health problems, including mental illness. Mental health services include hospitals 

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. 

Minority stress—The high levels of chronic stress experienced by members of minority populations 

(including lesbian, gay, bisexual, or transgender populations) as a result of the prejudice and 

discrimination they experience from the dominant group in society. 

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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. These disorders include depressive disorders, 
 

bipolar disorders, mood disorders because of 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. 
 

Nonsuicidal self-injury—Self-injury with no suicidal intent. Same as nonsuicidal self-directed violence 
 

(see Centers for Disease Control and Prevention surveillance definitions box at the end of this appendix). 
 

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.
 


Older adults—Persons aged 60 or more years. 
 

Outcome—A measurable change in the health of an individual or group of individuals that is attributable 
 

to an intervention. 
 

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—Response to and care for individuals affected in the aftermath of a suicide attempt or
 


suicide death.
 


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. 
 

Rate—The number per unit of the population with a particular characteristic, for a given unit of time. 
 

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—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. 

Root cause analysis—Root cause analysis (RCA) is a step-by-step method that leads to the discovery 

of a fault’s first or root cause. RCA uses a systematic approach to identify the progression of actions and 

consequences that led to an undesired event. In the context of suicide prevention, an RCA investigation 

means tracing the cause and effect trail from a suicide attempt or death back to the root cause. 

Safety plan—Written list of warning signs, coping responses, and support sources that an individual may 

use to avert or manage a suicide crisis. 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Screening—Administration of an assessment tool to identify persons in need of more indepth evaluation 

or treatment. 

Screening tools—Instruments and techniques (e.g., questionnaires, check lists, self-assessment forms) 

used to evaluate individuals for increased risk of certain health problems. 

Selective intervention—Intervention targeted to subgroups of the population whose risk of developing a 

health problem is significantly higher than average. 

Self-directed violence (same as self-injurious behavior)—Behavior that is self-directed and deliberately 

results in injury or the potential for injury to oneself. Self-directed violence can be categorized as either 

nonsuicidal or suicidal. 

Self-inflicted injuries—Injuries caused by suicidal and nonsuicidal behaviors such as self-mutilation. 

Sexual orientation—An individual’s sexual, physical, and/or romantic attraction to men, women, both, 

or neither. 

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. 

Substance use disorder—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 behaviors—Behaviors related to suicide, including preparatory acts, as well as suicide attempts 

and deaths. 

Suicidal self-directed violence—Behavior that is self-directed and deliberately results in injury or the 

potential for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent. 

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Suicidal ideation—Thoughts of engaging in suicide-related behavior. 

Suicidal intent—There is evidence (explicit and/or implicit) that at the time of injury the individual 

intended to kill him or herself or wished to die and that the individual understood the probable 

consequences of his or her actions. 

Suicidal plan—A thought regarding a self-initiated action that facilitates self-harm behavior or a suicide 

attempt; often including an organized manner of engaging in suicidal behavior such as a description of a 

time frame and method. 

Suicide—Death caused by self-directed injurious behavior with any intent to die as a result of the behavior. 

Suicide attempt—A nonfatal self-directed potentially injurious behavior with any intent to die as a result 

of the behavior. A suicide attempt may or may not result in injury. 

Suicidal behaviors—Acts and/or preparation toward making a suicide attempt, suicide attempts, and 

deaths by suicide. 

Suicide crisis—A suicide crisis, suicidal crisis, or potential suicide, is a situation in which a person is 

attempting to kill him or herself or is seriously contemplating or planning to do so. It is considered a 

medical emergency, requiring immediate suicide intervention and emergency medical treatment. 

Suicide attempt survivors—Individuals who have survived a prior suicide attempt. 

Suicide loss survivors—See bereaved by suicide. 

Surveillance—The ongoing, systematic collection, analysis, and interpretation of health data with timely 

dissemination of findings. 

Transgender—Someone whose gender identity or expression is different from the sex that was assigned to 

them at birth. Some transgender individuals take steps to physically and/or legally transition from one sex 

to another. 

Unintentional—Term used for an injury that is unplanned; in many settings, these are termed accidental 

injuries. 

Universal 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). 

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Uniform Definitions for Use in Surveillance, CDC 2011 

These definitions are from the 2011 report Self-Directed Violence Surveillance: Uniform Definitions 

and Recommended Data Elements, published by the Centers for Disease Control and Prevention 

(see Appendix E for more information). Developed in collaboration with the Department of Veterans 

Affairs, the definitions are meant to help standardize the collection of data on fatal and nonfatal selfdirected violence. 

Nonsuicidal 

self-directed violence 

Behavior that is self-directed and deliberately results in injury or the 

potential for injury to oneself. There is no evidence, whether implicit 

or explicit, of suicidal intent. 

Other suicidal behavior 

including preparatory acts 

Acts or preparation toward making a suicide attempt, but before 

potential for harm has begun. This can include anything beyond 

a verbalization or thought, such as assembling a method (e.g., 

collecting pills) or preparing for one’s death by suicide (e.g., writing a 

suicide note, giving things away). 

Self-directed violence Behavior that is self-directed and deliberately results in injury or the 

potential for injury to oneself. 

Suicidal ideation Thoughts of engaging in suicide-related behavior. 

Suicidal intent There is evidence (explicit and/or implicit) that at the time of injury the 

individual intended to kill self or wished to die and that the individual 

understood the probable consequences of his or her actions. 

Suicidal plan A thought regarding a self-initiated action that facilitates self-harm 

behavior or a suicide attempt. This will often include an organized 

manner of engaging in suicidal behavior such as a description of a 

time frame and method. 

Suicidal self-directed 

violence 

Behavior that is self-directed and deliberately results in injury or the 

potential for injury to oneself. There is evidence, whether implicit or 

explicit, of suicidal intent. 

Suicide Death caused by self-directed injurious behavior with any intent to die 

as a result of the behavior. 

Suicide attempt A nonfatal, self-directed, potentially injurious behavior with any intent 

to die as a result of the behavior. A suicide attempt may or may not 

result in injury. 

SOURCE: Crosby A, Ortega L, Melanson C. Self-directed violence surveillance: Uniform definitions and recommended data elements, Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 

2011. Available at www.cdc.gov/ViolencePrevention/pub/selfdirected_violence.html. 

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Appendix G: Federal Working Group 

Agency Descriptions 

U.S. Department of Agriculture 

Mission: To provide leadership on food, agriculture, natural resources, and related issues based on sound 

public policy, the best available science, and efficient management. 

The U.S. Department of Agriculture (USDA) wants to be recognized as a dynamic organization that is 

able to efficiently provide the integrated program delivery needed to lead a rapidly evolving food and 

agriculture system. 

USDA has created a strategic plan to implement its vision. The framework of this plan depends on these 

key activities: expanding markets for agricultural products and supporting international economic 

development; further developing alternative markets for agricultural products and activities; providing 

financing needed to help expand job opportunities and improve housing, utilities, and infrastructure in 

rural America; enhancing food safety by taking steps to reduce the prevalence of foodborne hazards from 

farm to table; improving nutrition and health by providing food assistance and nutrition education and 

promotion; and managing and protecting America’s public and private lands working cooperatively with 

other levels of government and the private sector. 

National Institute of Food and Agriculture 

The National Institute of Food and Agriculture (NIFA) is an agency within USDA and part of the executive 

branch of the federal government. Congress created NIFA through the Food, Conservation, and Energy 

Act of 2008. NIFA’s unique mission is to advance knowledge for agriculture, the environment, human 

health and well-being, and communities by supporting research, education, and extension programs in the 

Land-Grant University System and other partner organizations. 

For additional information: 

U.S. Department of Agriculture 

Web address: www.usda.gov 

National Institute of Food and Agriculture 

Web address: www.csrees.usda.gov 

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U.S. Department of Defense 

department’s headquarters is at the Pentagon. 

Mission: To provide the military forces needed to deter war and to protect the security of our country. The 

The Department of Defense (DoD) is America’s oldest and largest government agency. With our military 

tracing its roots back to pre-Revolutionary War times, the DoD has grown and evolved with our nation. 

Today, the department, headed by Secretary of Defense Leon E. Panetta, is not only in charge of the 

military, but it also employs a civilian force of thousands. With more than 1.4 million men and women on 

active duty and 718,000 civilian personnel, DoD is the nation’s largest employer. Another 1.1 million serve 

in the National Guard and Reserve forces. More than 2 million military retirees and their family members 

receive benefits. 

Headquarters of the DoD, the Pentagon is one of the world’s largest office buildings. It is twice the size of 

the Merchandise Mart in Chicago, and has three times the floor space of the Empire State Building in New 

York. Built during the early years of World War II, it is still thought of as one of the most efficient office 

buildings in the world. Despite 17.5 miles of corridors it takes only seven minutes to walk between any two 

points in the building. 

The nation’s security depends on its defense installations and facilities being in the right place, at the right 

time, with the right qualities and capacities to protect our national resources. Those resources have never 

been more important as America fights terrorists who plan and carry out attacks on U.S. facilities and the 

American people. U.S. military service members and civilians operate in every time zone and in every 

climate. More than 450,000 employees are overseas, both afloat and ashore. 

DoD manages an inventory of installations and facilities to keep Americans safe. The department’s physical 

plant is huge by any standard, consisting of more than several hundred thousand individual buildings and 

structures located at more than 5,000 different locations or sites. When all sites are added together, DoD 

utilizes more than 30 million acres of land. 

These sites range from the very small in size, such as unoccupied sites supporting a single navigational aid 

that sit on less than one-half acre, to the Army’s vast White Sands Missile Range in New Mexico, which 

occupies more than 3.6 million acres, or the Navy’s large complex of installations at Norfolk, Virginia, 

which includes more than 78,000 employees. 

For additional information: 

U.S. Department of Defense 

Web address: www.defense.gov 

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U.S. Department of Education 

Mission: To promote student achievement and preparation for global competitiveness by fostering 

educational excellence and ensuring equal access. 

The U.S. Department of Education (ED) was created in 1980 by combining offices from several federal 

agencies. ED’s 4,400 employees and $68 billion budget are dedicated to: 

Establishing policies on federal financial aid for education, and distributing as well as monitoring
 


those funds;
 


Collecting data on America’s schools and disseminating research; 

Focusing national attention on key educational issues; and 

Prohibiting discrimination and ensuring equal access to education. 

Office of Safe and Healthy Students 

The Office of Safe and Healthy Students, a program office within the Office of Elementary and Secondary 

Education, administers, coordinates, and recommends policy for improving the quality and excellence of 

programs and activities that are designed to: 

Provide financial assistance for: drug and violence prevention activities; activities that promote the 

health and well-being of students in elementary schools, secondary schools, and institutions of higher 

education; and school preparedness activities that contribute to improved conditions for learning. 

Activities may be carried out by other federal agencies, state and local educational agencies, and other 

public and private nonprofit organizations; 

Participate in the formulation and development of ED program policy and legislative proposals and 

in overall administration policies related to violence and drug prevention; this includes drafting 

program regulations; 

Participate in interagency committees, groups, and partnerships related to: drug and violence 

prevention, school preparedness, homeland security, missing and exploited youth, trafficked youth, 

and school health; 

Participate with other federal agencies in the development of a national research and data collection 

agenda for drug and violence prevention and preparedness; and 

Administer the department’s programs relating to citizenship and civics education. 

For additional information: 

U.S. Department of Education 

Web address: www.ed.gov 

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U.S. Department of Health and Human Services 

Mission: The mission of the Department of Health and Human Services (HHS) is to enhance the health 

and well-being of Americans by providing for effective health and human services and by fostering strong, 

sustained advances in the sciences, underlying medicine, public health, and social services. 

HHS is the 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. HHS represents 

almost a quarter of all federal outlays, and it administers more grant dollars than all other federal agencies 

combined. HHS’s Medicare program is the nation’s largest health insurer, handling more than 1 billion 

claims per year. Medicare and Medicaid together provide health care insurance for one in four Americans. 

HHS works closely with state and local governments, and many HHS-funded services are provided at 

the local level by state or county agencies or through private sector grantees. The department’s programs 

are administered by 11 operating divisions, including eight agencies in the U.S. Public Health Service 

and three human services agencies. The department includes more than 300 programs, covering a wide 

spectrum of activities. In addition to the services they deliver, HHS programs provide for equitable 

treatment of beneficiaries nationwide, and they enable the collection of national health and other data. 

Departmental leadership is provided by the Office of the Secretary. Also included in the department is 

the Office of Public Health and Science, the Office of the HHS Inspector General, and the HHS Office 

for Civil Rights. In addition, the Program Support Center, a self-supporting division of HHS, provides 

administrative services for HHS and other federal agencies. 

For additional information: 

U.S. Department of Health and Human Services 

Web address: www.hhs.gov 

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Administration on Aging 

Mission: To develop a comprehensive, coordinated, and cost-effective system of home and communitybased services that helps elderly individuals maintain their health and independence in their homes 

and communities. To achieve this mission, the Administration on Aging (AoA) works with states and 

communities to enhance the availability of effective and coordinated services that are responsive to the 

needs and preferences of older persons, persons with disabilities, and their family caregivers. 

AoA was established in 1965 with the passage of the Older Americans Act and is charged with advancing 

the concerns and interests of older people, persons with disabilities, and their family caregivers. To 

accomplish this vision, AoA administers a combination of competitive and formula grants that support 

the development, delivery, and evaluation of supportive services through the Aging Network, which 

consists of 56 State Units on Aging, 629 Area Agencies on Aging, 256 Tribal and Native organizations, 

20,000 service providers, and thousands of volunteers. By leveraging public and private resources and 

partnerships, the Aging Network delivers streamlined access to a robust menu of supports, including 

long-term care services, nutrition programs, preventive health services, family caregiver programs, care 

transitions interventions, and supports that prevent elder abuse and promote elder rights. 

Physical illness, emotional issues, and functional impairment are common risk factors for suicide among 

older adults. Through AoA’s evidence-based health, dementia, and wellness programs, the Aging Network 

is developing a national system of effective programs, including depression care and suicide prevention 

programs, that help older adults, persons with disabilities, and their family caregivers maintain their health 

and independence. AoA envisions the continuation of a vibrant, integrated system that provides access to 

person-centered supportive services that promote physical and emotional well-being. AoA has recently 

become a part of the Administration for Community Living. 

For additional information: 

Administration on Aging 

Web address: www.aoa.gov 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Agency for Health Care Research and Quality 

Mission: To improve the quality, safety, efficiency, and effectiveness of health care for all Americans. As 1 of 

12 agencies within HHS, the Agency for Health Care Research and Quality (AHRQ) supports research that 

helps individuals make more informed decisions and improves the quality of health care services. AHRQ 

was formerly known as the Agency for Health Care Policy and Research. 

AHRQ is committed to improving care safety and quality by developing successful partnerships and 

generating the knowledge and tools required for long-term improvement. The goal of its research is 

measurable improvements in health care in America, gauged in terms of improved quality of life and 

patient outcomes, lives saved, and value gained for what AHRQ spends. 

To achieve its goals, the agency is committed to organizational excellence, the use of efficient and 

responsive business processes to maximize the agency’s resources, and the effectiveness of its programs. 

The agency’s overall focus is: 

Safety and quality: Reduce the risk of harm by promoting delivery of the best possible health care; 

Effectiveness: Improve health care outcomes by encouraging the use of evidence to make informed 

health care decisions; and 

Efficiency: Transform research into practice to facilitate wider access to effective health care services 

and reduce unnecessary costs. 

AHRQ’s customers include: 

Clinicians and other health care providers, such as hospitals; 

Consumers and patients; 

Health care policymakers at the federal, state, and local levels; 

Purchasers and payers, such as employers and public and private insurers; and 

Other health officials, such as hospital systems and medical school faculty. 

For additional information: 

Agency for Health Care Research and Quality 

Web address: www.ahrq.gov 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Centers for Disease Control and Prevention 

Mission: Collaborate to create the expertise, information, and tools that individuals and communities 
 

need to protect their health—through health promotion, prevention of disease, injury and disability, and 
 

preparedness for new health threats. 
 

The Centers for Disease Control and Prevention (CDC), a part of HHS, is the primary federal agency for 
 

conducting and supporting public health activities in the U.S. Through its centers, institutes, and offices, 
 

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. 
 

CDC suicide prevention activities include efforts in the National Center for Health Statistics, National 

Center for Chronic Disease Prevention and Health Promotion, and National Center for Injury Prevention 

and Control. CDC maintains national data on suicides, conducts the 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: www.cdc.gov 

National Injury Center’s Division of Violence Prevention 

Web address: www.cdc.gov/violenceprevention 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Health Resources and Services Administration 

Mission: To improve health and achieve health equity through access to quality services, a skilled health 

workforce and innovative programs. 

Health Resources and Services Administration (HRSA) is the primary federal agency for improving access 

to health care services for people who are uninsured, isolated, or medically vulnerable. Tens of millions of 

Americans get affordable health care and other help through HRSA’s 100-plus programs and more than 

3,000 grantees. 

Comprising six bureaus and 10 offices, HRSA provides leadership and financial support to health care 

providers in every state and U.S. territory. HRSA grantees provide health care to uninsured people, people 

living with HIV/AIDS, and pregnant women, mothers, and children. They train health professionals and 

improve systems of care in rural communities. 

HRSA oversees organ, bone marrow, and cord blood donation. It supports programs that prepare against 

bioterrorism, compensates individuals harmed by vaccination, and maintains databases that protect 

against health care malpractice and health care waste, fraud, and abuse. 

Since 1943, the agencies that were HRSA precursors have worked to improve the health of needy 

people. HRSA was created in 1982, when the Health Resources Administration and the Health Services 

Administration were merged. 

For additional information: 

Health Resources and Services Administration 

Web address: www.hrsa.gov 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Indian Health Service 

Mission: To raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives 

(AI/AN) to the highest level. The goal is to assure that comprehensive, culturally acceptable personal and 

public health services are available and accessible to AI/AN people. 

The Indian Health Service (IHS) is the principal federal health care provider and health advocate for 

Indian people. IHS provides a comprehensive health service delivery system for approximately 2 million 

American Indians and Alaska Natives who belong to 566 federally recognized tribes in 36 states. 

Within IHS, the Behavioral Health Division’s mission is to instill balance, wellness, and resilience 

throughout AI/AN communities in partnership with tribes, tribal organizations, and urban Indian health 

organizations, as well as with federal, state, and local agencies. The division seeks to foster excellence in 

holistic approaches that promote healthy lifestyles, families, and communities. The division will coordinate 

national efforts to build capacity and share knowledge throughout Indian Country and will assist in the 

development, implementation, and evaluation of culture- and community-based programming. 

Suicide Prevention: The IHS Suicide Prevention Initiative has provided a crucial framework and 

coordination capability to maximize available resources for addressing the tragedy of suicide in AI/AN 

communities. This initiative builds on the foundation of HHS’s National Strategy for Suicide Prevention 

and the 11 goals and 68 objectives for the nation to reduce suicidal behavior and its consequences, while 

ensuring to honor and respect AI/AN traditions and practices. 

IHS has five targeted approaches for suicide prevention and intervention: (1) Assist IHS, tribal, and 

urban Indian programs and communities in addressing suicide utilizing community level cultural 

approaches; (2) Identify and share information on best and promising practices; (3) Improve access 

to behavioral health services; (4) Strengthen and enhance IHS epidemiological capabilities; and (5) 

Promote collaboration between tribal and urban Indian communities with federal, state, and local 

community agencies. 

The Methamphetamine and Suicide Prevention Initiative (MSPI) is a nationally coordinated program providing 

targeted methamphetamine and suicide prevention and intervention services. This initiative promotes the 

development of evidence-based and promising practices that are culturally appropriate prevention and 

treatment approaches to methamphetamine abuse and suicidal behaviors in a community-driven context. MSPI 

now supports 125 community developed prevention and intervention pilot programs across the country. 

IHS maintains the IHS Community Suicide Prevention website to share information on best and 

promising practices nationally. The website provides culturally appropriate information about best and 

promising suicide prevention and early intervention programs and training opportunities. 

For additional information: 

Indian Health Service 

Web address: www.ihs.gov/index.cfm 

IHS American Indian and Alaska Native Suicide Prevention Website 

Web address: www.ihs.gov/NonMedicalPrograms/nspn 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

National Institute of Mental Health 

Mission: To transform the understanding and treatment of mental illnesses through basic and clinical 

research, paving the way for prevention, recovery, and cure. 

The National Institute of Mental Health (NIMH) was formally established in 1949 by Congress through 

the National Mental Health Act to establish a biomedical and behavioral research program to study 

individual, social, and economic problems of people with mentally illness in the United States. Over the 

past 60 years, NIMH research initiatives have evolved to include health services, research training, and 

health information dissemination with respect to the cause, diagnosis, treatment, control, and prevention 

of mental illness. To accomplish its work, NIMH administers several types of competitive grant programs, 

including research project grants, center grants, career awards, fellowships and training grants, and 

contracts. NIMH also supports the development of research resources that will help stimulate work in 

this field. 

Current NIMH suicide prevention activities focus on multiple projects designed to develop the next 

generation of suicide prevention strategies. One notable activity is NIMH’s partnership with the 

Department of the Army to conduct the Army Study to Assess Risk and Resilience in Service Members 

Project—the largest study of mental health risk and resilience ever conducted among military personnel. 

This project, a cooperative agreement led scientifically by NIMH, specifically looks to identify and 

understand factors related to risk for suicide among Army soldiers. The results will contribute significantly 

to our understanding of risk and resilience associated with suicide, both within the Army and among the 

broader adult population. 

NIMH also has a lead role with the National Action Alliance for Suicide Prevention (Action Alliance), 

a public-private partnership tasked with developing the next National Strategy for Suicide Prevention. 

Alongside The Jed Foundation, NIMH is cochairing the Action Alliance’s Research Task Force (RTF), 

which is developing a research agenda to reduce suicide morbidity (attempts) and mortality (deaths) by at 

least 20 percent in 5 years, and 40 percent or more in 10 years. To develop this agenda, RTF is reviewing 

public and private research portfolios, performing a targeted review of the research literature, statistically 

simulating the effects of potential interventions, and gathering input from more than 700 stakeholders 

through a multistage survey process. RTF’s national research agenda will be structured around a set of 

short- and long-term strategic goals that address key issues in suicide prevention. 

For additional information: 

National Institute of Mental Health 

Web address: www.nimh.nih.gov 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Substance Abuse and Mental Health Services Administration 

Mission: To reduce the impact of substance abuse and mental illness on America’s communities. In order 

to achieve this mission, the Substance Abuse and Mental Health Services Administration (SAMHSA) 

has identified eight strategic initiatives to focus the agency’s work on improving lives and capitalizing on 

emerging opportunities. 

SAMHSA was established in 1992 and directed by Congress to target effectively substance abuse and 

mental health services to the people most in need and to translate research in these areas more effectively 

and more rapidly into the general health care system. Over the years, SAMHSA has demonstrated that 

prevention works, treatment is effective, and people recover from mental and substance use disorders. 

Behavioral health services improve health status and reduce health care and other costs to society. 

Continued improvement in the delivery and financing of prevention, treatment, and recovery support 

services provides a cost-effective opportunity to advance and protect the nation’s health. To accomplish its 

work, SAMHSA administers a combination of competitive, formula, and block grant programs and data 

collection activities. 

Suicide prevention activities of the Center for Mental Health Services (CMHS) within SAMHSA 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 those children at greatest risk of suicide. In addition, SAMHSA sponsors conferences, 

workshops, and meetings to further national goals for suicide prevention. SAMHSA sponsors the 

National Suicide Prevention Lifeline, a national network of more than 150 crisis centers that are available 

to respond to those in emotional distress and their families and friends. SAMHSA also supports the 

Suicide Prevention Resource Center, which provides prevention support, training, and resources to assist 

organizations and individuals to develop suicide prevention programs, interventions and policies, and to 

advance the National Strategy for Suicide Prevention. 

For additional information: 

Substance Abuse and Mental Health Services Administration 

Web address: www.samhsa.gov 

Center for Mental Health Services 

Web address: www.samhsa.gov/about/cmhs.aspx 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

U.S. Department of Veterans Affairs 

Mission: To fulfill President Abraham Lincoln’s promise, “To care for him who shall have borne the 

battle, and for his widow, and his orphan,” by serving and honoring the men and women who are 

America’s veterans. 

Although the Department of Veterans Affairs (VA) can trace its history back to the Revolutionary War, 

it became a cabinet-level Department in 1989. It includes three administrations: the Veterans Health 

Administration (VHA), the Veterans Benefits Administration (VBA), and the National Cemetery 

Administration (NCA). These administrations coordinate services for more than 22 million Americans 

who are veterans. As of the end of 2010, more than 8 million veterans were enrolled in VHA, and more 

than 4 million veterans and survivors received VBA compensation and pension benefits. VHA provides 

patient-centered health care in 153 medical centers, 974 outpatient clinics, 288 Vet Centers, 98 residential 

care facilities, and 133 Community Living Centers that provide nursing home services. Approximately 6 

million patients are treated during the year through more than 75 million outpatient visits. Altogether, 

VHA is the nation’s largest integrated health care system. It functions in close collaboration with DoD to 

support returning veterans in their transition from active duty to their communities, and with a network 

of academic affiliates to facilitate interactions with other systems and providers of health care. 

VA’s activities in suicide prevention include outreach and public information, clinical services, education, 

and research. The Office of Suicide Prevention was established in 2007 as a part of VA’s enhancement 

of its mental health programs to coordinate a program built on the principles that suicide prevention 

requires public health activities, ready access to high-quality mental health services, and clinical programs 

that specifically target individuals at high risk. The program centers around a call center linked with the 

SAMHSA-supported National Suicide Prevention Lifeline, suicide prevention coordinators in each of 

VHA’s medical centers, and a structured public messaging campaign. The program also includes two 

centers of excellence that conduct research, provide education, and develop new clinical programs, one 

focused on clinical care, and the other on public health strategies. 

For additional Information: 

Department of Veterans Affairs 

Web address: www.va.gov 

VA’s Suicide Prevention Program 

Web address: www.mentalhealth.va.gov/suicide_prevention 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Acknowledgments 

National Action Alliance for Suicide Prevention Executive Committee (EXCOM) 

The Honorable Secretary John M. McHugh 

Secretary of the Army 

Public Sector Co-Chair 

The Honorable Senator Gordon H. Smith 

President and CEO 

National Association of Broadcasters 

Private Sector Co-Chair 

Full Members 

Talitha J. Arnold, MDiv 

Senior Pastor 

United Church of Santa Fe 

Carl Bell, MD 

President and CEO 

Community Mental Health Council 

Director 

Institute for Juvenile Research 

Department of Psychiatry 

School of Medicine 

University of Illinois at Chicago 

Thomas J. Berger, PhD 

Executive Director 

Veterans Health Council for Vietnam 

Veterans of America 

Brian Boon, PhD 

President and CEO 

Commission on Accreditation 

of Rehabilitation 

Robert Certain, DMin 

Rector 

The Episcopal Church of Saint Peter 

and Saint Paul 

David Covington, LPC, MBA 

Vice President 

Adult and Youth Services 

Maricopa County Regional 

Behavioral Health Authority 

Magellan Health Services 

Judy Cushing 

President and CEO 

Oregon Partnership 

Mary Durham, PhD 

Vice President 

The Center for Health Research 

Kaiser Permanente 

Brian Dyak 

President and CEO 

Entertainment Industries 

Council, Inc. 

Saul Feldman, PhD 

Chairman Emeritus 

United Behavioral Health 

David Grossman, MD, MPH 

Medical Director, Preventive Care 

Group Health Research Institute 

McClellan Hall, MA 

Executive Director 

National Indian Youth 

Leadership Project 

Mary Hayashi, MBA 

Eighteenth District 

Chair, Assembly Business, Professions 

and Consumer Protection Committee 

California State Assembly 

Jack Heath 

President and CEO 

Inspire USA Foundation 

Michael Hogan, PhD 

Commissioner 

New York State Office of Mental Health 

Pamela Hyde, JD 

Administrator 

Substance Abuse and Mental Health 

Services Administration 

U.S. Department of Health and 

Human Services 

Robert Jesse, MD, PhD 

Principal Deputy Under Secretary 

for Health 

U.S. Department of Veterans Affairs 

PAGE 157 
Andrew Lane 

Executive Director 

Johnson Family Foundation 

Mary Lou Leary, JD 

Acting Assistant Attorney General 

Office of Justice Programs 

U.S. Department of Justice 

Beverly Malone, PhD, RN, FAAN 

CEO 

National League for Nursing 

Walter A. McNeil, MS 

Chief of Police 

City of Quincy, Florida 

Jamie Moyer 

Co-founder 

Moyer Foundation 

2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


Karen Moyer 

Co-founder 

Moyer Foundation 

The Center for Health Research 

Kaiser Permanente 

Jerry Reed, PhD, MSW 

Vice President and Director 

Suicide Prevention Resource Center 

Education Development Center, Inc. 

Phil Satow, MA 

Representative 

National Council for 

Suicide Prevention 

Paul M. Schyve, MD 

Senior Advisor, 

Healthcare Improvement 

The Joint Commission 

David Theron Smith, MA 

Divisional Vice President, 

Risk Management 

Family Dollar Stores, Inc. 

Joe Sullivan, JD 

Chief Security Officer 

Facebook, Inc. 

Robert W. Turner 

Senior Vice President, 

Corporate Relations 

Union Pacific Railroad 

Eduardo Vega, MA 

Executive Director 

Mental Health Association of 

San Francisco 

Former Members 

Derek Blumke 

Co-founder and Former President 

Student Veterans of America 

Michael Botticelli, MEd 

Director 

Bureau of Substance Abuse Services 

Massachusetts Department of 

Public Health 

Helen Darling, MA 

President and CEO 

National Business Group on Health 

Larry Echo Hawk, JD 

Former Assistant Secretary of 

Indian Affairs 

U.S. Department of the Interior 

Kevin Jennings, MA, MBA 

Former Assistant Deputy Secretary 

for Safe and Drug-Free Schools 

U.S. Department of Education 

Coloradas Mangas 

Ruidoso High School 

Mescalero, New Mexico 

Gordon Mansfield, JD 

Board Member 

Wounded Warriors Project 

Teri Popp, JD 

Advocate 

Laurie Robinson 

Former Assistant Attorney General 

Office of Justice Programs 

U.S. Department of Justice 

David Theron Smith, MA 

Divisional Vice President, 

Risk Management 

Family Dollar Stores, Inc. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION
 


Ex-Officio Members 

Regina Benjamin, MD, MBA 

Surgeon General of the United States 

Office of the Surgeon General 

U.S. Department of Health and 

Human Services 

Thomas Frieden, MD, MPH 

Director 

Centers for Disease Control 

and Prevention 

U.S. Department of Health and 

Human Services 

Kathy Greenlee, JD 

Assistant Secretary for Aging 

Administration on Aging 

U.S. Department of Health and 

Human Services 

Howard K. Koh, MD, MPH 

Assistant Secretary for Health 

U.S. Department of Health and 

Human Services 

Thomas Insel, MD 

Director 

National Institute of Mental Health 

National Institutes of Health 

U.S. Department of Health and 

Human Services 

Yvette Roubideaux, MD, MPH 

Director 

Indian Health Service 

U.S. Department of Health and 

Human Services 

Mary Wakefield, PhD, RN 

Administrator 

Health Resources and 

Services Administration 

U.S. Department of Health and 

Human Services 

PAGE 159 
2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

National Action Alliance for Suicide Prevention Task Forces 

American Indian/Alaska Native Task Force 

McClellan Hall, MA (co-lead); Yvette Roubideaux, MD, MPH (co-lead); Larry Echo Hawk, JD (former co-lead); 

Patrick Anderson, JD; Patrese Atine; Erin Bailey; Dolores Subia Bigfoot, PhD; Sheila Cooper; Kathy Etz, PhD; Jodi 

Gillette, MPP; Megan Gregory; Teresa LaFromboise, PhD; Ron Lessard; Coloradas Mangas; Bill Martin; Debbie 

McBride; Cheryl Peterson, MN, RN; LaShawndra Price, PhD; Jeffrey Schulden, MD; Natasha Singh, JD; Michalyn 

Steele, JD; Rose Weahkee, PhD; Cortney Yarholar, LMSW; and Marilyn Zimmerman, MSW 

Clinical Care and Intervention Task Force 

David Covington, LPC, MBA (co-lead); Mike Hogan, PhD (co-lead); Alan (Lanny) Berman, PhD, ABPP; Ed Coffey, 

MD; Kate Comtois, PhD, MPH; Chris Damle; Laurie Davidson, MA; John Draper, PhD; Shareh Ghani, MD; David 

Jobes, PhD; Christine Ketchmark, PsyD; Richard McKeon, PhD, MPH; Fred Meservey, LMSW; Gary O’Brien, DMin; 

Cindy Padilla; Phil Satow, MA; Paul Schyve, MD; Shannon Skowronski, MPH, MSW; and Heather Stokes, LCSW; and 

the following Magellan staff: Jose Abreu, PhD; Christian Comeau; Holly Dixon, MA, LAC; Gabriella Guerra, MSW; 

Meredith Mechenbier, LAC; Jill Robinson, LCSW; Roni Siebels, MSW; Liz Smithhart, LPC, CPRP, National Certified 

Counselor; and Gayle Tolman 

Clinical Workforce Preparedness Task Force 

Brian Boon, PhD (co-lead); Elise S. Y. Young, LICSW, DCSW, (co-lead); Mariquita Mullan, PhD, MPH (former 

co-lead); Laurie Davidson, MA; Nina Heller, PhD; Alan Holmlund, MSW; Mitch Jewett, RN, CEN, CPEN; Cynthia 

Kane-Hyman, CNS; Linda Kaplan, MA; Bradley E. Karlin, PhD; Susan Keys, PhD; Deborah Klamen, MD, MHPE; 

John Lemich, MA; Richard Lieberman, MA; Lynn Linde, EdD; Brent Longtin, PMHCNS-BS; Erin Mahn; Anthony 

Pisani, PhD; Scott Poland, PhD; Verl Pope, EdD, LPC, NCC, CCMHC, ACS; Lori Rogers, MPA; David Rudd, PhD, 

ABPP; Heather Stokes, LCSW; and Brian Van Brunt, EdD, LPC 

Data and Surveillance Task Force 

Robin Ikeda, MD, MPH (co-lead); Holly Hedegaard, MD, MSPH (co-lead); Jon Roesler, MS (former co-lead); Robert 

Bossarte, PhD; Alex Crosby, MD, MPH; Randy Hanzlick, MD; Regina Seider; Patricia Smith, MS; and Marjorie 

Warner, PhD 

Faith Communities Task Force 

Talitha Arnold, MDiv (co-lead); Robert Certain, DMin (co-lead); Jean Beil, MA, MSW; Dolores Subia Bigfoot, PhD; 

Charles Fogelman, PhD; Kalman Kaplan, PhD; John Livingstone, EdD; Sherry Mollock, PhD; Pamela Ovwigho, PhD; 

Alice Perry, DMin; Wesley Smith, DMin; Elsie Weyrauch, RN; Jerry Weyrauch, MBA; and William Young, DMin, 

LMFT, LPC, CPT 

Lesbian, Gay, Bisexual, and Transgender (LGBT) Populations Suicide Task Force 

Andrew Lane (co-lead); Mikel L. Walters, PhD (co-lead); David McFarland (former co-lead); Kevin Jennings, MA, 

MBA (former co-lead); Charles Robbins (former co-lead); Alan Acosta, MS; Amy Andre, MBA, MA; Kellan Baker, 

MPH, MA; Michael Botticelli, MEd; Thomas Bourdon; Eliza Byard, PhD; Michelle Carnes, PhD; Sylvia Fisher, PhD; 

Byron Garrett, MA; Ann Haas, PhD; David Kilmnick, PhD, MSW; Effie Malley, MPA; Nancy Martine-Alonzo; Henry 

Ng, MD; Kathleen O’Leary, MSW; Philip A. Rutter, PhD; Caitlin Ryan, PhD; Lance Toma, MA; and Garrett and 

Angela Wedel 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Military/Veterans Task Force 

Jan Kemp, PhD, RN (co-lead); Maggie Haynes LaRocca, MA (co-lead); Donna Barnes, PhD; Alan (Lanny) Berman, 

PhD, ABPP; Derek Blumke; Sean Clark, JD; Judy Cushing; Jackie Garrick, LCSW-C, BCETS; Courtney Knowles; 

Chaplain (Colonel) William Sean Lee, DMin, BCC; Gordon Mansfield, JD; Robert Mays, Jr., PhD, MSW; Ken Norton, 

MSW, LICSW; Teri Popp, JD; A. Kathryn Power, MEd; Jonathan Pruden, MPS, Captain, USAF (Ret.); Kim Ruocco, 

MSW; and Eileen Zeller, MPH 

Public Awareness and Education Task Force 

Jack Benson, MBA (co-lead); Brian Dyak (co-lead); Joe Sullivan, JD (co-lead); Mark Weber, MBA (co-lead); Monika 

Bickert, JD; Derek Blumke; Adam Conner; Anne Marie Cumming; Judy Cushing; Jeff Edwards; John Griffiths; Mary 

Hayashi, MBA; Jack Heath; Courtney Knowles; Gary Kreps, PhD, FAAHB; Alison Kreutzans; Richard Lieberman, 

MA; Wayne Lynch, MA; Karen Moyer; Teri Popp, JD; Dan Reidenberg, PsyD, FAPA; Mark Roth; Jason Rzepka; Nedra 

Weinreich, MS; Terry Wise, JD; and Fred Wolens 

Research Prioritization Task Force 

Thomas Insel, MD (co-lead); Phillip Satow, MA (co-lead); Alan (Lanny) Berman, Ph.D, ABPP; Mary Durham, PhD; 

Saul Feldman, PhD; Thomas Friedan, MD, MPH; Robert Gebbia, MA; David Grossman, MD, MPH; Michael Hogan, 

PhD; Daniel Reidenberg, PsyD, FAPA; NIH support: Jane Pearson, PhD; Cynthia Claassen, PhD; Beverly Pringle, 

PhD; Joel Sherrill, PhD; Robert Heinssen, PhD, ABPP; Belinda Sims, PhD; Liza Bundesen, PhD; David Zielinski, 

PhD; Keisha Shropshire, MPH, CHES; Yancy Bodenstein, MS, MPH; Anne Sperling, PhD; Gemma Weiblinger, MA; 

Rex Robison, PhD; Janet Heekin, MLS; Sherry Davis Molock, PhD, MDiv; Chelsea Booth, PhD; Task Force Liaisons: 

Alex Crosby, MD, MPH (Data and Surveillance Task Force); Denise Juliano-Bult, MSW (Youth in Contact with 

the Justice System Task Force); Ira Katz, MD, PhD (National Strategy Revision/Update Task Force); Barbara Tatem 

Kelley, MA, MEd (Youth in Contact with the Justice System Task Force); Robert Mays, PhD (Military/Veterans Task 

Force); and Kathleen M. O’Leary, MSW (LGBT Populations Task Force) 

Suicide Attempt Survivors Task Force 

John Draper, PhD (co-lead); Eduardo Vega, MA (co-lead); Chris Marshall (former co-lead); Heidi Bryan; Julie Cerel, 

PhD; Mark Davis, MA; Larry Fricks; Leah Harris, MA; DeQuincy Lezine, PhD; Edward Knight, PhD; Angela Mark; 

Lyn Morris, MFT; Shari Sinwelski, MS, EdS; and Stephanie Weber, MS 

Survivors of Suicide Loss Task Force 

Joanne Harpel, JD, MPhil (co-lead); Karen Moyer (co-lead); Larry Berkowitz, EdD; Julie Cerel, PhD; Franklin Cook, 

MA; John (Jack) R. Jordan, PhD; Michelle Linn-Gust, PhD; Doreen S. Marshall, PhD; Vanessa McGann, PhD; John 

McIntosh, PhD; Robert Neimeyer, PhD; Ken Norton, LICSW; Naomi Powell; and Sally Spencer-Thomas, PhD 

Workplace Task Force 

Beverly Malone, PhD, RN, FAAN, MA (co-lead); Helen Darling, MA (former co-lead); David Theron Smith, MA 

(former co-lead); Bob Anadell; Calvin Beyer, DBA, MPA; Connie DiCocco, MEd; Bernie Dyme AM, LCSW; Ron 

Finch, EdD; Ben Harrington, MA; Paul Heck, MEd; Jodi Jacobson, PhD; Patricia (Tricia) Kagerer, MA; Jungyai Ko, 

MSSA; Clare Miller; John Morrissey; Rich Paul, MSW; Alma Petrovic, MD, MPH; Adrienne Selko; Elizabeth Smith; 

Sally Spencer-Thomas, PsyD; and Bob VandePol, MSW 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Youth in Contact With the Juvenile Justice System Task Force 

Joe Cocozza, PhD (co-lead); Melodee Hanes, JD (co-lead); Laurie Robinson (former co-lead); Donald Belau, PhD; 

Mari Kay Bickett, JD; Laurie Garduque, PhD; Robert Glover, PhD; Thomas Grisso, PhD; Lindsey Hayes, MS; Larke 

Huang, PhD; Denise Juliano-Bult, MSW; Ned Loughran; Shawn Marsh, PhD; Roy Praschil; Jeff Slowikowski, MPA; 

Deb Stone, ScD, MSW, MPH; Linda Teplin, PhD; Eric Truplin, PhD; Carl Wicklund; and David Devoursney, MPP. 

Task Force support staff include: Karen Stern, PhD; Kathleen Skowyra; Steffie Rapp, LCSW-C; Kara McDonagh, 

MSW, LGSW; Barbara Kelley, MA, Med; Simon Gonsoulin, Med; and Nick Read, MA 

Other Contributors 

Writers of Appendix D: Groups With Increased Suicide Risk 

American Indians/Alaska Natives: Petrice Post, MA; Ellyson Stout, MS; and Cortney Yarholar, LMSW 

Individuals Bereaved by Suicide: John (Jack) Jordan, PhD 

Individuals in Justice and Child Welfare Settings: Lindsay Hayes, MS; Jason H. Padgett, MPA, MSM; and 

Katherine Wootten Deal, MPH 

Individuals Who Engage in Non-Suicidal Self-Injury: Morton Silverman, MD 

Individuals Who Have Attempted Suicide: Eduardo Vega, MA 

Individuals with Medical Conditions: Morton Silverman, MD 

Individuals with Mental and Substance Use Disorders: Morton Silverman, MD; and Michael Botticelli, MEd 

Lesbian, Gay, Bisexual, and Transgender (LGBT) Populations: Ann Haas, PhD; Andrew Lane; and Effie 

Malley, MPA 

Members of the Armed Forces and Veterans: Leonard Litton, III, Colonel (Ret.); Ira Katz, MD, PhD; and Jan 

Kemp, RN, PhD 

Men in Midlife: John R. Blosnich, PhD, MPH; and Eric Caine, MD 

Older Men: Yeates Conwell, MD; and Alisa O’Riley, PhD 

Community-Based Workshop Participants 

Robert Anderson, PhD; Catherine Barber, MPA; Don Belau, PhD; Carl Bell, MD; Robert Bossarte, PhD; Ryan
 


Breshears, PhD; Heidi Bryan; Eric Caine, MD; Donna Carender, MS; Yeates Conwell, MD; Lisa Colpe, PhD; 
 

Katherine Wootten Deal, MPH; Mark Evans, PhD; Barri Faucett, MA; Amy Fiske, PhD, CBSM; Ann Haas, PhD; 
 

Katherine Hempstead, PhD; Jeff Inman, MS; Sean Joe, PhD; Ira Katz, MD, PhD; Jan Kemp, PhD, RN; Marilyn 
 

Koenig; Lesley Levin, LCSW; Gary McConahay, PhD; Richard McKeon, PhD; Doreen S. Marshall, PhD, LPC; 
 

Elaine de Mello, LCSW; Matthew Miller, MD, MPH, ScD; Jason H. Padgett, MPA, MSM; Rich Paul, MSW; Richard 
 

Ramsay, MSW, RSW; Jerry Reed, PhD, MSW; Dan Reidenberg, PsyD, FAPA; Scott Ridgway, MS; Karl Rosston, LCSW; 
 

Jeremiah Simmons; Pat Smith, MS; and Hyong Un, MD
 


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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

Listening Session Contributors 

Garrett Lee Smith Memorial Act/SAMHSA Campus Grantee Meeting (January 26, 2011)
 


Garrett Lee Smith Memorial Act/SAMHSA State/Tribal Grantee Meeting (February 17, 2011)
 


Behavioral Health Subcommittee at the Legislative and Policy Conference of the National Association of
 


County Behavioral Health and Developmental Disability Directors, held in association with the spring meeting 
 

of the National Association of Counties (March 5, 2011)
 


Department of Defense, Department of Veterans Affairs Suicide Prevention Conference (March 16, 2011)
 


Annual Conference of the American Association of Suicidology (April 14, 2011)
 


National Council for Community Behavioral Healthcare Conference (May 2, 2011)
 


Other Reviewers 

Ella Arensman, PhD, MSc; Deborah, Azrael, PhD; Cathy Barber, MPA; David W. Fleming, MD; David Grossman, 

MD, MPH; Jeff Levi, PhD; Lars Mehlum MD, PhD; Matthew Miller, ScD; Paul Quinnett, PhD 

Staff Support 

Maryland Arciaga; Emily Barocas; Colleen Carr, MPH; Renata Casiel; Katherine Wootten Deal, MPH; Ingrid Donato; 

Magdala Labre, PhD, MPH; Liz Lebreton, MPH; David Litts, OD; Liliya Melnyk; Chris Miara, MS; Jason H. Padgett, 

MPA, MSM; Laurie Rosenblum, MPH; and Xan Young, MPH 

We also would like to acknowledge the important contributions of the numerous individuals 

who provided input and public comments throughout the revision process. 

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2012 NATIONAL STRATEGY FOR SUICIDE PREVENTION 

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