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Office of the Surgeon General (US); National Action Alliance for Suicide Prevention (US). 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. Washington (DC): US Department of Health & Human Services (US); 2012 Sep.

Cover of 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action

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.

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Introduction

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 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.

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 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 pages 12 and 13. 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.

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.

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) 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.1012 Because these factors can vary between individuals and across settings, the examples listed in the figure are not comprehensive.

Key Terms

  • Affected by suicide. All those who may feel the effect of suicidal behaviors, including those bereaved by suicide, community members, and others.
  • 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.
  • Bereaved by suicide. Family members, friends, and others affected by the suicide of a loved one (also referred to as survivors of suicide loss).
  • Means. The instrument or object used to carry out a self-destructive act (e.g., chemicals, medications, illicit drugs).
  • Methods. Actions or techniques that result in an individual inflicting self-directed injurious behavior (e.g., overdose).
  • Suicidal behaviors. Behaviors related to suicide, including preparatory acts, suicide attempts, and deaths.
  • Suicidal ideation. Thoughts of engaging in suicide-related behavior.
  • 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.

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.

picture of an ecological model sample

EXAMPLES OF RISK AND PROTECTIVE FACTORS IN A SOCIAL ECOLOGICAL MODEL

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

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

The Prevalance of suicide Behaviors by year - Graph

UNITED STATES SUICIDE RATES, 1950–2009

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).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.

picture of United States map showing age-adjusted suicide rates

AGE-ADJUSTED SUICIDE RATES PER 100,000 POPULATION BY STATE, UNITED STATES, 2009 NATIONAL AGE-ADJUSTED RATE, 2009: 11.77

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

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

Difference amoung groups by age group in years - Graph

SUICIDE RATES BY AGE GROUP AND SEX UNITED STATES, 2009

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.2123

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

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.)

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.3335 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.

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:

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.

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).

Picture of the National Prevention Allicance for Suicide Prevention Organizational Chart

NATIONAL ACTION ALLIANCE FOR SUICIDE PREVENTION ORGANIZATIONAL CHART

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 below) 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.

Key Documents Informing the Revision

  • National Prevention Strategy, National Prevention, Health Promotion, and Public Health Council, 2011
  • HealthyPeople 2020, U.S. Department of Health and Human Services, 2010
  • Charting the Future of Suicide Prevention, SPRC and SPAN USA, 2010
  • Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities, IOM, 2009
  • Reducing Suicide: A National Imperative, IOM, 2002
  • World Report on Violence and Health, WHO, 2002
  • Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies, UN, 1996

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 injury- and 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.

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
Picture of organization of goals and objectives with three strategic directions.

ORGANIZATION OF GOALS AND OBJECTIVES

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 below).

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 increased suicide risk.

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:

  • Foster positive public dialogue; counter shame, prejudice, and silence; and build public support for suicide prevention;
  • Address the needs of vulnerable groups, be tailored to the cultural and situational contexts in which they are offered, and seek to eliminate disparities;
  • Be coordinated and integrated with existing efforts addressing health and behavioral health and ensure continuity of care;
  • Promote changes in systems, policies, and environments that will support and facilitate the prevention of suicide and related problems;
  • Bring together public health and behavioral health;
  • Promote efforts to reduce access to lethal means among individuals with identified suicide risks; and
  • 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 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 below). 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 below) suggests that this type of approach has a tremendous potential for saving lives.

ACTION ALLIANCE PRIORITY AREAS: 2012–14

Priority AreaNational Strategy Objective(s)Implementation
1. Integrate suicide prevention into health care reform and encourage the adoption of similar measures in the private sector.Objective 1.5: Integrate suicide prevention into all relevant health care reform efforts.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.
2. Transform health care systems to significantly reduce suicide.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.Promote the adoption of “zero suicides” as an organizing goal for clinical systems care for defined populations. Recruit early adopters to implement the Suicide Care in Systems framework within their respective organizations and highlight successful programs.
3. Change the public conversation about suicide and suicide prevention.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.
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.
4. Increase the quality, timeliness, and usefulness of surveillance data regarding suicidal behaviors.Objective 11.1: Improve the timeliness of reporting vital records data.
Objective 11.2: Improve the usefulness and quality of suicide-related data.
Work with CDC to improve the quality, timeliness, and usefulness of the data collected and to expand existing data systems.

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.

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.

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.

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