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 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 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.

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.

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 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.

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 community 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. 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.

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 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.