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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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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 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 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.

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.7477 Individuals who own firearms are not more likely than others to have a mental disorder or have attempted suicide.7880 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 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 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;
  • 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;
  • 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 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.

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

State, Territorial, Tribal, and Local Governments Can

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

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)
  • 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)

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