Abstract
The science of suicide risk and prevention is growing, making one thing very clear. While suicide risk involves a complex set of risk factors, the end common pathway is a life-threatening health crisis. As is the case with all health-related causes of death, a robust public health strategy can reduce mortality. This chapter provides a framework for understanding the public health approach to preventing suicide. Examples of effective public health suicide prevention strategies at national and regional levels are provided.
Quick Check
A Introduction
The science of suicide risk and prevention is growing, making one thing very clear. While suicide risk involves a complex set of risk factors, the end common pathway is a life-threatening health crisis. As is the case with all health-related causes of death, a robust public health strategy can reduce mortality. This chapter provides a framework for understanding the public health approach to preventing suicide. Examples of effective public health suicide prevention strategies at national and regional levels are provided.
B Principles
As is the case with all complex health problems, a robust public health strategy can reduce suicide mortality.
The public health model is a multi-tiered approach including universal education and health promotion, selective and targeted prevention, and treatment and recovery.
Successful suicide prevention programs have been carried out at the national level as well as at local community levels.
Examples of suicide prevention efforts that have reduced suicide rates include a program in New Mexico focused on American Indian youth, a US Air Force Program, a province-wide program in Québec, a classroom management program for kindergarteners and first graders, and the Garrett Lee Smith Memorial Grants in the USA.
National suicide prevention programs with full scale implementation that have proven successful include those in Finland, Norway, Sweden, and Australia.
In addition to community level prevention, healthcare settings have a critical role to play in preventing suicide. This includes behavioral healthcare, primary care, and all healthcare settings.
Language related to suicide is important, to be in line with science-informed ideas, to correct myths, and to be respectful of people with lived experience and/or loss. Language tips are provided.
C The Public Health Approach to Suicide Prevention
Figure 3.1 Public health approach
Optimal results are achieved with a multi-layered approach to achieve health outcome goals, including suicide prevention. When health promotion and prevention tactics at all levels are strategic and sustained, and when treatment and recovery resources are well developed and accessible to the population, the opportunity to reduce suicide mortality is optimized.1
Why Universal Education Matters for Suicide Prevention
When community members share a basic common knowledge about a health issue, stigma is reduced and family members, schools, and workplaces are able to apply that knowledge to their daily lives and work in several ways: to build healthier families and communities, to recognize risk when present, and to lead at-risk individuals to seek medical/professional evaluation and treatment.
Examples of Mental Health Education Campaigns
Health promotion for suicide prevention includes pro mental health ad campaigns such as SeizeTheAwkward (developed by the Ad Council, the American Foundation for Suicide Prevention (AFSP), and the Jed Foundation), #RealConvo (AFSP), and #BeThe1To (Lifeline), which teach basic principles of the importance of communicating about mental health needs both for oneself and with others.
Prevention strategies can target three levels for suicide prevention: universal (e.g., resilience and mental health promotion, safe media messaging, lethal means reduction, increased access to support/mental health services), selective (e.g., screening programs, training for specific roles who work with subsets of the population – teachers, corrections professionals, health providers), and indicated (e.g., intervention for those whose risk is detected, case management, skills training for high risk groups).
You as a health professional have a role to play in preventing suicide at all spokes of the wheel of prevention and intervention. By speaking out, educating patients and families about mental health and suicide prevention, you are serving as an effective mental health educator/promoter. By screening patients for mental health and suicide risk or facilitating a support group for at-risk LGBTQ youth, you are doing selective prevention. When you treat patients for depression, anxiety, PTSD, eating disorders, and addiction, you are doing targeted prevention. And when you hone in on suicidal thoughts and provide specific care steps outlined in Chapters 6–8, you are providing risk reducing treatment. When you follow up with patients and continue to check in and provide support, and help the family know how to provide support after a suicidal crisis has resolved, you are participating in patients’ recovery.
D Examples of Universal Prevention through Programs in Schools and Communities
Implementing key strategies across an entire population (universal) can drive down suicide rates.1 Suicide prevention efforts are therefore critically important at regional and national levels. In addition to effective healthcare showing evidence for reducing suicide risk, other types of interventions at the community level have found promising results for reducing suicide risk.
Model Adolescent Suicide Prevention Program for American Indian Youth in New Mexico: reduced the number of adolescent suicide attempts by an astonishing 80% between 1988 and 2002, using lay education, trained peers, and referral to counseling.2 Psychiatric conditions often have their onset early in the life cycle, with 50% of all mental illness manifesting prior to age 14. So identifying mental health conditions in children and adolescents and ensuring that effective and ongoing treatment is provided, or ways to reduce the morbidity and mortality, are examples of a critical approach to reducing the morbidity and mortality associated with mental illness, including preventing suicide risk in youth or later life.
Sources of Strength shifted schoolwide coping and help seeking norms and improved students’ perceptions of adult availability using student “peer leaders” to deliver messaging and conduct prevention activities to enhance healthy coping and help seeking norms.3
Wingman-Connect: US Air Force.4 A universal intervention that focuses on building protective factors among classes of young enlisted personnel was rigorously evaluated in technical training school. Airmen in Wingman-Connect trained classes reported significantly lower suicide and depression scale scores one month after training, and after six months the likelihood of a trainee reporting elevated risk for suicidal thoughts and behaviors was 19% lower, just outside of conventional statistical significance (p = .067). Wingman-Connect is, to our knowledge, the first prevention training evaluated through a randomized controlled trial (RCT) that reduced risk for suicidal thoughts/behaviors and depression in a general Air Force population.
A trend analysis in the US Air Force Suicide Prevention Program showed that suicide rates of Air Force members decreased by 33% between 1996 and 2004 while a comprehensive program was enacted to educate all levels of the force on warning signs and help seeking. Rates in the US population were also decreasing during that time, so it is not clear that the change was due to the program but the results were encouraging.5
Help for Life Program, Québec, Canada: A multi-pronged approach involving 40 organizations in Québec to carry out a province-wide prevention strategy, including media, training, and youth referrals to mental healthcare; 33% reduction in province suicide rate from 1999 to 2012.6
The Good Behavior Game: a universal classroom behavior management method, tested in first- and second-grade classrooms in inner city Baltimore, Maryland beginning in the 1985–1986 school year. Follow-up at ages 19–21 found significantly lower rates of drug and alcohol use disorders, regular smoking, antisocial personality disorder, delinquency, and incarceration for violent crimes, and >50% less prevalence of suicidal ideation among students who had been in classes using the Good Behavior Game method.7
Figure 3.2 Examples of effective national rate reductions
Trends in male suicide rates in four nations with national suicide prevention plans implemented and sustained over five years versus males in four control countries without a national prevention plan.
E Examples of National Suicide Prevention Programs that reduced rates
A study of four countries (Finland, Norway, Sweden, and Australia) with full scale implementation of national suicide prevention plans compared the trends in suicide rates over the years before and after plan launch, with four control countries without such plans (Canada, Austria, Switzerland, and Denmark), matched for factors such as culture, religion, population, and surveillance of suicide rates. This analysis found a reduction in suicide rates especially among the adult male populations of the countries with suicide prevention plans compared with the countries without plans.8 Strategies in suicide prevention plans for these nations include a public health approach utilizing universal education about mental health, suicide risk factors, and warning signs, and resources for support, crisis level support, and mental healthcare. Additionally efforts to optimize engagement of high risk populations, shore up crisis services, and enhance suicide prevention within healthcare settings with a focus on screening and continuity across transitions of care are common approaches.
F Youth Suicide Prevention Advocacy Initiative that Reduced Rates
Evidence for Suicide Reduction with Universal and Selective Prevention
Another powerful example of evidence for the effectiveness of universal and selective suicide prevention programming is the Garrett Lee Smith (GLS) Memorial Act grant, which has funded youth suicide prevention activities in the USA since 2004 on college campus, community, and tribal settings in many states. Over a 15-year period, a large portion of counties in the USA received financial support to engage in youth suicide prevention initiatives including outreach, awareness raising, screening, “gatekeeper” training (meaning training for key front-line roles to recognize risk and act), developing coalitions, policies/protocols, and supporting crisis support hotlines. A total of 40% of GLS grants are awarded in rural areas of the USA where suicide rates are higher and where resources for programs and clinical treatment tend to be much lower. In a major evaluation study, counties with GLS activities were compared with control counties unexposed to GLS programs (matched for demographic characteristics, race/ethnicity make-up, median household income, unemployment rates, and suicide rates of youth and adults), and significant reductions were found both for short- and longer-term impact on suicidal behaviors and suicide deaths. The positive effect was greatest in rural areas of the USA.9
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