National Strategy for Suicide Prevention:
Goals and Objectives for Action

CHAPTER 12:
Looking Ahead

Designed to encourage and empower groups and individuals to work together, the National Strategy for Suicide Prevention creates a frame-work for suicide prevention for the Nation. The stronger and broader the support and collaboration, the greater the chance for the success of this public health initiative. Suicide and suicidal behaviors can be reduced as the general public gains more understanding about the extent to which suicide is a major public health problem, about the ways in which it can be prevented, and about the roles individuals and groups can play in prevention efforts.

The National Strategy is comprehensive and sufficiently broad so that individuals and groups can select those objectives and activities that best fit their interests, constituencies and resources. The plan's objectives suggest a number of roles for different groups. Individuals representing a variety of occupational fields such as health care, social work, education, law and faith-based care should be involved in implementing the plan. Institutions such as community groups, religious organizations, and schools all have a necessary part to play. Sites for suicide prevention work include jails, emergency departments, and the workplace. The survivors, consumers and the media need to be partners as well. State and local governments are key players, as is the Federal government, whose role is to judiciously provide funding for research and programs that protect and enhance the health and well-being of their citizens.

Ideally, the National Strategy will motivate and illuminate. But for the NSSP to have any effect, people need to use it as a guideline to develop their own priorities. The National Strategy can serve as a model that can be adopted or modified by States, communities, and tribes as they develop their own suicide prevention plan. The information on evidence-based strategies included in this document can help. The

National Strategy

The knowledge base about suicide and suicide prevention remains incomplete. Research resulting in the acquisition of new knowledge must continue to contribute by suggesting new strategies and approaches. Evaluation activities must be incorporated into all prevention efforts to ensure ongoing monitoring and refinement.

In the last decade, suicide prevention efforts have received renewed support from Federal and private sources. Most of these efforts have taken the form of educational campaigns and development of health education modules for school systems. The pharmaceutical industry has developed new medications to treat mental and substance use disorders that are often associated with suicidal behavior and there is promising evidence that these medications do reduce suicidal behaviors among those who receive them in therapeutic doses over sufficient time (Jamison & Baldessarini, 1999; Meltzer & Okayli 1995). However, patients may also need non-pharmacologic interventions to reduce their risk for suicidality.

Educational institutions have increased their training in prevention sciences and health promotion. However, the courses offered may not specifically address suicide, suicidal behaviors, mental health services, or the prevention of mental or substance use disorders. New advances in therapeutic modalities such as cognitive behavioral therapy, dialectical behavioral therapy, and interpersonal psychotherapy, hold promise for reducing suicidal behaviors in those individuals at risk (Hawton et al., 1998). Renewed attention has focused on building social and interpersonal competencies as protective factors against mental disorders (Mrazek & Haggerty, 1994). Systemic interventions, such as the Air Force Suicide Prevention Program, have made an impact (Litts et al., 1999). Nevertheless, access to these quality programs is not universal and not all mental health centers or substance abuse treatment facilities have the available expertise to offer these interventions.

Implementing a national suicide prevention strategy successfully requires overcoming some specific obstacles and barriers. Some are well-known to the prevention field in general, such as the real dilemma of allocating scarce human and monetary resources among the many deserving health-related prevention programs. Acquiring and maintaining appropriate levels of public and private funding for suicide prevention efforts can be a challenge. The potential impact on local, state, and federal budgets must be carefully considered.

Another obstacle is the argument that prevention is a luxury and funds should be allocated instead to treatment, which is of the moment. Both are important and necessary and public health efforts work more effectively when these components operate in unison. In an oftcited metaphor, prevention is likened to the work of posting warnings and constructing protective railings at the river's edge, while treatment is seen as the work of pulling those who have fallen in and cannot swim from the cold waters. There will always remain a role for both kinds of work. One goal of prevention is to prevent those at risk from "drowning," because the treatment programs cannot always keep pace with the demand for services.

Another challenge to overcome is the institutional tendency towards short-term and isolated prevention planning. Because effective prevention efforts may take years to show true benefits, instituting plans in 2- to 5-year increments may not permit prevention efforts to come to fruition. Additionally, suicide prevention goals and objectives must be woven into the fabric of community and local human services, training, and education. Standing alone, suicide prevention efforts fail to benefit from the resources, experience and community acceptance of established programs and services. There are challenges and complexities surrounding priority setting, data collection, measurement of progress, resource allocation and programmatic refinement over time.

Probably the greatest challenge to the successful implementation of a national suicide prevention strategy comes from the twin nemeses of stigma and disparity: the societal stigma associated with mental illness, substance abuse, and suicidal behaviors, and the current disparity in access to mental health and substance abuse care compared to other forms of health care. Taken together, these two threats–one of psychological and cultural origins, the other due to organizational and economic roadblocks–represent a formidable twin obstacle. Overcoming them must engage the energies, political will and creativity of all members of society.

Collaboration is a keystone of the National Strategy. There is in our Nation a tremendous human resource potential of volunteer and grassroots advocates who are committed to advancing suicide prevention efforts. Many groups and individuals have been involved in developing the plan's goals and objectives and as activities for implementing the plan are developed, many others will be called upon to lend their support. The involvement of a diverse group of participants will lead to the formation of partnerships for successful implementation. Everyone must be involved for the plan to succeed and for the suicide rate to be reduced.

Decisions about which diseases and conditions should receive the most attention are difficult and complex. Opportunities arise only so often to capture the spirit and attention of the public around a particular public health problem. The momentum and activity focused in the last few years on suicide and suicidal behaviors suggest that the time is right for bold and concerted movement forward with suicide prevention efforts.

Beyond the written plan presented in this document, the National Strategy for Suicide Prevention encompasses the development, promotion and support of programs that will be implemented in communities across the country. These activities are designed to achieve significant, measurable, and sustainable reductions in suicide and suicidal behaviors. This requires a major investment in public health action. For any preventive action to go forward, three ingredients are necessary: a knowledge base, the public support for change, and a social strategy to accomplish change (Atwood, Colditz, & Kawachi, 1997). The next steps for the NSSP recognize that each ingredient is dependent upon the other, and that balance among all three must be achieved to make progress.

A significant step is to develop an operating structure or coordinating body for the National Strategy that reflects the essential need for a public/ private partnership. Public (for instance Federal, State, and local officials) and private sector representation would guide public action. Private sector representatives would include business, voluntary organizations, survivor groups, faith-based groups, professional associations, and the media. The coordinating body, with defined responsibility, funding, authority, and accountability for its work, would be the national focus for prevention activities and would provide a mechanism for engaging public will.

Development of an action agenda, complete with specific activities defined for national, state, and community partners would ideally be shepherded by the coordinating body although to expedite progress, development of a coordinating body and an action agenda may proceed in tandem. When stakeholders participate in the development of prevention activities, political will is generated for the resources to accomplish them. Moreover, bridging the knowledge and practice communities in this way leads to sound prevention activities applicable to specific cultures. Some activities will be directed towards critical expansion of the knowledge base with, for example, the addition of translational research connecting advances in neuroscience to "active preventive interventions" (e.g., biological, social, psychological) that lower the risk of suicide, of applied research that carries prevention science into community action, and of research on program evaluation. This knowledge continuum supports development of practice guidelines for all disciplines and sectors engaged in suicide prevention.

Ideally, objectives are measurable; that is, one is able to follow some essential piece of information associated with the stated objective. This information, known as a benchmark, or indicator, permits one to quantify the achievement of a result. For instance, in Objective 3.1 the benchmark (indicator) is the proportion of the public that views mental and physical health as equal and inseparable components of overall health. Thus, to track success in achieving an objective it is required to have identified at least one benchmark, a baseline (the measurement of the benchmark from which change will be assessed) and a target (the number or percentage change desired in the benchmark). Not all objectives require benchmarks to determine if the Nation has achieved them. Policy and organizational objectives (see Objective 2.2) can often be deemed accomplished simply by the fact of their having been established. Benchmarks can be a commonsense way to communicate to the public the value of their investment in suicide prevention activities. By measuring the same benchmark over time, one may determine the amount and direction of change towards fulfilling the objective. In this way, benchmark measures can guide decision making by providing information about the success or failure of efforts that are being applied in support of a particular objective.

Each objective in the U.S. National Strategy is potentially, if not practically, measurable. For some objectives, benchmark data may already exist or its collection will be straightforward. For others, benchmarks have not yet been identified or collecting information on the benchmark may just not be practical at this time. For most of the objectives in Goals and Objectives for Action, no baseline benchmark data has yet been established. Without this baseline information, it is difficult to set a numerical target for change, since it is not clear just how much progress should be expected by the year 2005. Developing appropriate indicators, determining baseline measures and establishing a benchmarking system for National Strategy progress is a key next step.

Plans are already underway to launch the National Strategy for Suicide Prevention website <http://mentalhealth.samhsa.gov/suicideprevention> and document clearinghouse so that the available knowledge can be in the hands of those who will be can use it for effective decision-making in suicide prevention. The website/clearinghouse will provide electronic linkages among partners involved in the NSSP to support their collaboration and progress. It will provide up-to-date information that can help shape public will.

Now is the time for making great strides in suicide prevention. Implementing this National Strategy for Suicide Prevention provides the means to realize success in reducing the toll of this serious public health problem. The work ahead can extend public and private collaboration to sustain action on behalf of all Americans because suicide prevention is truly everyone's business.

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