National Strategy for Suicide Prevention:
Goals and Objectives for Action

GOAL 4:
Develop and Implement Community-Based
Suicide Prevention Programs

Research has shown that many suicides are preventable; however, effective suicide prevention programs require commitment and resources. The public health approach, as described in the Introduction, provides a framework for developing preventive intervention programs: clearly define the problem, identify risk and protective factors, develop and test interventions, implement programs that are based on local needs, and evaluate effectiveness. Programs may be specific to one particular organization, such as a university or a community health center, or they may encompass an entire State. While other goals in the National Strategy address interventions to prevent suicide, a special emphasis of this goal is that of ensuring a range of interventions that in concert represent a comprehensive and coordinated program and of fostering planning and program development work.

The methodological problems inherent in conducting suicide prevention research have led to the current situation, in which considerably less is known about effective programs than is desirable; nevertheless, some interventions have proven effective and others appear promising but, are in need of evaluation (Silverman & Felner, 1995). The term "evidence-based" is often used to suggest the importance of implementing those interventions that have scientific evidence of effectiveness. The Introduction presents a matrix that can assist in program planning by clarifying the group(s) targeted for intervention and the focus of interventions– biopsychosocial, environmental, or sociocultural. Appendix C includes information on some interventions currently in progress that are, or could be evaluated.

The objectives established for this goal are designed to foster the implementation of suicide prevention interventions, especially through organizations and agencies that have access to groups of individuals for other purposes. The objectives also address the need for systematic planning at both the State and local levels, the need for technical assistance in the development of suicide prevention programs, and the need for ongoing evaluation.

Suicide prevention is a complex problem. It intersects public health (especially injury prevention), mental health, and substance abuse; it requires commitment from education, justice, and social services; and it requires the commitment of various private sector groups, including business and labor. Effective programming requires collaboration and coordination of the State and local agencies that deliver services in these three arenas, as well as mobilization of the private sector. The planning process itself can help States and local jurisdictions accomplish a variety of activities that will help to prevent suicide: bring together partners who each play a role in solving the problem; raise awareness of suicide; develop a comprehensive approach to suicide prevention; and ensure that the most current research is employed in developing strategies. At a minimum, the plan should include an assessment of the problem, including a statistical analysis of suicide in the State and its communities; goals, objectives, and timetable; and actions to be taken. State plans may include resources for local communities, such as task force recommendations and screening tools (Children's Safety Network, 2000). It may help communities address the local issues important in suicide prevention; for example, the suicide rate is affected by community norms and cultural values, and suicide rates vary with such factors as percent of the population residing in rural areas and the ethnic composition of the population. A plan implies a locus of responsibility and appropriate resources to carry it out. Both State and local leadership are needed for suicide prevention planning and implementation.

Considerable attention has been devoted to youth suicide prevention. In 1985, a bill was introduced into the House of Representatives to provide funding to States to address youth suicide. Though the bill was not enacted into law, many States did engage in suicide prevention planning. However, during the early 1990s, suicide prevention programs and plans in some States were discontinued and allowed to lapse (Metha et al., 1998). Regional conferences for States were sponsored by the Health Resources and Services Administration in the mid-1990s to encourage renewed State planning for youth suicide prevention, and the National Suicide Prevention Conference held in Reno, Nevada, in 1998 also spurred interest in State-level planning for suicide prevention across the life span. While a number of States currently have suicide prevention plans, few are comprehensive and the plans do not uniformly link public health, mental health and substance abuse programs (Metha et al., 1998; West, 1998). Moreover, not all address the entire life span and few involve all key stakeholders, such as education, justice, social services, and the private sector.

Most school-based suicide prevention efforts are curriculum-based, with a focus on increasing awareness of the problem of adolescent suicide, identifying adolescents at risk, and teaching referral techniques and resources. In 1996, the New Zealand Department of Education developed and published a guide for schools that summarizes the literature on school-based programs and recommends improving the awareness of teachers and other adults about issues related to youth suicide and suggests a tiered structure of counseling for students identified by these adults as at risk of suicide (Beautrais et al., 1997; Ministry of Education, 1998). Limited evaluation of curriculum-based programs has found minimal increases in knowledge, that attitudes towards suicide remain unchanged, or that attitudes have changed in negative ways (Garland & Ziegler, 1993; Hazell & King, 1996). Yet, given the nature of our current knowledge, it is premature to dismiss curriculum-based efforts in suicide prevention, though prudence is clearly indicated.

Efforts concentrating on teaching youth to identify the warning signs of suicide in themselves and their peers may not be effective, since prior research has found that suicidal youth are not likely to self-refer or seek help from school staff, nor do knowledgeable peers request adult help (Kalafat & Elias, 1995). This suggests that schools should screen for youth at risk and that school staff need to be trained and aware of the warning signs for suicidal youth and have a plan of action for helping those at risk.

An alternative approach to school-based efforts that focus on suicide prevention is to target risk and protective factors that occur earlier in the pathways to suicide, and to also consider specific needs and subcultures of the school population (e.g., gay and lesbian youth) (McDaniel et al., 2001). For example, there are many proven prevention programs that reduce substance use and aggressive behavior by teaching techniques in problem solving and building positive peer relations (see Appendix C). When implemented effectively, these programs have the potential for reducing risk for suicide simultaneous with other negative outcomes, in this case substance use and aggressive behavior.

Suicide is the third leading cause of death among the U.S. college-aged population. Among adults, those aged 18-24 have the highest incidence of reported suicide ideation (Crosby et al., 1999). One fourth of all persons aged 18-24 years in the U.S. are either full- or part-time college students, suggesting that a large proportion of young adults could be reached through college-based suicide prevention efforts. Colleges and universities are increasingly challenged to identify and manage mental health and substance use problems in students. In part this is because more youth with disorders are able to attend college thanks to effective treatments that improve symptoms of their illness, and the age of onset of a number of psychiatric disorders is in young adulthood (Barrios et al., 2000; Brener et al., 1999; Silverman et al., 1997). Because many of the risk and protective factors for suicide among young adults are similar to those for mental disorders and other problem behaviors, including alcohol, drug abuse and interpersonal violence (Brent et al., 1994; Henriksson et al., 1993), suicide prevention may be best integrated within broad prevention efforts.

Because so many teens and adults are in the workforce, employers have an important role to play in suicide prevention. It is in the interests of employers to prevent suicide and suicidal behaviors; for example, providing mental health treatment, or reducing maladaptive substance use, can improve an employee's functioning. A suicide in the family of an employee may result in such grief that the employee becomes incapacitated.

Employers are a very important player in health insurance in the United States since so many people obtain coverage through their work; employers are the payors of health care and therefore help determine the coverage that workers can obtain. Employers who insist on mental health and substance abuse parity in the insurance policies they offer to workers assure that their workers can obtain treatment for depression and other mental illnesses and substance abuse disorders.

Employee Assistance Programs (EAP) are one example of worksite-based programs that employers may use to help prevent suicide. EAPs help employees identify and resolve personal concerns, including mental or physical health, marital, family, financial, alcohol, drug, or other personal issues, that may affect job performance. Some employers provide family services for their workers, and others engage in a variety of activities and programs in their communities designed to foster a higher quality of life for their workers; it is possible to integrate suicide prevention into such programs.

Jails and juvenile justice facilities have exceptionally high suicide rates, although rates in Federal prisons are relatively low. Suicide rates in jails have been estimated to be approximately nine times higher than that of the general population (Hayes & Rowan, 1988), while suicide rates in some State prisons are at least one and a half times higher (Hayes, 1995). Jail rates are especially high because arrestees may be under the influence of or in withdrawal from alcohol and/or drugs within the first twenty- four hours of arrest (Hayes, 1995).

The suicide rate in the Federal prison system is lower than the rate for the general population of males, and there have been no reported suicides of a female offender in the Federal system since the 1960's. These facts suggest that the experience of the Federal prison system, strategies are available to prevent suicide in correctional settings (Condelli et al., 1997; Cox & Morschauser, 1997). Jail or "lock up" suicides most often occur within 24-48 hours after arrest, suggesting an important role for appropriate medical assessment of substance abuse and administration of standardized suicide assessments. Comprehensive programs include training, screening, effective communication methods, intervention, use of reporting protocols, and mortality review (Hayes, 1997).

Since the elderly have the highest overall suicide rate of all age groups, organizations that have special access to older persons have an important role in suicide prevention. State Aging Networks exist in every State and Territory. They plan, develop and fund a variety of in-home and community- based services for older people. States organize the provision of such services through area agencies on aging, which coordinate a broad range of services for older people in a designated geographic area. In addition, State aging networks or the hundreds of tribal and native organizations that provide services to older American Indians, Alaskan Natives, and Native Hawaiians may also help to maintain protective factors among those elderly at somewhat lower risk for suicide.

The integration of suicide prevention into existing service-based organizations provides opportunities to expand the numbers of individuals who may be reached by preventive interventions. For example, county extension and 4-H programs have unique access to rural populations, and tribal service organizations may be best positioned to reach Native American youth. Homeless youth and young people who have dropped out of school require special attention by these organizations since school-based programs will not reach them. Faith-based organizations have a special role to play, as do natural community helpers.

Resource centers can serve a number of important functions, such as disseminating information on evidence-based interventions and serving as an information repository; convening meetings; coordinating regional activities; providing technical assistance in planning and program design; and monitoring regional changes in the suicide rate.

While there is now considerable understanding of risk factors for suicide, less progress has been made in the design and evaluation of programs to prevent suicide (Bonnie et al., 1999). A key function of suicide prevention resource centers is evaluation. Useful evaluation is an enormous undertaking for local programs, and measurement at the local level is difficult. Given the need for evaluation of preventive interventions, technical assistance in evaluation is particularly important. Evaluations promoted by the centers can be structured to involve practitioners in evaluations to ensure that the evaluations address questions of particular interest to practitioners and are sensitive to local issues. They may also include a feed-back loop to project staff in programs being evaluated to document findings as they are generated. Moreover, the centers can be given the task of interpreting evaluation findings more widely to the practitioner community. Finally, the resource centers may help to further specify ethnic and culturally-specific risk and protective factors in the implementation of interventions.

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