National Strategy for Suicide Prevention:
Goals and Objectives for Action

GOAL 7:
Develop and Promote Effective Clinical
and Professional Practices

As defined by the public health approach, one way to prevent suicide is to identify individuals at risk and to engage them in early and aggressive treatments that are effective in reducing the personal and situational factors associated with suicidal behaviors (e.g., depressed mood, hopelessness, helplessness, agitation, severe anxiety, pervasive insomnia, alcohol and drug abuse, among others). Another way to prevent suicide is to promote and support the presence of protective factors such as skills in problem solving, conflict resolution, and nonviolent handling of disputes.

By promoting effective clinical practices in the assessment, treatment, and referral for individuals at risk for suicide, the chances are greatly improved for preventing those individuals from acting on their despair and distress in self-destructive ways. Moreover, the development and implementation of protective factors for these individuals can contribute importantly to reducing their risk.

As in illnesses of all types, individuals who are receiving appropriate treatment for mental disorders have the best likelihood of recovery (Jamison & Baldessarini, 1999; Kleespies, 1998; Rudd, 2000; Rudd & Joiner, 1998). It is critical that individuals with psychiatric disorders or otherwise at increased suicidal risk receive adequate assessment, treatment, and follow- up care.

The nature of being in a suicidal crisis can sometimes impede an individual's ability to obtain appropriate medical care for themselves. Some individuals with psychiatric disorders may at times be unable to serve as their own best advocates when their illnesses involve impaired cognitions, emotions or interpersonal skills. Patients with suicidal thoughts report fear of being stigmatized or rejected if they reveal these thoughts to others (see Objective 8.1). Family members and significant others of those who have died by suicide may, as well, be at increased risk for suicide. Appropriate attention and sensitivity to their unique situation is often lacking.

Currently, there are only two psychopharmacological treatments that have been associated with reduced suicide– lithium and clozapine (Baldessarini, Tondo, & Hennen, 1999; Meltzer & Okayli, 1995). The data regarding lithium is extensive—stretching over 28 studies around the world. The 6-8 fold reduction in the suicide rate associated with this particular treatment is dramatic and needs to be more widely publicized. New interventions are being developed and tested for the treatment of disorders associated with suicidal behaviors. Because few studies of treatments for mental disorders have included suicidal individuals (most are excluded from clinical trials), new treatments need to be assessed for their potential to reduce suicide and suicidal behaviors as well as reduce symptoms of the disorder.

A heightened awareness of the presence or absence of risk and protective conditions associated with suicide will result in better triage systems and better allocation of resources for those in need of specialized treatment. Accurate assessment of how individuals respond to significant life events, transitions, and challenges to their mental and physical well-being can lead to appropriate and timely interventions. Health care providers and clergy are often called upon to attend to end of life care issues, including spiritual, religious, and familial reconciliation. Taken together, goals 7 and 8 will ensure that key service personnel are trained to conduct thorough suicide assessments, deliver appropriate interventions, make appropriate referrals when indicated, and that health systems are appropriately organized to provide patients with needed and effective clinical care.

Suicide attempts are a significant public health problem, particularly among adolescents and young adults. Without adequate intervention, this population is at increased risk for repeat attempts and death by suicide. Studies have found that fewer than 50 percent of adolescent attempters are referred for treatment following an emergency department (ED) visit (Piacentini et al.; 1995; Spirito et al., 1989), and a large proportion of those fail to attend their initial appointment.

Clinical studies have shown the efficacy of training ED staff to treat suicide attempts with due seriousness, and to emphasize to adolescents' family members the dangers of ignoring suicide attempts and the benefits of follow-up treatment to reduce the reoccurrence of attempted suicide. Such staff training has been associated with greater completion of treatment on the part of persons having sought care in emergency departments (Rotheram-Borus et al., 2000). From a health care perspective, both the patient and the health care delivery system benefit from better linkages between emergency and appropriate follow-up care.

Case management is not the usual role of emergency departments, but in facilitating continuity of care they can champion processes that provide the missing link between an emergency evaluation and appropriate mental health treatment. Hospitals should confirm that patients receive appropriate referral and follow-up information through ongoing quality assessment programs while emergency departments identify and develop linkages with mental health and substance abuse follow-up resources for referral and treatment of patients with self-destructive behaviors (see Objective 8.1).

Persons at risk for suicide arrive in emergency departments and primary health care settings in a variety of circumstances, with a variety of concerns, such as mental and substance use disorders, physical abuse, recent losses, and painful physical illnesses, that can place persons at increased risk for suicide (Harris & Barraclough, 1997; WHO, 2000a, 2000c). Currently, there are no universally accepted guidelines for the assessment of suicidal risk in these patients (Shea, 1999). Such guidelines would assure that these assessments become part of the routine protocol for providing clinical care to all individuals seen in these health care settings and assist in the process of making clinically appropriate referrals for mental health and substance abuse treatment.

Studies indicate that there is a very high association between some mental (particularly schizophrenia and mood disorders) and substance use (alcohol) disorders and increased risk for suicide (Harris & Barraclough, 1997; Inskip, Harris & Barraclough, 1998; Tanney, 2000). Many patients with such diagnoses are seen in specialty mental health and substance abuse treatment centers, where they receive treatment for their primary psychiatric diagnosis. To provide good clinical care, these centers must have in place policies, procedures, and evaluation programs designed to identify the level of suicide risk and interventions to reduce suicidal behaviors. Such approaches will likely lead to ensuring that more patients receive the appropriate assessment for suicidal risk and protective factors. Evaluation of these policies and procedures over time will result in more effective and efficient delivery of health care to those at risk.

It is well known that one of the highest risk periods for suicide is immediately following discharge from institutional settings (Morgan & Stanton, 1997). Often the investigations of such deaths identify problems in assessing a patient's readiness for discharge or transition to a less restrictive level of care, or with post-discharge planning and communications. The transition from mental health and substance abuse institutional treatment settings to community life can be difficult and challenging for individuals at high risk for suicide. All too often the assumption is that individuals are no longer at risk for suicide once they are discharged from inpatient hospital or institutional settings and placed in after-care treatment programs. Unfortunately, this is not always the case. Thus, it is critical that after-care treatment programs develop guidelines for the appropriate assessment, management, and treatment of individuals exhibiting suicidal behaviors following treatment in emergency set-tings or in inpatient hospital settings (Bongar et al., 1998). Such programs often incorporate some of the following elements: telephone contact, transportation arrangements to ensure attendance at clinical appointments, appropriate housing arrangements, resources to guarantee purchasing of medications, and family or support group education. It is important to provide education and psychological support to families and significant others of those who have exhibited suicidal behavior.

When suicide occurs it results in shock and disruption for those who may have witnessed the event or arrived on the scene soon thereafter, as well as responding emergency personnel. Often emergency medical technicians and first responders (including law enforcement officers and firefighters) are the individuals to have first contact with suicide survivors. These are emotionally charged situations that leave indelible memories for all those involved. First responders have the opportunity to set the tone for being respectful and sensitive to the needs of survivors and the need to be prepared themselves for the impact such events may have on their own thoughts and emotions.

These personnel are also often the first on the scene when called to assist with a suicide attempt. Here, too, the situation is often emotionally charged, volatile, and unpredictable. The judicial use of tact, patience, sensitivity, authority, judgment, and professional skills can result in a successful assessment and management of the situation. In a similar fashion, other service-oriented professionals (clergy, funeral directors) can provide information about local support services when appropriate.

A mood disorder is an alteration in an individual's ability to regulate emotions or feelings. Episodes of depression often recur. A large number of suicidal patients suffer from mood disorders alone or in combination with other mental, substance use or physical disorders (co-morbidity) (Henriksson et al., 1993). Often patients with mood disorders are reluctant to seek treatment because of the stigma associated with having a mental disorder.

The effective treatment of patients with mood disorders (which are often recurrent illnesses, necessitating close monitoring and regular evaluations) may last many months and sometimes even years. For those patients receiving medications, it may take weeks before they are effective and symptoms are significantly reduced. Once symptom relief occurs it is recommended that individuals remain on medication for a minimum of 6-9 additional months and sometimes even longer (Stahl, 2000). Remaining on a therapeutic regimen of medications is an important element in preventing a relapse or recurrence of the illness.

Courses of psychotherapy for mood disorders also are important and curative. Psychotherapy has been found to be as effective as some pharmacologic treatments and some combinations of these two are superior to either alone. Once individuals begin to feel better and their mood disorder is improved, some tend to discontinue regular treatment and do not complete a full course of medication management or psychotherapy. Premature termination of treatment can increase the risk of relapse and return of symptoms, including suicidal behaviors. The available treatment modalities for mood disorder are effective when administered over time and monitored appropriately. Patients must be educated to understand the need to complete the full course of recommended treatment, continue maintenance treatment as recommended, and learn to recognize and manage risk for relapse.

Clinical studies suggest that a high proportion of victims of sexual assault and/or physical abuse are at increased risk for psychiatric disturbances associated with suicidal behavior, and at increased risk for self-destructive behaviors without necessarily developing a psychological disorder (Herman, 1997). It is important for hospital emergency departments to provide immediate post-trauma psychological support and mental health education for victims of violence, recognizing the traumatic nature of their experience and the risk for self-destructive behaviors they may face in the future. Protocols must be developed to assist these patients and to ensure proper follow-up and after-care treatment.

This objective is related to Objective 6.8 to increase the availability of programs to educate family members and significant others about understanding, monitoring, and intervening with persons who are at risk of suicide. In combination, these two objectives are intended to ensure that the educational material is available, and that it is appropriately delivered to those who can benefit from the information.

Family members, significant others, and support networks play very important roles in the care of individuals at increased risk for suicide. Personal knowledge and daily proximity means that family members are in the best position to quickly note changes in demeanor and behavior that may signal a deterioration in thier loved one’s condition. Educating family members and significant others about how to watch for changes in mood and behavior, and how to access help when needed are important to ensure that a person at risk does not become self-destructive.

Millions of individuals are treated through Federally-supported health care programs, including military personnel and their dependents and elderly, physically and mentally challenged, and indigent persons. Opportunities exist for these programs to become models for incorporating screening tools and techniques for depression, substance abuse, and suicide risk.

Mental and substance use disorders, as well as suicide risk, are often not assessed in primary care settings because of the time constraints involved and because the staff is not appropriately trained to recognize the presence of these conditions. Incorporating targeted screening tools and techniques into Federally-supported primary care settings, hospices, and skilled nursing facilities is expected to increase the number of individuals identified with symptoms of depression, substance abuse, and suicide risk. Appropriate treatment and follow-up care for these problems, over time, would be expected to prevent suicides.

The Health Plan Employer Data and Information Set (HEDIS) is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. HEDIS is sponsored, supported and maintained by the National Committee for Quality Assurance (NCQA), a private, not-for-profit organization dedicated to improving the quality of health care.

The performance measures in HEDIS are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes. Screening for depression, substance abuse and suicide should be added to its performance measures for the same reasons outlined in objective 7.9, and would provide similar, expected results contributing to the prevention of suicide.

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