National Strategy for Suicide Prevention:
Goals and Objectives for Action

GOAL 8:
Improve Access to and Community Linkages
with Mental Health and Substance Abuse Services

This goal is designed to prevent suicide by ensuring that individuals who are at high risk due to mental health and substance use problems can receive prevention and treatment services. Barriers to access need to be eliminated and linkages between various community agencies and mental health and substance abuse treatment programs need to be established. The elimination of health disparities and the improvement of the quality of life for all Americans are central goals for Healthy People 2010 (DHHS, 2000). Some of these health disparities are associated with differences of gender, race or ethnicity, education, income, disability, geographic location, or sexual orientation. Many of these factors place individuals at increased risk for suicidal behaviors, because they limit access to mental health and substance abuse services.

Barriers to equal access and affordability of health care may be influenced by financial, structural, and personal factors. Financial barriers include not having enough health insurance or not having the ability to pay for services outside a health plan or insurance program. Structural barriers include the lack of primary care providers, medical specialists, or other health care professionals to meet special needs or the unavailability of health care facilities. Personal barriers include cultural or spiritual differences, language, not knowing when or how to seek care, or concerns about confidentiality or discrimination (Healthy People 2010). Reducing disparities is a necessary step in ensuring that all Americans receive appropriate physical health, mental health, and substance abuse services. Improving access will help ensure that at-risk populations receive the services they need, and that all community members receive regular preventive health services. Communities need to take responsibility for preventing suicide and promoting health, but must remain sensitive to the balance between preserving individual civil liberties and imposing mandatory treatment in those instances where it may be indicated. Developing partnerships with mental health and substance abuse services will enable all components of the community to work together to ensure the overall health and vitality of its members.

In the last decade, much effort has been put forth to improve community health service delivery systems. It is believed that providing better access and linkages has resulted in a decrease in unnecessary illness and death due to health problems such as unintentional injury, heart attacks, and chronic illnesses. Most communities are proud of their emergency medical services, police and fire emergency services, emergency departments, and available health services.

Society's view of suicide and suicidal behaviors is evolving from seeing such behavior as an individual act directly affecting a single person, to a societal event in which the suicide of one individual affects many facets of a community — a community that must then accept a leading role in preventing its occurrence. The extent of suicidal behavior is now seen as a reflection of the overall health and welfare of the community, and many communities have made it a priority concern.

As society shifts its attention to addressing public health concerns such as violence, suicide, and other intentional injuries, the courts, schools, churches, social service agencies, correctional institutions, and other community institutions must work with mental health and substance abuse service systems to forge better relationships.

Achieving this goal is dependent on the extent to which community organizations and service delivery systems communicate with each other to facilitate the provision of health services to those in need, and on the extent to which individuals at risk use these services. As activities to achieve objectives are implemented, one outcome will be an initial increase in the number of individuals identified to be in need of mental health and substance abuse services and preventive interventions. This is often the initial result of improved risk identification and referral systems. However, the long-term benefit to identifying those in need of services is that the overall health and well-being of the community is better served by addressing the range of these health problems in the community at an earlier and less debilitating stage. This benefit extends to suicide survivors who are among those for whom linkages with mental health services may be indicated. Not only would there be a long-term reduction in the rate of suicidal behaviors, but also in the morbidity associated with many other disorders (depression, bipolar illness, schizophrenia, alcohol and drug abuse).

One reason that many mental health problems go untreated in America is that employee benefit plans tend to provide more liberal coverage for physical illness (general medical and surgical services) than for mental ill-ness or substance abuse treatment. This disparity has worsened in recent years due to changes in the nation's health care delivery systems. Without parity, those in need of specialty mental health and substance abuse treatment will be denied adequate access. States and the Federal government have begun to require that mental health and/or substance abuse treatment be covered in the same way as other medical care (parity). Following the passage of the 1996 Mental Health Parity Act, some States have passed mandatory parity laws that to varying degrees require parity in mental health and/or substance abuse benefits. Others have enacted legislation conforming to the Federal mandate. Most State parity laws are limited in scope or application. Few address substance abuse treatment, and many are limited only to treatment for serious mental illnesses. Many parity laws exempt small businesses or only apply to plans for government employees. A necessary first step for States is to require coverage for mental health and substance abuse care on par with coverage for physical health care.

It is important to help populations at risk receive needed services. National voluntary organizations such as the American Lung Association, the American Heart Association, and the American Cancer Society have been successful in their outreach efforts. They excel in providing timely and targeted public information, public health messages, and referral recommendations. It is also critical that the services themselves are available in the community, and are able and willing to reach out to populations at risk to offer appropriate health and/or social services that address their needs. At risk populations are not always able to access health services easily or to do it on their own. Often the mental health and substance abuse service provider systems need to provide ways to help individuals access care and to follow up with care over time. Such programs, which include outreach programs for the homeless and street health programs for runaway youth, reach out by contacting these individuals where they congregate.

Suicide in adolescents and young adults (aged 15-24) remains the third leading cause of death for this population. The onset of most major mental and substance use disorders is in this age range. A number of communities have already instituted guidelines for mental health screening and referral of students demonstrating at risk behaviors for suicide (CDC, 1992). These efforts have been shown to reduce the suicide ideation and attempt rates as well as to improve the overall provision of mental health care for the school population (See Objectives 4.2 and 4.3) (Zenere & Lazarus, 1997). Nevertheless, there are no national guidelines for mental health or substance abuse screening and referral for at-risk students. Such guidelines might include assessment tools and criteria, protocols, algorithms for assessing risk status, referral guidelines, and evaluation measures (Grossman & Kruesi, 2000).

It is not sufficient to identify students at risk in public and private school systems without also ensuring that appropriate linkages to receiving services are instituted. The process of effecting a referral for treatment services must be carefully spelled out, tailored to the special circumstances of the school setting, and remain sensitive to the need for adolescents, young adults and their families to feel supported and protected while receiving timely and effective interventions.

Sometimes it is difficult to effect linkages with mental health and substance abuse services when such services are not within close proximity to school districts and colleges, or when they are not readily available in the community. It would be advantageous to increase the proportion of school districts in which school-based clinics incorporate mental health and substance abuse assessment and management as part of their mission and scope of activities. When it is in the best interests of all concerned for the student at risk to receive care within the school setting and not be referred elsewhere, school-based clinics need to apply assessment and management techniques appropriate to the age group that they serve.

For a variety of reasons, correctional institutions, jails, and detention centers have not been designed to provide mental health assessment and intervention programs and services, nor organized to offer suicide preventive intervention programs (see Objective 4.5) (Hayes, 1997). However, many individuals in these institutional settings are at increased risk for self-destructive behaviors (WHO, 2000). Efforts should focus on providing appropriate assessment and treatment services to those individuals in correctional facilities, particularly juveniles who are in detention centers and holding units (Bonner, 2000).

Current estimates suggest that for every suicide, there are 6-8 individuals who have been closely associated with the person who has died by suicide. These family members, significant others, or acquaintances who have experienced the loss of a loved one due to suicide may be at increased risk for self-destructive behaviors as well as for a range of adjustment problems, often directly linked to their sudden status as survivors. As these individuals organized into support groups and national advocacy organizations, they have documented the benefit of effective comprehensive support programs (Callahan, 2000). Although such programs exist in many areas, there remain many regions with a dearth of such support groups. Making such programs available to those in need will increase the likelihood of utilization and benefit.

Currently, there are no standardized utilization management guidelines for use by health care provider systems and health insurance plans for the effective response to, and treatment of, individuals at risk for suicide. In part, due to the lack of uniform operational definitions for suicidal risk, suicide attempts, and other suicidal behaviors, such guidelines have been lacking. With better definitions and better surveillance techniques to identify both individuals at risk and those who might benefit from certain types of interventions, standardized utilization management guidelines can be developed, and existing guidelines can be field-tested and refined (Risk Management Foundation of the Harvard Medical Institutions, 1996).

NSSP Homepage | Table of Contents | Previous | Next

Substance Abuse and Mental Health Services Administration

Centers for Disease Control and Prevention

National Institutes of Health

Health Resources and Services Administration