National Strategy for Suicide Prevention:
Goals and Objectives for Action

Introduction

What is the U.S. National Strategy for Suicide Prevention?

The National Strategy for Suicide Prevention (National Strategy or NSSP) is designed to be a catalyst for social change with the power to transform attitudes, policies, and services. Representing the combined work of advocates, clinicians, researchers and survivors, the National Strategy lays out a framework for action and guides development of an array of services and programs yet to be set in motion. It strives to promote and provide direction to efforts to modify the social infrastructure in ways that will affect the most basic attitudes about suicide and its prevention, and that will also change judicial, educational, and health care systems.

As conceived, the Strategy requires a variety of organizations and individuals to become involved in suicide prevention and emphasizes coordination of resources and culturally appropriate services at all levels of government– Federal, State, tribal and community. The NSSP represents the first attempt in the United States to prevent suicide through a coordinated approach by both the public and private sectors.

This document, Goals and Objectives for Action, is a key element in the National Strategy. Its clear articulation of a set of goals and objectives provides a roadmap for action. The next step will be to develop a detailed plan that includes specific activities corresponding to each objective. The Strategy, as represented here, is highly ambitious because the devastation wrought by suicide demands the strongest possible response.

The NSSP is based on existing knowledge about suicidal behavior and suicide prevention. It employs the public health approach, which has helped the nation effectively address problems as diverse as tuberculosis, heart disease, and unintentional injury. This Introduction to Goals and Objectives for Action outlines the components of a comprehensive suicide prevention plan, describes the public health approach as it relates to suicide, and summarizes the knowledge gained from the experience of suicide prevention initiatives in other nations.

A Plan for Suicide Prevention: Goals, Objectives and Activities

This document presents the 11 goals and 68 objectives of this component of the National Strategy.

A set of activities will be developed for each objective in the next phase of the NSSP. Goals, objectives and activities are defined as follows:

GOAL: A goal is a broad and high-level statement of general purpose to guide planning around an issue. It is focused on the end result of the work.

OBJECTIVE: An objective narrows the goal by specifying the who, what, when and where associated with obtaining the goal or clarifies by how much, how many, or how often. Ideally, an objective offers measurable milestones or targets and is very specific–it clearly identifies what is to be achieved. The objectives that appear in the Goals and Objectives for Action should be considered "developmental" until all these requisites are established. Until then, the target date of 2005 is used as a place holder on most Objectives to convey a sense of urgency, while considering the time needed for government and private-sector organizations to make progress toward the goal (see also Chapter 12 for the discussion on benchmarks).

ACTIVITIES: Activities specify how objectives will be reached. They are the “things that will be done” to ensure that the goals and objectives are met. A small selection of activities are suggested within “Ideas for Action” boxes that are placed throughout this document. These are designed primarily to be illustrative of the types of activities that will be developed in the next phase of the NSSP, and their presence in the Goals and Objectives for Action is not meant as proof of their effectiveness, but rather as a stimulus to creative thinking in developing suicide prevention activities. The final set of activities for the National Strategy will occur through a national consensus process designed to fully engage the Nation and assure maximum involvement in its implementation.

The public health approach to suicide prevention, reflected in the National Strategy, represents a rational and organized way to marshal prevention efforts and ensure that they are effective. In contrast with the clinical medical approach, which explores the history and health conditions that could lead to suicide in a single individual, the public health approach focuses on identifying patterns of suicide and suicidal behavior throughout a group or population.

These steps may occur sequentially, but they also sometimes overlap. For example, the techniques used to define the problem, such as determining the frequency with which a particular problem arises in a community, may be used in assessing the overall effectiveness of prevention programs. Information gained from evaluations may lead to new and promising interventions.

Clearly Define the Problem

Collecting information about the rates of suicide and suicidal behavior is known as surveillance. Surveillance may also include collection of information on the characteristics of individuals who die by suicide, the circumstances surrounding these incidents, possible precipitating events, and the adequacy of social support and health services. Sometimes data are collected on the cost of injuries related to suicidal behavior. Surveillance helps to define the problem for a community. It documents the extent to which suicide is a burden to a community and how suicide rates vary by time geographic regions, age groups, or special populations.

While data on suicides are available, data on attempted suicides, particularly among adults, are much less complete. Suicide rates vary by age, gender, and ethnic groups.

It is generally agreed that not all deaths that are suicides are reported as such. Deaths may be misclassified as homicides or accidents where individuals have intended suicide by putting themselves in harm's way and lack of evidence does not allow for classifying the death as suicide. Other suicides may be misclassified as accidental or undetermined deaths in deference to community or family. Many studies suggest that the actual suicide rate is considerably higher than recorded. (Clark et al., 1992; Gibbs et al., 1988; O'Carroll, 1989).

Suicide rates have changed over time, especially among certain subgroups. For example, from 1980 to 1996, the rate of suicide among children aged 10-14 increased by 100 percent, and among African-American males aged 15-19, the rate increased by 105 percent (Peters et al., 1998).

While no national data base of attempted suicide exists, the Youth Risk Behavior Survey, conducted by the CDC biennially, provides important information on young people (CDC, 1999). This survey consistently finds that a large number of youth in grades 9-12 consider or attempt suicide (Brener, Krug, & Simon, 2000).

Suicide is very costly to the Nation. In addition to the emotional suffering experienced by family members of those who have died by suicide and the physical pain endured by those who have attempted suicide, there are financial costs. However, attempts to compute such costs on a national basis are based on incomplete data (e.g., underreporting of suicides and an absence of reliable data on suicide attempts); in addition, such estimates, like economic analyses of other health problems, are of necessity based on certain assumptions, and the accuracy of these cannot always be assured. Consequently, there is no firm consensus on the true dollar costs of suicide. One economic analysis, however, estimated the total economic burden of suicide in the U.S. in 1995 to be $111.3 billion; this includes medical expenses of $3.7 billion, work-related losses of $27.4 billion, and quality of life costs of $80.2 billion (Miller et al., 1999).

While national data provide an overall view of the problem, State and local suicide rates vary considerably from these national rates. Local data are key to effective prevention efforts. It is important to note, however, that local suicide rates, due to the significant fluctuations that occur in small populations, are often not useful in evaluating the effectiveness of suicide prevention programs in the short-run. "Proxy" measures may work better, including changes in risk and protective factors.

Risk factors may be thought of as leading to or being associated with suicide; that is, people "possessing" the risk factor are at greater potential for suicidal behavior. Protective factors, on the other hand, reduce the likelihood of suicide. They enhance resilience and may serve to counterbalance risk factors. Risk and protective factors may be biopsychosocial, environmental, or sociocultural in nature. Although this division is somewhat arbitrary, it provides the opportunity to consider these factors from different perspectives.

Understanding the interactive relationship between risk and protective factors in suicidal behavior and how this interaction can be modified are challenges to suicide prevention (Móscicki, 1997). Unfortunately, the scientific studies that demonstrate the suicide prevention effect of altering specific risk or protective factors remain limited in number (see Appendix C).

However, the impact of some risk factors can clearly be reduced by certain interventions such as providing lithium for manic depressive illness or strengthening social support in a community (Baldessarini, Tando, Hennen, 1999). Risk factors that cannot be changed (such as a previous suicide attempt) can alert others to the heightened risk of suicide during periods of the recurrence of a mental or substance abuse disorder or following a significant stressful life event (Oquendo et al., 1999). Protective factors are quite varied and include an individual's attitudinal and behavioral characteristics, as well as attributes of the environment and culture (Plutchik & Van Praag, 1994). Some of the most important risk and protective factors are outlined below.

Measures that enhance protective factors play an essential role in preventing suicide. However, positive resistance to suicide is not permanent, so programs that support and maintain protection against suicide should be ongoing.

Information about risk and protective factors for attempted suicide is more limited than that on suicide. One problem in studying nonlethal suicidal behaviors is a lack of consensus about what actually constitutes suicidal behavior (O'Carroll et al., 1996). Should self-injurious behavior in which there is no intent to die be classified as suicidal behavior? If intent defines suicidal behavior, how is it possible to quantify a person's intent to die? The lack of agreement on such issues makes valid research difficult to conduct. As a result, it is not yet possible to say with certainty that risk and protective factors for suicide and non-lethal forms of self-injury are the same. Some authors argue that they are, whereas others accentuate differences (Duberstein et al., 2000; Linehan, 1986).

Suicide prevention interventions reduce risk or enhance protective factors; some address both. Interventions, like risk and protective factors, may be characterized along biopsychosocial, environmental, and sociocultural dimensions. An intervention might attempt to influence some combination of psychological state, physical environment, or the cultural/subcultural conditions. Alternatively, suicide prevention efforts have been classified as either universal, selective, or indicated: a universal approach is designed for everyone in a defined population regardless of their risk for suicide, such as a health care system, or a county, or a school district; a selective approach is for subgroups at increased risk, for example, due to age, gender, ethnicity or family history of suicide; and an indicated approach is designed for individuals who, on examination, have a risk factor or condition that puts them at very high risk, for example, a recent suicide attempt (Gordon, 1983). The intersections of these dimensions in a matrix shows the intended mechanisms of action and the level of population addressed by interventions. The matrix can identify gaps for development of additional suicide prevention approaches and help match intervention evaluations to the intended outcomes and mechanisms of action.

Rigorous scientific testing of interventions, prior to large scale implementation, is important to ensure that interventions are safe, ethical, and feasible. This testing usually undergoes several stages including small scale, or pilot studies, of efficacy and effectiveness. Efficacy studies test whether a preventive or treatment intervention works under ideal conditions. The application of the intervention is monitored closely and the question, "Can it work?" is addressed. Only if the answer is "yes" are effectiveness studies undertaken in real world settings. A different question is answered here: "If you do this in the real world, does it prevent suicide?" When interventions have been documented as safe, ethical and feasible, further testing with larger groups can also lead to refinements and enhancements based on important differences among age, gender, geographic, and cultural groups. It is frequently difficult to conduct efficacy studies, although in the absence of such studies, if an intervention does not work, there is no way to know if that is because the program idea was flawed or because the implementation was flawed.

In actuality, definitive pilot studies are frequently missing for many types of social and mental health interventions, including those designed to prevent suicide. By default, program planners may incorporate "promising" interventions into community suicide prevention plans before the evidence base is fully developed. This makes careful evaluation of local outcomes especially important.

State and local organizations will often develop suicide prevention programs that consist of a broad mix of interventions. By selecting interventions from several cells in the "Matrix of Interventions for Suicide Prevention," a more comprehensive program can be developed. Considerations for selecting the elements of a program, i.e., the mix of interventions that will be implemented, include local needs (based on a specific assessment of the problem of suicide in the community) and an analysis of cost vs. potential effectiveness of different interventions. Moreover, program planners will need to consider ways to integrate interventions into existing programs and to strengthen collaboration.

Such comprehensive suicide prevention programs are believed to have a greater likelihood of reducing the suicide rate than are interventions that address only one risk or protective factor, particularly if the program incorporates a range of services and providers within a community. Comprehensive programs engage community leaders through coalitions that cut across traditionally separate sectors, such as health and mental health care, public health, justice and law enforcement, education and social services. The coalitions involve a range of groups, including faith communities, civic groups, and business. Suicide prevention programs need to support and reflect the experience of survivors, build on community values and standards, and integrate local cultural and ethnic perspectives (U.S. Department of Health and Human Services, 1999). For example, cultural prohibitions on talking about suicide may have to be taken into account in the development of certain types of programs. Evaluation can help determine if community interventions are having the desired effect for all groups.

It is important to note that most interventions that are assumed to prevent suicide, including some that have been widely implemented, have yet to be evaluated. An ideal, "evidence-based" intervention is one that has been evaluated and found to be safe, ethical, and feasible, as well as effective. Determination of cost effectiveness is another important aspect of evaluation. Evaluation can help determine for whom a particular suicide prevention strategy is best fitted or how it should be modified in order to be maximally effective. Appendix B provides additional information on evaluation.

Through the NSSP, the United States has joined the small number of nations that have created a national strategy for the prevention of suicide that is both comprehensive and multifaceted and in which there is a planned integration among different prevention components (Taylor et al., 1997). The U.S. strategy builds on the experience of other nations and also incorporates the recommendations of the 1996 publication Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies, published by the United Nations/World Health Organization (United Nations, 1996).

The first national suicide prevention strategy was initiated in Finland in 1986; the Finnish initiative has provided tremendous amounts of information that have been helpful in the creation of the national suicide prevention strategies of other countries, including the U.S. The U.S. strategy also benefits from the national suicide prevention efforts of Norway, Sweden, New Zealand, Australia, the United Kingdom, The Netherlands, Estonia, and France.

National strategies for suicide prevention share a number of common elements. These include a focus on educational settings as a site of intervention; attempts to change the portrayal of suicidal behavior and mental illness in the media; efforts to increase the detection and treatment of depression and other mental illnesses, including alcohol and substance use disorders; an emphasis on reducing the stigma associated with being a consumer of mental health or substance abuse services; strategies designed to improve access to services; promotion of effective clinical practices; and efforts to reduce access to lethal means of suicide. Not every country with a national suicide prevention strategy, however, includes all of these elements in its strategy, although all current strategies do include plans for increasing research on suicide and suicide prevention (IASP, 1999).

Even when nations address the same issue in their strategies, they frequently do so in different ways. For instance, interventions after a suicide has occurred (called postvention) aimed at reducing the impact of suicide on surviving friends and relatives have been proposed by all countries. However, approaches to postvention vary across countries. For example, Norway has proposed outreach services to relatives and friends of those who died by suicide in the community, while other countries that have focused on youth suicide prevention, such as New Zealand, suggest specific postvention efforts to minimize suicide contagion in school settings.

One important difference among nations with respect to their national strategies is the extent to which the community is involved in the creation and implementation of the initiative. The UN/WHO guidelines recommend that no single agency, organization, or governmental body have sole responsibility for suicide prevention (Ramsey & Tanney, 1996). In this regard, a particular strength of the Finnish strategy has been strong community involvement in the process of developing and implementing its strategy. Other countries with different resources, have needed to rely heavily on government agencies to implement their strategies. The development of the National Strategy in the U.S. has been led by the Federal government, but in collaboration with numerous non-governmental organizations and with advice from hundreds of interested, individual citizens.

National suicide prevention strategies vary in terms of their target audiences. The National Strategy is aimed at the entire population of the U.S. and in this respect is similar to the strategies of Norway, Sweden, and Finland. In contrast, New Zealand and Australia focus exclusively on youth suicide. Finland has also targeted young men for special attention, given their increasing rate of suicide in that country.

The UN/WHO guidelines recommend that suicide prevention programs be coherent in their approach. Nations take different approaches to ensuring such coherence. For example, the Finnish initiative commenced with a national research study on suicide, using the psychological autopsy method. Data derived from this research were used to help in the development and implementation of suicide prevention programs. In contrast, the New Zealand strategy was guided by a literature review born out of a workshop that included representation from both governmental and non-governmental organizations, including advocacy groups. The development of the U.S. strategy has been based on the public health model, which has proven so effective for approaching other health problems.

The extent to which evaluation is a central component of a nation's suicide prevention strategy varies considerably. The Finnish government commissioned both an internal and external evaluation to assess the outcome of the strategy (Upanne, 1999). Norway has plans for an external evaluation of its strategy, and Australia requires evaluation for all funded demonstration projects. New Zealand agencies are self-monitoring; in addition, a small steering group convenes annually and reports to the Ministers of Health and Youth Affairs on the progress of the strategy. As recommended by the UN/WHO guidelines, the U.S. strategy includes specific objectives with the potential for measurement. Provision is also made for the evaluation of specific preventive interventions.

Suicide is a major cause of death in the U.S. and also contributes–through suicide attempts–to disability and suffering. Suicide is a serious public health problem. Persons who experience the loss of someone close as a result of suicide experience tremendous emotional trauma. Suicide is a special burden for certain age, gender, and ethnic groups, as well as particular geographic regions. The public health approach provides a framework for a national strategy to address this serious national problem. The Goals and Objectives for Action that follow are designed to provide direction to the Nation on ways to prevent suicide and suicidal behavior.

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