Guest Editorial: Federal, State, and Community Partnerships to Prevent Youth Suicides

Margaret A. West, PhD, MSW

An 11-year-old boy in Vaughn, Washington, died on December 1, 1997, after he shot himself in the head with his father's 9-mm semiautomatic handgun. The Seattle Times reported that he "had been having problems at school." Stories such as this are happening at an increasing rate in the United States, especially in western states.

In 1994 there were 5,274 suicides, more than 14 per day, of people under age 25. This is a threefold increase over the number of suicide deaths in 1979. More than a decade ago Seiden (1984) published an article, Death in the West, which described the high rates of youth suicide in western states. Thirteen western states (Alaska, Arizona, Colorado, Idaho, Montana, North Dakota, Nevada, New Mexico, Oregon, South Dakota, Utah, Washington, and Wyoming) have youth suicide rates that are 200-300% higher than the national average, with suicide deaths exceeding deaths from homicide. The rate of increase for suicide deaths for 10-14-year-olds has been more than 170%. The most frequent method of completed suicide is firearms, which account for 60% of all suicides and 68% of suicides for youth 15-24 years of age (National Center for Health Statistics, 1994). A recent study conducted by the Department of Health in Washington state found that "In 1995 the most common method of suicide (58%) in Washington State was firearms" (Centers for Disease Control and Prevention, 1997, p. 502).

Suicide is the third leading cause of death in the United States and the second leading cause of death in most western states for young people. In 1992 more teens and young adults died from suicide than died from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease combined (Fleming, 1996). We do not know why the 10 states with the highest rates for youth suicide are all western states. The August 1997 issue of (Morbidity and Mortality Weekly Report) reports that across all age groups "suicide rates were highest for persons residing in the West (14.1 per 100,000 population), followed by "the South (13.1), Midwest (11.4) and Northeast (9.3)" (Regional Variations, 1997, p. 790). After adjusting rates for race/Hispanic, ethnicity, and sex, rates remained highest in the West. All rates were significantly different from the total U.S. adjusted rate and from each other (Centers for Disease Control and Prevention, 1997a). Metha, Weber, and Webb (this issue) suggest that this difference is due to firearms. However, a recent analysis of data by the Centers for Disease Control and Prevention (CDC) has not found this to be an adequate explanation.. The Morbidity and Mortality Weekly Report reports that the proportion of suicide by firearms was higher in the South than in the West (69.8% and 58.3%, respectively; Regional Variations, 1997).

Since the advent of external cause (E) coding for hospital information, national and state data on suicide attempts are more available. A study conducted by Spicer and Miller (1997) of suicide attempts based on the 1993-1994 National Hospital Ambulatory Medical Care Survey emergency department data reports 121,000 medically identified suicide survivors admitted to the hospital and 98,000 treated and released annually (Miller & Spicer, 1997). The rate of suicide attempts for people ages 15-24 using the estimates from this study is 220.3/100,000 (Spicer & Miller, 1997). This represents more than 20 suicide attempts resulting in documented emergency room treatment for each reported completed suicide.

Two targeted federal efforts, the 1985 Youth Suicide Prevention Act providing funds for model suicide prevention programs in local school districts and the 1990 Public Health Service Act amendment providing funds for the National Institute of Mental Health for demonstration projects targeting prevention. of youth suicide have brought some attention to this serious threat to our nation's youth (Metha, Weber, & Webb, this issue). On May 6, 1997, the U. S. Senate passed Resolution 84, which outlines the extent of the problem and the need for prevention programs, and resolves that the Senate:

1.  Recognize suicide as a national problem and declares suicide prevention to be a national-priority:
2.  Acknowledges that no single suicide prevention program or effort will be appropriate for all populations or communities:
3.  Encourages initiatives dedicated to: A. Preventing suicide, B. Responding to people at risk for suicide ... C. Promoting safe and effective treatment for persons at risk for suicidal behavior, D. Supporting people who have lost someone to suicide, and E. Developing an effective national strategy for prevention of suicide;
4.  Encourages the development, and the promotion of accessibility and affordability of mental health services, to enable all persons at risk for suicide to obtain the services, without fear of any stigma. (S. Res., 1997)

This resolution was supported by SPAN, the Suicide Prevention Advocacy Network, which delivered over 20,000 signed petitions from 47 states calling for the action accomplished by this resolution.

The article by Metha, Weber, and Webb (this issue) summarizes findings from a 1992 survey, updated in 1996, of legislation, funding, curriculum, task force, and state plans in all 50 states. Efforts have been underway during the past several years to build on the programs and other measures identified in this article. The U.S. Department of Health and Human Services Maternal and Child Health Bureau in the Health Resources and Services Administration (HRSA) and the National Center for Injury Prevention and Control in the CDC have supported the development of community, state, and federal partnerships in western states for the development of suicide prevention efforts. Multiagency teams from 10 western states (Alaska, Colorado, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming) have participated in three working conferences. These state teams included representatives from public health, mental health, education, social services, substance abuse, and law enforcement agencies, as well as emergency medical service providers, crisis lines, and parent survivors. During each of these working conferences participants learned from experts about current knowledge, the extent of the problem, strategies that have proven effective in reducing suicides and suicidal behavior, and processes undertaken to develop awareness of the problem and to obtain resources to address it. The state teams developed strategies for youth suicide prevention efforts and completed written plans for state and local efforts.

The state team participation has been coordinated by the Adolescent Health and/ or Injury Prevention Coordinator in the state Department/Division of Health. These individuals have been most often located in the state Maternal and Child Health/Title V program. They have recruited and coordinated participation from a diverse group of partners including parent/family survivors of suicide, education, mental health, substance abuse, crisis lines, higher education, medical examiners/coroners, juvenile justice, legislators, local health jurisdictions, emergency medical service (EMS), health care providers, law enforcement, and voluntary organizations such as girl scouts, PTA, gay and lesbian youth advocacy/support groups, and clergy. These teams have worked to develop a broad range of targeted state and local efforts for suicide prevention. Some examples of their efforts are public information and awareness campaigns, improved efforts in data collection and publication, obtaining state-based sanction and funding for ongoing efforts focused on youth suicide prevention, community-based pilot programs for prevention, and development of training materials for providers.

State teams have developed broad partnerships that have demonstrated significant progress since the survey conducted by Metha, Weber, and Webb. These partnerships have gained a great deal of strength from the diversity of their membership. Some examples of this strength can be seen in the contributions brought by family survivors of youth suicide, medical examiners, and health providers. Parent survivors have brought a voice and a perspective to the partnership that have gained the attention of state legislators, resulting in passage of state legislation and funding for youth suicide prevention efforts in Oregon and Washington and in support for a study profiling completed youth suicides in Utah. The partnership of medical examiners and coroners has helped states to identify problems in reporting of data and to increase public awareness of the extent of the risk of suicide among youths. In several states, medical care providers have helped to raise the awareness of the link between suicide and firearms.

The accomplishments of western state efforts have been impressive. They have included two states (Oregon and Washington) with legislation and state funding for youth suicide prevention and state task forces in Colorado and North Dakota. Rural school crisis community-based suicide networks have been established in nearly 60 communities in Alaska. Colorado is implementing Child Fatality Reviews of all youth suicide deaths, and Utah is completing its study of youth suicide deaths. Idaho has conducted training for educators, clergy, coroners, and funeral directors on youth suicide. A simple, three-question youth suicide risk screening questionnaire is being developed for use by EMS providers in Alaska. The efforts in Washington state since the initial funding of youth suicide prevention have lead to the completion of a state plan, a media campaign to increase public awareness about the signs and risks of youth suicide, training for gatekeepers to recognize signs and risks, and increasing capacity of community crisis response groups to reach and respond to youth at risk for suicide.

At the 1997 Bi-Regional HRSA/CDC sponsored meeting for youth suicide prevention held in Breckenridge, Colorado, there were over 140 participants and teams from 13 western states, The sessions included summaries of state accomplishments in prevention efforts; research issues in prevention of youth suicide; updates on results of program and research efforts of the Division of Violence Prevention at the National Center for Injury Prevention and Control (part of the CDC); role of the medical examiner/coroners in investigation of suicide; suicide and the media; initiatives on asset building for youth; school-based programs; EMS and trauma care contributions to prevention; programs for rural, ethnic, and culturally diverse populations; gatekeeper training; suicide postvention; and exemplary community-based suicide prevention and youth development efforts.

All participating state teams developed plans. These plans included defining goals and objectives and activities that will be the focus of ongoing efforts to reduce youth suicidal behavior and completed suicides. They are built around action steps with identified lead persons and targeted indicators for completion. Some of the new areas for efforts identified in the 1997 plans include the following.

1.  Collaboration between Hawaii and Alaska teams to train gatekeepers in suicide prevention.
2.  Insuring screening for depression and access to behavioral and mental health services for adolescents in the state Title XXI Child Health Insurance Plans.
3.  Conducting surveys in schools to determine capacity and needs for responding to traumatic incidents.
4.  Increasing identification and referral of at-risk youth by health care providers for appropriate care and services.
5.  Promoting development of assets in youth through local and state programs.
6.  Expanding efforts to increase public awareness of the problem of youth suicide.
7.  Conducting evidence-based research on youth suicide prevention.
8.  Expanding efforts to address issues of survivors (parents, families, and friends).
9.  Supporting efforts of SPAN (Suicide Prevention Advocacy Network).
10.  Expanding efforts to include investigation of completed suicides in Child Fatality Review Panels.
11.  Expand efforts to collaborate with First Nations and other Native American suicide prevention efforts.
12.   Develop firearm education for youth leaders and providers and support safe storage efforts.
13.  Expand collaboration with, juvenile justice partners.
14.  Continue and support efforts for gatekeeper training.
15.  Increase capacity of and access to crisis response for youth.

While there are clearly no simple, single-focus approaches that can turn around the very disturbing and difficult problem of youth suicides and suicidal behavior, the experience of the efforts of the western states described here provides a model of cooperative/collaborative efforts that can be undertaken. In public health we have not shied away from working toward the prevention of difficult problems such as teen pregnancy, infant mortality, and sexually transmitted diseases. We have also learned that making a difference requires a sustained and multiyear commitment. In order to reduce youth suicide, we need to be prepared to make similar commitments of time, energy, and resources. Protecting our youth, their friends, families, and communities from a leading cause of death will require partnerships among individuals and groups who are not used to working together where there is an uncharted course that must be explored, recorded, and redirected to reduce these deaths, injuries, and grief.

References

"Boy 11 dies after suicide attempt" (1997, Dec. 2) Seattle Times, p. B-2.
Centers for Disease Control and Prevention. (1997). Regional variations in suicide rates-United States, 1990-1994. Morbidity and Mortality Weekly Report, 46, 789-793.
Centers for Disease Control and Prevention. (1997a). Suicide in Washington, 1980-1995. Morbidity and Mortality Weekly Report, 46, 502-506.
Fleming, M. (1996). Healthy youth 2000, a mid-decade review. Department of Adolescent Health, American Medical Association, 29-31.
National Center for Health Statistics. (1994). Vital Statistics, 43, 95-1120. S. Res, 84, 105th Cong., Ist Sess., 143 Cong. Rec. 57 (1997).
Seiden, R. H. (1984). Death in the West: A regional analysis of the youthful suicide rate. Western Journal of Medicine, 40, 969-973.
Spicer, R. S., & Miller, T. R. (1997). Epidemiology of medically identified suicide attempts. Paper presented at the American Public Health Association conference, Indianapolis.

Margaret A. West is Regional Program Consultant at the Seattle Field Office, Health Resources and Services Administration, U.S. Department of Health and Human Services. Address correspondence to Margaret A. West, Maternal and Child Health, Seattle Field Office, Health Resources and Services Administration, 2201 Sixth Avenue, Mail Stop RX-27, Seattle, WA 98121.

Suicide and Life-Threatening Behavior, Vol. 280, Summer 1998 0c 1998 The American Association of Suicidology