RESOURCES FOR RESEARCHERS AND PROGRAM EVALUATORS

Prevention Targeting

In suicide prevention, "targeting" refers to a focus on modifying something that is causally related to self-injury within a specific population. The goal is to break the causal chain and prevent self-injury. There are two complementary ways to think about prevention targeting. One is to focus on the level of the prevention target. The other is to focus on the injury stage.

Target levels

One way to think about prevention is to focus on the level of the intervention target. A commonly used framework for describing intervention levels is "indicative," "selective," and "universal":

• Indicated interventions are highly targeted and frequently involve identification, treatment, and skill building among individuals and families. At this level the focus is on early detection and, frequently, intensive individual treatment relying on one-on-one, provider-to-patient interaction. Early-treatment programs are examples of indicated strategies. Indicated interventions tend to occur within the traditional health and mental health care delivery system and tend to be resource-intensive per person served.
• Selective interventions are targeted at high-risk groups with a focus on screening and group prevention activities. Peer support programs for students with a number of risk indicators would be an example. Selective interventions are less resource-intensive than indicated programs.
• Universal interventions are targeted at communities or larger aggregations and may include media or educational campaigns and other broad-population-based prevention strategies. Universal interventions may also be environmental prevention strategies that focus on physical changes that reduce risk. In suicide prevention, barriers on high places, modifications to automobile exhaust systems, and reducing access to lethal means, especially firearms, are examples of environmental strategies.

Targeting by stage

In suicide prevention, there are three stages of prevention— primary, secondary, and tertiary—which correspond to "before suicidal behavior occurs, as suicidal behavior occurs," and "after suicidal behavior occurs," respectively. Intervention strategies will vary, depending on the stage being targeted.

• Primary prevention refers to an effort that targets the causes of suicide-related behavior and injury before self-injury or suicidal behavior occurs. Such conditions as depression, impulsive behavior, or alcohol and drug abuse might be targets of primary prevention, usually through health and mental health services. Implementing programs that prevent alienation or isolation of youth, such as bullying prevention and improving access to health and mental health care for individuals, are other examples of primary prevention strategies. Finally, primary prevention strategies also include efforts to reduce access to lethal means or to address media coverage of suicide.
• Secondary prevention attempts to target intervention as behavior is occurring, with the goal of minimizing any selfinjury that may occur. Early detection of suicidal ideation, or planning, and appropriate referral and treatment for suicide risk are examples of secondary prevention.
• Tertiary prevention targets intervention following self-injury or behavior to minimize the impact and reduce the likelihood of subsequent self-injury. Effective intervention in a suicidal crisis, therapeutic treatment following suicidal behavior to prevent future attempts or to reduce the severity of an injury are examples of tertiary prevention. Referral for other supportive services following a suicide attempt is another example.

By combining the level of intervention and the stage of intervention we can describe and compare different strategies. The efficacy, effectiveness, and cost of each prevention strategy are important when making such comparisons. For example, comparing the effects of screening and treatment for depression (indicated, primary) with training gatekeepers (selective, secondary), or comparing a particular clinical treatment for depression (indicated, primary) with a strategy to reduce access to firearms among youth (universal, primary), can provide sound data to help us choose among and combine different strategies.

The key is to consider the effectiveness of various strategies for reducing suicide. With this information we can make decisions about the best use of scarce resources.

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