Suicide prevention is complex and necessary at many levels. One obvious suicide prevention strategy includes supporting healthy childhood environments in which child maltreatment, intimate partner violence, and substance abuse are absent. Suicide prevention demands individual-level prevention and broader public health strategies that reduce the likelihood of suicide before individuals become vulnerable or before vulnerable individuals engage in suicidal behaviors. Current knowledge suggests reaching individuals early when developmental patterns leading to problematic behaviors in youth and psychiatric symptoms can be prevented or changed. Suicide prevention includes surveillance of suicidal acts to determine patterns and intervention points. The best suicide prevention incorporates multiple interventions at different levels because of overlapping of risk and protective factors across many domains of influence.
Clinical Interventions for At-Risk Individuals And Families
The ability of primary care and other health providers to recognize and treat depression, substance abuse, and other mental illnesses associated with suicide risk, often as comorbid conditions, and to make referrals to specialty care when appropriate, all constitute prevention. Reducing stigma associated with suicidal behaviors and supporting help seeking for mental illness, including substance abuse disorders, contribute to reducing suicidal risk. Accessibility to and acceptability of effective clinical care for mental, physical, and substance abuse disorders, and family and community support are protective, as are removing financial barriers and alleviating geographic distance as barriers to clinical interventions.
With the availability of many antidepressants, it is critical to work with a knowledgeable service provider to determine the best medication(s) and most appropriate levels if a drug regimen is indicated. Suicide prevention contracts are widely used. Their effectiveness may depend on the strength of the therapeutic relationship between clinician and patient. They are likely overvalued and should not be used as the sole treatment for patients with suicidal behaviors.
Means Restriction
Evidence suggests that means restriction has an immediate impact on suicidal behavior. Examples of lethal means (and restrictions) include firearms (not having them in the home, removing them from the home to prevent access for at-risk persons, locking them away, separating the firearm from ammunition); bridges (barriers, particularly on bridges that are symbolic, e.g., the Golden Gate bridge); and potentially deadly medications, for example, acetaminophen (bubble wrap, where only one tablet can be undone at a time). Evidence consistently indicates that firearms are the most common method for suicide completion for all demographic groups in the United States, and are particularly highly used in the 24 and younger age groups. Declines in suicides following means restrictions sometimes occur without means substitution, resulting in reduced suicides, especially in the short term. The impact of such restrictions over longer time periods is not clear. Evidence suggests legislation can be effective in promoting means restriction. Health care professionals should involve families in reducing access to means. Education of health care professionals about means restriction can increase their potential effectiveness in helping reduce suicidality among their patients.
School Prevention Programs
School suicide prevention programs that include longer-term education and clinical referral have shown success in reducing suicidal acts. Components include skills training, gatekeeper training, crisis response plan(s), and screening for youth at risk. Onetime assemblies teaching about suicide have not been determined effective; some evidence indicates they may be harmful. Concern has been raised that indiscriminate suicide awareness efforts and overly inclusive screening risk factor lists may promote suicide as a possible solution to ordinary distress or suggest that suicidal thoughts and behaviors are normal responses to stress. Recent evidence from a randomized control trial suggests, however, that no harm came from screening universally in school settings for suicidal risk. Given that youth suicides are often impulsive, screening should take place at regular intervals. Natural or peer helpers have been used in schools with some success since youth often confide in peers before adults. It is critical that peer or natural helpers are backed with knowledgeable adults and clinical support in the school setting.
Community Prevention Programs
Hotlines are used throughout the United States; some evidence indicates that they do not reduce suicide completions, but may have some impact on suicide attempts. The value of hotlines to reduce suicidal risk is limited because they are not used by high percentages of those at risk and successful treatment referral is limited. Gatekeeper training, when included with other integrated suicide prevention programs, has shown some success. Much of the focus on suicide prevention is among youth. Few programs focus on older adults. Those programs that do need to address suicidality complicated with chronic illness, bereavement, and isolation.
In the U.S. Air Force, following the implementation of a multipronged suicide prevention intervention, suicide deaths were reduced by 33% from 1997 to 2002. The program provided easily available and free treatment. In some cases, treatment was mandated. Other efforts focused on institutionalized communitywide training to heighten awareness of suicide risk factors, community-wide education about policy changes regarding availability of resources, and senior officials endorsing radical changes in social norms to decrease stigma around help-seeking behaviors. This program is one of very few that has been extensively evaluated. Continuous evaluation will determine whether the Air Force program maintains success in substantially reducing suicidal acts.
Suicide prevention necessitates ongoing vigilance. Anecdotal evidence indicates that suicidal activity increases when successful programs cease to operate systemically at multiple levels.
Media
Educating media professionals about appropriate reporting of suicides seems to reduce suicidal acts in certain contexts. However, data are limited, calling for evaluation of long-term public education campaigns and media training to change public knowledge and attitudes toward suicide and reduce suicidal behaviors.
Stateand National-Level Suicide Prevention
Comprehensive multilevel integrated state and national suicide prevention strategies that focus on suicide risk factors and barriers to treatment appear to reduce suicidal acts. Evaluation of these programs is challenging due to the many variables at individual and population levels that interact to impact suicide rates.
National strategies for suicide prevention were outlined in 1999, calling for national-level federal and private partnerships, state suicide prevention plans, school and gatekeeper programs, and other promising prevention strategies. Lack of adequate planning and funding for programs and evaluation continue to challenge suicide prevention efforts.
Bibliography:
- Goldsmith, S. K., Pellmar, T. C., & Kleinman, W. E. (Eds.). (2002). Reducing suicide: A national imperative. Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide and Board on Neuroscience and Behavioral Health. Institute of Medicine. Washington, DC: National Academies Press.
- Gould, M. J., Marrocco, F. A., Kleinman, M., Thomas, J. G., Mostkoff, K., Cote, J., et al. (2005). Evaluating iatrogenic risk of youth suicide screening programs. Journal of the American Medical Association, 293, 1635–1643.
- Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer D. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Child and Adolesdent Psychiatry, 42, 386–405.
- Knox, K., Litts, D. A., Talcott, G. W., Feig, J. C., & Caine, E. D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention program in the U.S. Air Force: A cohort study. British Medical Journal, 327, 1376–1380.
- S. Public Health Service. (1999). The Surgeon General’s call to action to prevent suicide. Washington, DC: Author.
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