National Strategy for Suicide Prevention

National Strategy for Suicide Prevention: Goals and Objectives for Action CEU Course


1. Increase awareness of suicide prevention methods
2. Increase familiarity with broad based support systems
3. Become familiar with strategies to reduce stigma
4. Learn how to promote efforts to reduce efforts to lethal means of self harm.
5. Identify at risk behavior
6. Implement appropriate treatment and resources
7. Develop and Promote Effective Clinical and Professional Practices
Table of Contents:
1. GOAL 1: Promote Awareness that Suicide is a Public Health Problem that is Preventable
2. GOAL 2: Develop Broad-Based Support for Suicide Prevention
3. GOAL 3: Develop and Implement Strategies to Reduce the Stigma Associated with Being a Consumer of Mental Health, Substance Abuse, and Suicide Prevention Services
4. GOAL 4: Develop and Implement Community-Based Suicide Prevention Programs
5. GOAL 5: Promote Efforts to Reduce Access to Lethal Means and Methods to Self-Harm
6. GOAL 6: Implement Training for Recognition of At-Risk Behavior and Delivery of Effective Treatment
7. GOAL 7: Develop and Promote Effective Clinical and Professional Practices
8. GOAL 8: Improve Access to and Community Linkages with Mental Health and Substance Abuse Services
9. GOAL 9: Improve Reporting and Portrayals of Suicidal Behavior, Mental Illness, and Substance Abuse in the Entertainment and News Media
10. GOAL 10: Promote and Support Research on Suicide and Suicide Prevention
11. GOAL 11: Improve and Expand Surveillance Systems
12. Looking Ahead
13. References
GOAL 1: Promote Awareness that Suicide is a Public Health Problem that is Preventable
Why is this Goal Important to the National Strategy?
In a democratic society, the stronger and broader the support for a public health initiative, the greater its chance for success. The social and political will can be mobilized when it is believed that suicide is preventable. If the general public understands that suicide and suicidal behaviors can be prevented, and people are made aware of the roles individuals and groups can play in prevention, many lives can be saved.
In order to mobilize social and political will, it is important to first dispel the myths that surround suicide. Many of these myths relate to the causes of suicide, the reasons for suicide, the types of individuals who contemplate suicide, and the consequences associated with suicidal ideation and attempts. Better awareness that suicide is a serious public health problem results in knowledge change, which then influences beliefs and behaviors (Satcher, 1999). Increased awareness coupled with the dispelling of myths about suicide and suicide prevention will result in a decrease in the stigma associated with suicide and life-threatening behaviors. An informed public awareness coupled with a social strategy and focused public will lead to a change in the public policy about the importance of investing in suicide prevention efforts at the local, State, regional, and national level (Mrazek & Haggerty, 1994).
Background Information and Current Status
The factors that contribute to the development, maintenance, and exacerbation of suicidal behaviors are now better understood from a public health perspective (Silverman & Maris, 1995). A public health approach allows suicide to be seen as a preventable problem, because it offers a way of understanding pathways to self-injury that lend themselves to the development of testable preventive interventions (Gordon, 1983; Potter, Powell & Kachur, 1995). Although some have criticized the public health model of suicide as being too disease-oriented, it does, in fact, take into account psychological, emotional, cognitive, and social factors that have been shown to contribute to suicidal behaviors (Potter, Rosenberg, & Hammond, 1998).
Did You Know?
In the 10 years 1989-1998, 307,973 people died as a result of suicide.
Suicide is a major public health problem. It is one of the top ten leading causes of death in the United States, ranking 8th or 9th for the last few decades. For the approximately 31,000 suicide deaths per year, there are an estimated 200,000 additional individuals who will be affected by the loss of a loved one or acquaintance by suicide. The economic and emotional toll on the Nation is profound (Palmer, Revicki, Halpern, & Hatziandreu, 1995).
How Will the Objective Facilitate Achievement of the Goal?
The objectives established for this goal are focused on increasing the degree of cooperation and collaboration between and among public and private entities that have made a commitment to public awareness of suicide and suicide prevention. To accomplish this goal, support for innovative techniques and approaches is needed to get the message out, as well as support for the organizations and institutions involved.
Objective 1.1:
By 2005, increase the number of States in which public information campaigns designed to increase public knowledge of suicide prevention reach at least 50 percent of the State's population.
Suicide has been designated as a serious public health problem by the U.S. Surgeon General, and the 105th U.S. Congress has recognized that this problem deserves increased attention [U.S. Senate Resolution 84 (5/6/97) and U.S. House Resolution 212 (10/9/98)]. They recognize suicide as a national problem and declare suicide prevention as a national priority, encouraging the development of an effective national strategy for the prevention of suicide. Public and private organizations have developed information campaigns to educate the public that suicide is preventable, as it can be a consequence of other treatable disorders such as depression, schizophrenia, bipolar illness, alcohol and drug abuse, and certain medical conditions. Campaigns alert professional, community, and lay groups about the common signs and symptoms associated with suicidal behavior. Some organizations with existing campaigns include the American Association of Suicidology (AAS), the American Foundation for Suicide Prevention (AFSP), the Suicide Awareness\Voices of Education (SA\VE), the Suicide Prevention Advocacy Network (SPAN USA), and Yellow Ribbon Suicide Prevention Program.
Ideas for Action Work with local media to develop and disseminate public service announcements describing a safe and effective message about suicide and its prevention.
Public information campaigns can take many forms. No single slogan or message works for everyone. For example, the primary purpose of the annual National Depression Screening Day is to identify, in a variety of settings, individuals with symptoms of depression and refer them for treatment (Jacobs, 1999b). However, such a screening program performed at primary care centers, mental health and substance abuse treatment centers, colleges, universities, and places of employment can play an important role in raising awareness and educating large groups of individuals about this mental disorder and its association with suicidal behaviors. Because no one
is immune to suicide the challenge is to develop a variety of messages targeting the young and the old, various racial and ethnic populations, individuals of various faiths, those of different sexual orientations, and people from diverse socioeconomic groups and geographical regions.
Objective 1.2:
By 2005, establish regular national congresses on suicide prevention designed to foster collaboration with stakeholders on prevention strategies across disciplines and with the public.
Broad-based participation and involvement is needed to ensure progress in reducing the toll of suicide. Open discussion and assessment of suicide prevention programs can only lead to their refinement and better chances for success.
The techniques and tools to create and implement prevention initiatives can be taught and demonstrated. Learning how to develop and disseminate public health messages and to mount public health campaigns is critical to implementing suicide prevention efforts.
A number of organizations have convened annual, national meetings devoted to suicide prevention. Currently, such meetings are sponsored by AAS, AFSP, and biennially by the International Association for Suicide Prevention (IASP). The establishment of regular national congresses on suicide prevention, collaboratively sponsored by more than one organization, will maintain interest and focus on this issue. Ideally, these national congresses should be sponsored by public/private partnerships (see Objective 2.2), and focus on needs and plans for coordinating effective suicide prevention efforts.
Ideas for Action Identify foundations and other stakeholders to contribute to the support of national congresses on suicide prevention.
Objective 1.3:
By 2005, convene national forums to focus on issues likely to strongly influence the effectiveness of suicide prevention messages.
National forums increase awareness of the problem of suicide and serve to mobilize social will. Such meetings keep the subject in the forefront of attention and raise concerns to the national level. Such activities increase connectedness between and among key stakeholders, and serve to bring support, consensus and collaboration to suicide prevention efforts.
Focusing on factors that influence the effectiveness of suicide prevention initiatives is critical to an overall strategy. National forums are opportunities to focus on specific issues that affect all efforts to mount suicide prevention initiatives. By highlighting specific areas, consensus can be reached on how best to incorporate elements into a suicide prevention plan and how best to evaluate effectiveness.
Ideas for Action Incorporate suicide awareness and prevention messages into employee assistance program activities in businesses with greater than 500
employees.
Objective 1.4:
By 2005, increase the number of both public and private institutions active in suicide prevention that are involved in collaborative, complementary dissemination of information on the World Wide Web.
The World Wide Web offers an unparalleled opportunity to bring public health information to a much broader audience because it can be accessed at home, at work, at schools, at community centers, at libraries, or at any other location where there is access to the Internet. Not only does the World Wide Web offer exciting possibilities for the delivery of public health messages (including promoting awareness and referral sources for those in need), but it offers an opportunity to develop preventive interventions as well.
For example, the World Wide Web offers the potential for interactive dialogue and exchange of accurate information. Clear, concise, and culturally sensitive public health messages are key to assisting individuals to evaluate their at-risk status accurately and to know where and how to get help. It therefore is important that both public and private institutions committed to suicide prevention activities collaborate and cooperate to deliver information that is consistent, comparable, complementary, and not competitive. In addition to several Federal websites (see Appendix D); some of the key national organizations currently disseminating suicide prevention information on the World Wide Web include AAS, AFSP, IASP, SPAN USA, and the American Academy of Pediatrics.
Did You Know? Suicide is the eighth leading cause of death for all Americans.
GOAL 2: Develop Broad-Based Support for Suicide Prevention

Screening Children and Adolescents (5–18 Years)

Screening Children and Adolescents (5–18 Years)
Screening for child and adolescent behavioral disorders using the Pediatric Symptom Checklist (PSC) is widely used in many medical practices and Medicaid programs. The current literature documents the ability of this brief, one-page instrument to identify children in need of further behavioral evaluation. Unfortunately, there are no randomized, controlled studies that document outcomes on screened individuals or groups, compared with populations not screened. PSC screening is classified “targeted” rather than “general” because the studies needed to provide a firmer evidence base have not been done.

A. Screening for Evidence of Behavioral Disorder

The PSC is a brief, one-page, 35-question instrument designed for use by parents in the doctor’s waiting room. The questionnaire is designed to detect behavioral and psychosocial problems in children from 2 to 16 years of age, and it has been used effectively in persons up to 18 years of age (Bernal et al., 2000). Each of the questions can be answered with a “never,” sometimes,” or “often,” with scores of 0, 1, or 2, respectively, attributed to each answer. Scores of 24, 28, or higher, depending on the age of the child, are considered indicative of a possible behavioral or psychosocial problem and will warrant further exploration by the clinician (Jellinek & Murphy, 1999).

The PSC has been suggested as a tool for universal use with children 2 to 16 years of age to screen for behavioral and psychosocial problems (Jellinek & Murphy, 1988; Walker, LaGrone, & Atkinson, 1989; Murphy, Arnett, Bishop, Jellinek, & Reede, 1992; Jellinek & Murphy, 1999, Gardner, 2002; Jellinek et al., 1999). In use since the 1970s, the PSC has been tested and used in tens of thousands of children; scored well in a test of its usefulness to the Medicaidsponsored Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program (Murphy et al., 1996); and is used in several States in the context of their EPSDT programming (Jellinek & Murphy, 1999; Bernal et al., 2000; Gardner, Kelleher, & Pajer, 2002).

The PSC has been found to be acceptable to parents, regardless of socioeconomic status or ethnicity, and to clinicians and clinic office staff (Murphy et al., 1992; Murphy, Reede, Jellinek, & Bishop 1992; Jellinek et al., 1999; Navon, Nelson, Pagano, & Murphy, 2001). It has been validated against more elaborate classification instruments—the Child Behavior Checklist (CBCL) and the Clinician’s Global Assessment Scale (CGAS (Walker et al., 1989; Jellinek & Murphy, 1999). It also routinely generates prevalence rates for pediatric psychosocial and behavioral disorders of approximately 12 percent, which is consistent with other estimates of pediatric behavioral and psychosocial disorders (Jellinek & Murphy, 1999; Jellinek, 1999). The expected increase in psychosocial dysfunction with lower socioeconomic class (Jellinek, Little, Murphy, & Pagano, 1995) and the expected correlation with maternal psychological distress and marital adjustment (Sanger, MacLean, & Van Slyke, 1992) have been clearly documented.

The primary outcome measure noted in the PSC literature has been the percentage of children referred for behavioral or psychosocial evaluation and treatment. This rate of referral has dramatically increased with the introduction of the PSC in every study where this measure has been reported (Navon et al., 2001). In one study, the referral rate increased from 1.5 percent before implementation of the PSC to 12 percent, then dropped back to 2 percent after the PSC screening was discontinued (Murphy et al., 1992). This review found no studies that address the behavioral and psychosocial benefits to the children screened or costs associated with referral of false-positive cases.

One study published in 2000 (Bernal et al., 2000) reported average log costs for health and psychiatric care for all children studied at $393 per year, and costs of those with anxious, depressed symptoms at $805 per year. Chronically ill children showed the highest health care costs, with average log costs of $1,138 per year. Psychosocial dysfunction was associated with higher costs. Unfortunately, this study did not explore whether detection and treatment of the psychosocial dysfunction could lower these costs. With a documented minimum sensitivity (accurately detecting true “positives” or those with the illness) of 80 percent, and a specificity (detecting those without disease) of 68 percent or better (Jellinek et al., 1988; Jellinek & Murphy, 1999), this screening instrument may miss up to 20 percent of children who have serious problems, and refer up to 32 percent of well children to diagnostic interviews that prove negative for any treatable behavioral or psychosocial behavior. Although these efficacy statistics are within acceptable ranges for screening instruments, they do speak to costs of program implementation that need to be considered. Like virtually all other screening programs, little or no benefit will accrue without follow-up treatment for those found to be in need of such treatment. Owing to the research findings, the PSC may be considered a “targeted” service for use in health care delivery settings with providers and health care systems wishing to use it.

The available literature leaves unanswered the possible use of the PSC when the primary care practitioner suspects a significant behavioral problem but does not have enough information to confirm or deny this impression. For such cases, health care systems may wish to make this instrument available to providers for selective use, at their discretion.

The PSC, along with articles describing its proper use on the Pediatric Development and Behavior Web site, is available at www.dbpeds.org/handouts/ (Jellinek & Murphy, 1999) under “screening.” It should be used without modification, other than for translation when working with non- English-speaking families.

The PSC consists of 35 very brief statements to which the parent responds “never,” “sometimes,” or “often.” Presented on a single page with check-off boxes, sample statements include: “Complains of aches/pains; tires easily, little energy; has trouble with a teacher; acts as if driven by a motor … .” The responses are graded on a zero-to-two scale. Depending on age, a score of 24, 28, or greater is considered indicative of significant psychosocial impairment (Jellinek & Murphy, 1999).

Summary: Children and Adolescents 5–18 Years

Screening for potential child and adolescent behavioral disorders using the PSC is widely used in medical practices and Medicaid programs. Because of its low burden (brief), ease of use, wide applicability, and validity, the literature supports its use by health plans with all children in a health care system. In this report, such screening is classified as a “targeted” service rather than “general” because no randomized controlled trials that could document outcomes have been attempted.