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National Strategy for Suicide Prevention:
Goals and Objectives for Action
Appendix C
Examples of Research Efforts that May Yield
Information Important to Suicide Prevention Efforts
Preventive efforts to reduce suicide should be grounded in research
that provides information about modifiable risk and protective factors, as
well as about appropriate target populations on which to focus prevention
efforts (see The Public Health Approach as Applied to Suicide,
Introduction). Once these are identified, prevention programs must be
carefully tested to determine if they are safe, truly effective, and worth
the considerable cost and effort needed to implement and sustain them.
Included in this appendix are examples of approaches for delivering
preventive interventions aimed at target populations and/or particular
settings. In the absence of clear evidence demonstrating that such
approaches are effective, ongoing studies are highlighted to show where
existing efforts are currently being tested, or approaches which could be
evaluated with regard to their potential to reduce suicide. Because completed
suicide is a relatively rare event, many programs will be limited to
proving effectiveness in reducing suicide attempts and serious suicide
ideation, reducing risk factors strongly associated with suicide, or
strengthening protective factors.
Preventing Youth Depression and Violence
Suicide is difficult to predict, but it does not usually "come out of the
blue." Many of the factors that put youth at risk for suicide are understood,
specifically mental disorders, substance abuse, prior suicide
attempt, sexual abuse, impulsive and aggressive behavior, and access to
a firearm (USPHS, 1999). Logically, reducing such risk factors should also
reduce risk for suicide. While there are effective treatments for many of
the risk factors of suicide, including depression (Findling et al., 1999;
Lewinsohn & Clarke, 1999), and a growing number of ways to prevent
violence and to prevent and treat substance use (USPHS, 2001), the long-
term outcome of these interventions in reducing suicide is not yet
known.
Prior research suggests that suicidal youth are not likely to self-refer or
seek help from school staff, nor do knowledgeable peers request adult
help (Kalafat & Elias, 1995). This suggests that in the absence of effective
ways to improve self-or peer-referral, schools would need to screen for
youth at risk, and that school staff need to be trained to be aware of the
warning signs for suicidal youth, and have a plan of action for helping
youth at risk. The U.S. Department of Education recently issued Early
warning, timely response: A guide to safe schools which offers research-based
practices designed to assist school communities in early identification
of these warning signs and in developing prevention, intervention
and crisis response plans
(http://www.ed.gov/about/offices/list/osers/osep/gtss.html).
Perhaps the greatest challenge for school-based suicide prevention
efforts is monitoring and evaluation. A monitoring system has
been successfully used by the Dade County Public Schools to assess the
prevalence of suicidal behavior, identify the grade level and school classification
of those youth most at risk, as well as assess progress of prevention
efforts (Zenere & Lazarus, 1997). Screening approaches should
be carefully considered with regard to their costs and benefits, such as
the problem of over-identifying youth in need of services, lack of adequate
and timely referrals, or inadvertently further stigmatizing youth at
risk.
Many of the established treatments known to reduce mental and substance
use disorders have been tested on youth who typically have come
to the attention of care providers (parents, teachers, pediatricians).
Because mental disorders and substance use disorders are under-detected
and under-treated in youth (U.S. Department of Health and Human
Services, 1999;
http://www.surgeongeneral.gov/library/mentalhealth/home.html),
another approach to prevention has been the use of school-based
screening to identify youth at risk. At least two screening approaches are
currently being investigated. One approach identifies youth at risk for
dropping out of school through poor attendance and failing grades, further
evaluates those youth, and then provides various types of interventions
to reduce the potential for suicide and substance use (Thompson &
Eggert, 1999). To date, there is no strong evidence that this approach
reduces suicidality, but it has been shown to increase adolescents' sense of
personal control, which may have other long-term beneficial effects. In
another school-based approach, brief screening instruments are used to
identify youths with depressive symptoms and/or suicidal thoughts. They
are then evaluated in a more thorough manner and referred to appropriate
treatment (Shaffer & Craft, 1999). The effectiveness of this approach
has yet to be evaluated. While such screening efforts are more likely to
detect youth at risk, they are not precise in their ability to detect only those
at risk for suicide. Because of the likelihood of identifying youth with multiple
problems, including those not necessarily at risk for suicide, such
screening efforts can quickly burden a limited referral or service system.
The hazards of labeling and not treating youth detected in such screening
efforts must also be considered.
Another approach being promoted to identify at-risk youth who are not
yet in treatment is gatekeeper training, involving the education of adults
who regularly come in contact with suicidal youth in schools and the community.
Some efforts also attempt to train youth so that they can refer
other youth at risk to sources of help. The Centers for Disease Control and
Prevention (CDC) has described a range of gatekeeper training approaches
(O'Carroll et al., 1992; http://www.cdc.gov/ncipc/pub-res/youthsui.htm
).
Although some evidence suggests increased knowledge and improved attitudes
toward helping suicidal youth following gatekeeper training pro-grams,
none has been systematically evaluated to determine if more youth
at risk are receiving treatment as a result of these programs or if the programs
are preventing suicidal behavior.
Universal interventions encompass a broader health-promotion
approach. Such interventions are applied to all youth and typically focus on
promoting protective factors or halting the development or progression of
risk factors. These efforts are applied across home, school, and peer contexts.
Successful universal interventions commonly feature efforts to build
one's assets in social, problem solving, and other skills. Many initiated
early in a child's life (e.g., improving early parent-child relationships,
enhancing problem solving skills; increasing adaptive social behavior)
have been shown effective in reducing aggression and early substance
use (e.g., see Catalano et al., 1998; for a review, Olds et al., 1998)
Although these programs modify risk and protective factors for suicide,
they have not been evaluated specifically for suicide as an outcome in
adolescence or young adulthood.
The Surgeon General recently reviewed the effectiveness of violence
prevention programs (USPHS, 2001), providing a comprehensive list of
model programs (http://www.surgeongeneral.gov/library/youthviolence/report.html
).
Safe Schools/Healthy Students, a collaborative effort of the U.S.
Departments of Education, Justice, and Health and Human Services is
currently funding 77 school-based violence prevention programs across
the U.S. that offer opportunities to examine aspects of suicidal behavior
in this population (http://www.samhsa.gov/centers/cmhs/cmhs.html).
Programs with the goals of promoting healthy development, fostering
resilience, and preventing violence and suicidal ideation and behavior
have been planned and implemented. Data collection is ongoing and
promises to yield important information about the effectiveness of the
application of evidence-based practices on a large scale.
While a school setting can be considered a focus for a type of community-
based prevention, other prevention approaches have considered
geographic areas, such as neighborhoods. Preventive interventions for
these contexts include building community assets or "collective efficacy"
(Sampson, Raudenbush, & Earls, 1997). Again, whether increased collective
efficacy is associated with lower suicidality has yet to be demonstrated.
The U.S. Air Force approach to reducing suicide can also be considered
a type of community-based intervention for adults in a work set-ting
(see below). Additionally, some universal "policy" interventions suggest
that broad-based environmental changes can have an impact on suicide
rates (See the example under Individuals with Substance Use
Disorders).
Improving Follow-Up Treatment from Emergency Departments
Because the vast majority of persons do not seek follow-up treatment
after attempting suicide (Piacentini et al., 1995), one approach being taken
to reduce repeat attempts is to refer individuals to treatment after they
have been seen in the emergency department (ED). Since adolescents and
young adults are more likely to make nonfatal suicide attempts, a number
of studies have focused on these subgroups. One study compared standard
care to an intervention in which emergency department staff were
taught to recognize the seriousness of suicide attempts, to reinforce the
importance of outpatient treatment and to provide for an ED-based initial
family education/therapy session. When compared to standard care, this
enhanced ED intervention was shown to increase treatment attendance
and decrease depression among adolescent Latino suicide attempters.
(Rotheram-Borus et al., 2000). However, the sample size was too small to
determine whether the intervention had an effect on the number of future
suicide attempts. Another study currently being conducted is testing the
effectiveness of a cognitive-behavioral therapy intervention implemented
immediately after patients have been evaluated in an ED following a sui-cide
attempt (see grant by Aaron Beck; http://www.nimh.nih.gov/suicideresearch/suiabs.pdf).
The targets of the intervention are modifiable risk factors such
as substance abuse, depression, hopelessness, and suicidal ideation, which
are addressed through problem-solving strategies, utilization of social support,
and increasing compliance with adjunctive medical, substance abuse,
psychiatric and social interventions.
Primary Care Interventions for Depressed Elders
Multiple studies have found that elderly are much more likely to have
contact with primary care doctors than mental health specialists in the
weeks preceeding their death. Follow-back studies have also shown that
the most common psychiatric disorder among elderly persons who have
died by suicide is a single episode of non-psychotic, unipolar major depression
without comorbid illness (Conwell et al., 2001). Because this is the
most treatable type of depression, a logical approach to prevention that
has been recommended is to improve the screening and treatment of
depression conducted in primary care practices. Improvement could come
about with the addition of screening measures, assistants dedicated to the
treatment of depression and other mental health issues, or through better
prescribing practices. A controlled study, PROSPECT (Prevention of Suicide
in Primary Care Elderly Collaborative Trial), is currently testing the effectiveness
of using Health Specialists (HS) to collaborate with physicians helping
them recognize depression, offer timely and appropriately targeted
treatment recommendations, and encourage patients to adhere to treatment.
In addition, procedures are implemented to educate patients, families
and physicians on depression and suicidal ideation (Bruce & Pearson,
1999).
Prison/Jail Suicide
Suicide is one of the leading causes of death in our Nation's jails (Bureau
of Justice Statistics, 1995). However, very little research or evaluation has
been conducted on the success of suicide prevention programs implemented
in jail or prison settings. Although no research directly supports
any particular prevention approach in jails, guidelines for suicide prevention
in jails have been implemented in some settings. Often programs are
multidimensional in nature, recommending steps such as adequate mental
health treatment, staff training in suicide prevention, intake
screening/assessment, increasing communication in detention settings,
changes in housing practices, changes in level of supervision/observation,
direct intervention after suicide attempts, and adequate reporting and follow-
up (Hayes, 1999). Some States have implemented State-wide jail suicide
prevention programs. Of these, New York and Texas have seen drops
in the rate of jail suicide since the programs were implemented. The
American Correctional Association, the National Commission on
Correctional Health Care, the National Juvenile Detention Association, and
other national organizations have developed guidelines for suicide prevention.
However, the effect of these guidelines has not been studied. In addition,
Lindsay Hayes has created a comprehensive suicide prevention plan
for both adult and child detention facilities that has yet to be evaluated
(Hayes, 1999).
Special Populations at Risk
American Indians and Alaska Natives
As illustrated in Figure 4, American Indians and Alaska Natives (AIAN)
have a 50 percent higher rate of suicide than the general U.S. population,
with young males having the highest risk (Indian Health Service, 1997). The
most common risk factors for suicide among young male AIANs is alcohol
and substance use, and depression. However, there are dramatic differences
in suicide rates across tribes. Many tribes, in partnership with the
Indian Health Service (IHS) and other government agencies, have designed
and implemented programs intended to address suicide prevention and
intervention for suicide and related problems (Middlebrook et al., 2001).
Prevention efforts include reducing risk behaviors (alcohol and substance
use) and promoting protective factors (increasing employment opportunities
and promoting positive and encouraging attitudes among adults
toward AIAN youth). Unfortunately, too few descriptions and analyses of
these efforts have been published, and little is known about their effectiveness
(see Middlebrook et al., 2001 for a review).
Gay, Lesbian, and Bisexual Youth
Several State and national studies have reported that high school students
who report same-sex sexual behavior or self-identify as gay, lesbian,
or bisexual (GLB) have higher rates of suicidal thoughts and
attempts in the past year compared to youth who report exclusively heterosexual
sexual behavior or self-identify as heterosexual in orientation
(McDaniel & Purcell, 2001). Experts do not agree completely about the
best way to measure reports of adolescent suicide attempts, or sexual
orientation, so the data are subject to question. But they do agree that
efforts should focus on how to help GLB youth grow up to be healthy
and successful despite the obstacles that they face. Because school-based
programs limited to suicide awareness have not proven effective for
youth in general, and in some cases have led youth to consider suicide as
a normal response to stress or have caused increased distress in vulnerable youth
(Vieland et al., 1991), there is reason to believe that they may
not be helpful for GLB youth either. Issues of stigma, labeling, privacy,
and appropriateness of referrals for youth needing services must be considered
to ensure that prevention programs for sexual minority populations
are safe and effective.
Individuals with Borderline Personality Disorder
Three to nine percent of those diagnosed with Borderline Personality
Disorder (BPD) commit suicide, a rate comparable to that for people diagnosed
with mood disorders and schizophrenia (Tanney, 2000). Recurrent
suicide attempts, self-injury, and impulsive aggression are often associated
with BPD and often result in expensive emergency and inpatient treatment.
To date, approaches to the prevention of suicidal behavior among
individuals with BPD have focused on treatment to reduce self-injurious
behavior with and without intent to die, including certain types of psychotherapy
and pharmacotherapy. One psychosocial treatment – dialectical
behavior therapy (DBT), a cognitive-behavioral treatment – has been
shown to significantly decrease self-injurious behaviors in BPD (Koerner &
Linehan, 2000). Although DBT has become increasingly popular as the
treatment of choice for suicidal patients with BPD, no replication studies
have been done other than those conducted by the developer. One study
is evaluating DBT and pharmacological approaches aimed at reducing self-injurious
behavior in individuals with BPD (see grant by Barbara Stanley,
http://www.nimh.nih.gov/suicideresearch/suiabs.pdf).
Individuals with Schizophrenia
The risk for suicide among individuals with schizophrenia is comparable
to the risk for individuals with mood disorder, substance abuse, and
BPD. In individuals with schizophrenia, the risk is particularly heightened
during the early stages of the illness, and has been found to increase
soon after inpatient discharge (Caldwell & Gottesman, 1990; Fenton,
2000). This suggests that adequate aftercare treatments may reduce risk
during this phase of disease management. Other approaches to reducing
suicide risk among individuals with schizophrenia include investigations
of medications that target the key symptoms of the disorder. In industry
sponsored treatment trials, one of the new atypical anti-psychotic medications
was observed to have the possible effect of reducing suicidal
behavior in persons with schizophrenia. To confirm these findings, the
International Clozaril/Leponex Suicide Prevention Trial will compare clozapine
and olanzapine in 900 patients with schizophrenia and a history of
suicidality (Meltzer, 1999). If these findings indicate that clozapine is
effective in reducing suicidality, the makers of the drug clozapine plan to
seek FDA approval for this use.
Individuals with Substance Use Disorders
Individuals with substance use disorders, including alcoholism, are at
increased risk for suicide. Follow-back studies of suicide decedents have
shown that 15-56 percent of individuals had diagnoses of alcoholism
and/or other substance use and dependence, a rate much higher than
that in the population (Murphy, 2000). Alcohol and substance abuse
problems contribute to suicidal behavior in several ways. In addition to
increasing the risk of suicide directly through lowered inhibitions, people
who abuse substances or alcohol also tend to have other risk factors such
as depression and social and financial problems. Substance use and
abuse are also common among persons prone to be impulsive, and
among persons who engage in many types of high risk behaviors that
result in self-harm. Fortunately, there are a number of effective prevention
efforts that reduce risk for substance abuse in youth, and there are
effective treatments for alcohol and substance use problems. While a
number of treatments have been found to be effective for the treatment
of substance abuse (National Institutes of Drug Abuse, 1999;) and alcoholism
(National Institute on Alcohol Abuse and Alcoholism, 2000;
http://www.niaaa.nih.gov/publications/aa49.htm), few have measured
concurrent effects of treatment on rates of suicide or suicide attempts.
Currently, some studies are looking at suicidal behavior among individuals
who are abusing substances and are trying to treat substance use,
abuse and dependence along with other comorbid psychiatric problems,
as well as dealing with stressful life events (see Emergency Departments
above). Some alcohol policies may be effective in reducing suicide
deaths. For example, an assessment of minimum legal drinking age
(MLDA) found that between 1970 and 1990, the suicide rate of 18- to
20-year-old youths living in States with an 18-year MLDA was 8 percent
higher than the suicide rate among 18- to 20-year-old youths in States
with a 21-year MLDA (Birckmayer & Hemenway, 1999).
Individuals with Mood Disorders
Mood disorders are very common among individuals who commit suicide,
with 36-70 percent of individuals having a mood disorder at the
time of death (Barraclough et al. 1974; Foster et al., 1999; Henriksson et
al., 1993; Rich, Young, & Fowler, 1986). A number of long-term follow-up
studies of individuals with bipolar disorder found that those who
remain on lithium maintenance treatment have a lower risk of suicide
than individuals who do not remain in treatment or are non-responsive
to lithium (Jamison, 2000). A study in progress is testing whether lithium
can prevent suicide attempts among individuals with bipolar disorder
who have previously attempted suicide (see grant by Maria Oquendo, http://www.nimh.nih.gov/suicideresearch/suiabs.pdf). The large, multisite
Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)
study will track the frequency of suicidal behavior and treatment
approaches used to minimize suicidal behavior (http://www.stepbd.org/).
Suicide prevention approaches in STEP-BD focus on reducing inclination
and minimizing opportunity through medication, psychosocial, and environmental
interventions.
With regard to individuals with major depression, retrospective data
indicate that many who are at risk for suicide often receive inadequate
treatment (Oquendo et al., 1999). The Swedish Island of Gotland study
is an uncontrolled study that has inspired efforts to increase primary care
providers' abilities to detect and treat depression, and in turn reduce suicide
(Rutz et al., 1989). An educational program for all general practitioners
on the island to improve recognition and treatment for depression,
the program was associated with more appropriate antidepressant
medication prescriptions and fewer inpatient hospitalizations of
depressed individuals. The island had fewer adult female suicides in the
several years following the intervention (Rutz, 2001). While these results
suggest that some suicide deaths may be prevented through improving
the diagnosis and ongoing treatment of depression, possibly through the
education of providers and the public about depression treatment, controlled
studies are needed to determine the effectiveness of these
approaches to reduce suicide, particularly among males.
Populations that Need Further Attention
White males aged 24-55 constitute the greatest numbers of suicide
deaths in the U.S., yet this subgroup of individuals is the least likely to have
sought mental health treatment prior to death (Pirkis & Burgess, 1998).
Currently there are almost no prevention approaches aimed specifically at
preventing suicide among males who do not seek mental health treatment.
One approach which shows promise is the prevention strategy used
by the Air Force (Centers for Disease Control and Prevention, 1999;). This
strategy is a multi-faceted approach to suicide prevention that intervened
at a community-wide level. Interventions included widespread and repeat-ed
suicide awareness and prevention training, gatekeeper training, screen-ing
questionnaires, changes in mental health confidentiality policy, and
messages from the Air Force Chief of Staff to change community attitudes
about seeking and providing help. Surveillance results suggest that the prevention
program has been effective in reducing suicide among Air Force
personnel, in both majority and minority populations. Because this effort
was not experimentally controlled, however, it is not known if certain
aspects, or all approaches combined, were effective. Nevertheless, this
intervention demonstrates the potential for suicide prevention among late
adolescent and adult males in the U.S. through a combination of universal
and targeted interventions.
Summary and Future Prospects
Rates of suicide and suicidal behavior and their risk factors vary across
age, gender and ethnic groups. The broad array of prevention strategies
described in this appendix reflect the variation in risk factors for different
subgroups, as well as the different types of disorders where suicide risk
is increased. Testing interventions in different settings are ways to study
these diverse risk groups. While the broad range of prevention
approaches may seem unsystematic, at the same time it suggests many
opportunities for individuals, organizations, and communities to consider
who is at most risk for suicide and what are the strategies consistent
with our understanding of protective and risk factors to reduce suicide in
their communities.
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