Suicide Prevention from a Public Health Perspective

The public health approach to health problems provides a strong framework and rationale for developing and implementing suicide prevention programs. This approach consists of health-event surveillance to describe the problem, epidemiologic analysis to identify risk factors, the design and evaluation of interventions, and the implementation of prevention programs. The application of each of these components to suicide prevention is reviewed. Suggestions for improving surveillance include encouraging the use of appropriate coding, reviewing suicide statistics at the local level, collecting more etiologically useful information, and placing greater emphasis on analysis of morbidity data. For epidemiologic analysis, greater use could be made of observational studies, and uniform definitions and measures should be developed and adopted. Efforts to develop interventions must include evaluating both the process and the outcome. Finally, community suicide prevention programs should include more than one strategy and, where appropriate, should be strongly linked with the community's mental health resources. With adequate planning, coordination, and resources, and the public health approach can help reduce the emotional and economic costs imposed on society by suicide and suicidal behavior.     

Background Papers to The National Suicide Prevention Conference: An Overview and Perspective

T he recognition of suicide as a serious public health problem and the advocacy of Americans who have experienced the loss of someone to suicide together have galvanized action to create a national strategy to prevent the loss of life and the suffering that suicide causes. The process began in 1993, when the World Health Organization (WHO) and the United Nations (UN) convened the first Interregional Expert Meeting on the Formulation of National Strategies for the Prevention of Suicide in Calgary and Banff, Alberta, Canada. Building on a document emanating from these deliberations, Prevention of Suicide: Guidelines for the Formation and Implementation of National Strategies ( UN, 1996 ), a public/private partnership has begun national strategy development for the United States. The articles in this special supplement represent one significant achievement of that collaborative effort and a foundation for ongoing work in developing a comprehensive National Suicide Prevention Strategy.     

Factors Associated with Achieving Complete Mental Health among Individuals with Lifetime Suicidal Ideation

The objective of this study was to identify factors associated with complete mental health among Canadians who had ever seriously considered suicide. Data for this study were obtained from Statistics Canada's 2012 Canadian Community Health Survey–Mental Health (N = 2,844). The outcome variable examined in this study was complete mental health and was analyzed using binary logistic regression. Of the 2,844 respondents with lifetime suicidal ideation, 1,088 (38.2%) had complete mental health (i.e., had flourishing mental health, no mental illness, and no suicidal ideation in the past 12 months). Those who had a confidant were seven times more likely to have complete mental health. Other factors associated with achieving complete mental health among formerly suicidal respondents include being older, being a woman, having higher income, use of religious coping, and never previously having a mental illness. Considering the importance of these protective factors in formulating public health policies will allow for a more wide‐reaching approach to suicide prevention.     

Changing the Direction of Suicide Prevention in the United States

It is axiomatic that the goal of suicide prevention is the prevention of suicide. Yet in spite of significant efforts to this end since the middle of the last century, and most notably in the last decade, the rate of suicide in the U.S. has not declined; rather, it has increased. To address this issue, Suicide Awareness Voices of Education (SAVE) brought together leading prevention specialists from other public health problems where successes have been achieved, representatives from countries where suicide rates have declined, and U.S. based suicide prevention researchers and program directors, to “think outside the box” and propose innovative, scalable approaches that might better drive success in achieving desired results from U.S. suicide prevention efforts. The recommendations should challenge our preconceptions and force us outside our own mental constraints to broaden our perspectives and suggest catalysts for real change in suicide prevention.     

Awareness Effects of a Youth Suicide Prevention Media Campaign in Louisiana

Research on the efficacy of mediated suicide awareness campaigns is limited. The impacts of a state‐wide media campaign on call volumes to a national hotline were analyzed to determine if the advertisements have raised awareness of the hotline. We use a quasi‐experimental design to compare call volumes from ZIP codes where and when the campaign is active with those where and when the campaign is not active. Multilevel model estimates suggest that the campaign appears to have significantly and substantially increased calls to the hotline. Results from this study add evidence to the growing public health literature that suggests that mediated campaigns can be an effective tool for raising audience awareness.     

Trends in suicide ideation and suicidal behavior among high school students in the United States, 1991-1997

To examine trends in suicide ideation and behavior over time, the authors analyze data from nationally representative samples of between 10,904 and 16,296 students participating in the 1991, 1993, 1995, and 1997 Youth Risk Behavior Surveys. These data describe the proportion of United States students in grades 9 through 12 that reported having (1) seriously considered attempting suicide, (2) made a plan to attempt suicide, (3) attempted suicide, and (4) made an injurious suicide attempt. From 1991 to 1997, the percentage of students seriously considering suicide and the percentage that made a suicide plan showed significant linear decreases. However, the percentage of students that made an injurious suicide attempt showed a significant linear increase. These trends make it unlikely that relevant national health objectives for the year 2000 will be met. Additional efforts are needed to identify and disseminate strategies that effectively reduce suicidal thoughts and behaviors among adolescents.     

Belief in the inevitability of suicide: results from a national survey

To examine public opinion regarding the effectiveness of means restriction as an approach to preventing suicide we asked a national sample of 2,770 respondents a hypothetical question about what effect a suicide barrier might have had on the ultimate fate of the more than 1,000 people who have jumped to their death from the Golden Gate Bridge. Thirty-four percent of respondents believed that every single jumper would have found another way to complete suicide and an additional 40% believed that "most" would have completed suicide using other means. The strongest predictors of belief in complete substitution were firearm ownership and cigarette smoking. Belief in the inevitability of suicide may be a political impediment to adopting potentially effective suicide prevention efforts.     

Suicide in America--moving up the public health agenda

Despite improvements in the health of Americans over the last 30 years, the problem of suicide, and its disturbing rise in the last three decades, remains a major American health riddle. Recognizing suicide as a public health concern is essential to discovering strategies to prevent suicide. Such strategies and prevention efforts must be multifaceted, incorporating a number of public health principles and approaches. These approaches include the refinement of epidemiological methods in the study of suicide; development of health education, information, and intervention programs dealing with suicide; and increased community awareness of and participation in all suicide prevention efforts.     

The science of public messages for suicide prevention: a workshop summary

There is minimal guidance for efforts to create effective public messages that increase awareness that suicide is preventable. To address this need, several agencies in the U.S. Department of Health and Human Services and the Annenberg Foundation convened a workshop consisting of suicide prevention advocates and persons with expertise in public health evaluation, suicide contagion, decision-making, and marketing. "Logic models" were used to define intended messages and audiences, assumed mechanisms of change, and outcomes. This summary describes some of the challenges and opportunities identified by workshop participants in evaluating public awareness campaigns in suicide prevention, technical assistance needs, and a proposed research agenda.     

Understanding suicidal ideation and assessing for risk

The UK government's health strategy, The Health of the Nation , included a target for reducing the population suicide rates by 15% over an 8-year period [Department of Health (1992), London: HMSO]. This thrust has been carried forward in subsequent work embodied in the ninth standard of the National Service Framework for Mental Health [Department of Health (1999), London: HMSO] and Safety First: FiveYear Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness [Department of Health (2001), London: HMSO]. A crucial aspect in reducing suicide rates is the accurate assessment of those who may be at risk to enable appropriate interventions to take place.While any person who wants to end his or her own life may find a way to do so, it is most important for the clinician to approach any potential suicide with the conviction that it is possible to prevent at least some suicides. This paper outlines best practice regarding the exploration and assessment of suicidal ideation and suicidal potential.     

The Kurt Cobain Suicide Crisis: Perspectives from Research,Public Health,and the News Media

The suicide of rock star Kurt Cobain in 1994 raised immediate concerns among suicidologists and the public at large about the potential for his death to spark copycat suicides, especially among vulnerable youth. The Seattle community, where Cobain lived and died, was especially affected by his sudden death. An overview of Cobain's life and death is presented and various crisis center and community-based interventions that occurred are discussed. Preliminary data collected from the Seattle Medical Examiner's Office and from the Seattle Crisis Center to assess the potential impact of Cobain's death on completed suicides and the incidence of suicide crisis calls are presented. The data obtained from the Seattle King County area suggest that the expected “Werther effect” apparently did not occur, but there was a significant increase in suicide crisis calls following his death. It is hypothesized that the lack of an apparent copycat effect in Seattle may be due to various aspects of the media coverage, the method used in Cobain's suicide, and the crisis center and community outreach interventions that occurred. The Cobain suicide and the role of media influence on copycat suicides are further discussed in commentaries from public health and news media perspectives.     

Treating the Capability for Suicide: A Vital and Understudied Frontier in Suicide Prevention

Current efforts at suicide prevention center largely on reducing suicidal desire among individuals hospitalized for suicidality or being treated for related psychopathology. Such efforts have yielded evidence‐based treatments, and yet the national suicide rate has continued to climb. We propose that this disconnect is heavily influenced by an unmet need to consider population‐level interventions aimed at reducing the capability for suicide. Drawing on lessons learned from other public health phenomena that have seen drastic declines in frequency in recent decades (HIV, lung cancer, motor vehicle accidents), we propose that current suicidality treatment efforts trail current suicidality theories in their lack of focus on the extent to which individuals thinking about suicide are capable of transitioning from ideation to attempt. We summarize extant evidence for specific capability‐centered approaches (e.g., means safety) and propose other options for improving our ability to address this largely overlooked variable. We also note that population‐level approaches in this regard would represent an important opportunity to decrease risk in individuals who either lack access to evidence‐based care or underreport suicidal ideation, as a reduced capability for suicide would theoretically diminish the potency of suicidal desire and, in this sense, lower the odds of a transition from ideation to attempt.     

Suicidality in adolescence: review and legal considerations

Adolescence is a unique developmental stage in which suicidality first emerges as a public health problem. The increasing trend of teenage suicide since the 1950s has only relented in the past ten years. The risk factors for adolescent suicide, suicidal ideation, and suicide attempts and an approach to assessing the suicidal adolescent for risk of future self-harm are reviewed. Treatment consists of ensuring safety and then treating the underlying psychiatric, psychological, and interpersonal disturbances. Issues of consent, confidentiality, and malpractice actions are addressed.     

Primary prevention of acculturative stress among refugees. Application of psychological theory and practice

Primary prevention in refugee mental health requires information from clinical, health, and cross-cultural psychology. Primary prevention's roots are in public health, which is distinguished by a communitywide perspective for addressing mental health concerns. This article summarizes research suggesting that refugees are an at-risk population, making them especially suitable for public health interventions. Research on stress and acculturation is highlighted, given its importance to prevention in refugee mental health. The opportunities for primary prevention programs and policies at 3 levels (i.e., local community, national, and international) are illustrated with case examples from both the United States and Canada. Prevention at the international level is highlighted by a World Health Organization Mental Health Mission to camps on the Thai-Cambodian border.     

Suicide Among Health Care Practitioners and Technicians in Colorado: An Epidemiological Study

Suicide is a public health concern with risks that vary between occupation groups. Many suicide victims with a health care occupation die by poisoning, but few studies have epidemiologically studied this association. The objective of this study was to quantify the increased risk of suicide death by poisoning among health care professionals in Colorado. Eleven years (2004–2014, N = 8,753) of suicide deaths in Colorado were compiled from the Colorado Violent Death Reporting System. A retrospective cohort study using multivariate logistic regression was conducted to examine the risk associated with having a health care occupation and eventual suicide death by poisoning, compared independently to firearm and hanging methods. Suicide victims with a health care occupation were more likely to die by poisoning rather than by hanging (RR 1.54, 95% CI: 1.41–1.68) or firearm (RR 1.79, 95% CI: 1.60–2.01), when compared to suicide victims without a health care occupation. The association between health care occupation and suicide method was significantly (p = .032) modified by gender. The results show that health care workers who die by suicide have an increased risk of eventual suicide death by poisoning rather than by firearm or hanging. These results can be used to inform tailored suicide prevention efforts in health care professionals.     

Suicide reduction and prevention: strategies and interventions

This paper focuses on suicide reduction and prevention. It considers what the United Kingdom government and associated bodies such as Department of Health, the National Health Service and Prison Service could do and are considering doing to prevent suicide in Britain. UK suicide statistics for the period 1971 and 1997 are compared and the Highland Health Board suicide prevention strategy for the 1990s is considered. The articles in this symposium are introduced and the recent UK legal cases involving Ms B and Diane Pretty are included.

Counsellors and psychotherapists have always been concerned, to varying degrees, about clients committing or attempting suicide [1]. It is a topic which can trigger much concern and interest with both neophyte and experienced therapists [2]. In the past decade there has been a growth in individual membership of counselling and psychotherapeutic professional bodies with more therapists becoming accredited and/or registered as qualified practitioners. Thus there has been additional pressure on therapists to adhere to professional codes of practice and ethics.To take the correct action and to be seen to take the correct action within client-therapist relationships is now paramount. It could be argued that this has always been the case. However, therapists not working within a professional framework may have had less incentive to act in a professional manner. A proactive approach may be recommended when seeing clients with suicidal ideation and/or intention (Palmer, 1995). In these cases, inaction can sometimes prove fatal so it is incumbent upon the therapist to support and help the client through the difficult period (Curwen, 1997).     

Seasonality of Violent Suicides in the Athens Greater Area

The aim of the study was to ascertain suicide seasonality in the Greek population and to associate this seasonal variation with age, sex, and suicide method. Studying seasonality can be of help in establishing a public health policy, related with suicide prevention. This is an epidemiologic study based on forensic evidence. We studied the deaths caused by self‐injury (trauma), namely deaths by violent suicide (not self‐poisoning). Statistically significant suicide seasonality was established with a peak in May. This seasonal variation is attributed mainly to males. As for the method, suicide by hanging peaks in June and by shooting in April. It was also observed that seasonality for individuals above the age of 45 peaks in early May.     

The future of genetics in public health

During the 1980s, we have witnessed an erosion in federal and state funding for the coordination of genetic services in state health departments. As this decade begins, the federal budget for the support of the national genetics program is less than half of the total available in 1980. In addition, priorities in state maternal and child health programs have changed, and genetic services have often received lower rankings aside of programs to improve prenatal care and to address problems such as teenage pregnancy. Clearly we are at a critical point for the future of genetics programs in the public health arena. Fortunately, despite the problems with funding and priority setting, important coalitions have been built during the past decade and continued advances in medical genetics have made it difficult for public health officials to ignore the potential impact of genetic services. Council of Regional Networks for Genetic Services (CORN) and the regional genetic services networks have provided opportunities for interaction and coordination between genetic services providers and public health officials that had not been available to any significant extent. The full potential of these coalitions has yet to be realized, but efforts in data collection, development of national guidelines and standards, and information sharing and networking have already had an influence on state genetic services programs. Continuing research on the genetics of chronic diseases and the influence of discoveries in molecular genetics will undoubtedly broaden the current scope of state public health programs in genetics, which all too often have been limited to newborn screening and administration of grants for genetic services. The regional and national genetic services programs should be strengthened and appropriate training programs should be developed in Schools of Public Health to provide the expertise and leadership that will be needed to guide the future of genetics in public health.     

Aspects of suicidal behavior, depression, and treatment in college students: results from the spring 2000 national college health assessment survey

The National College Health Assessment Survey (NCHA), sponsored by the American College Health Association, measured depression, suicidal ideation, and suicide attempts among 15,977 college students in the academic year 1999-2000. Similar to the National College Health Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention in 1995, 9.5% of students reported that they had seriously considered attempting suicide and 1.5% of students reported that they had attempted suicide within the last school year. The NCHA findings show a relationship between suicidal behavior and depressed mood. Depressed mood, difficulties of sexual identity, and problematic relationships all increase the likelihood of vulnerability to suicidal behavior. Less than 20% of students reporting suicidal ideation or attempts were receiving treatment.     

Changing the Legacy of Suicide

In the United States, despite the increase in knowledge about suicide, the rate of suicide has remained virtually unchanged for the past 30 years. The members of the American Association of Suicidology (AAS) are uniquely qualified to determine what, if anything, can be done to reduce the rate of suicide. The restructuring of the association has produced the potential for cross-divisional collaboration, and yet conventional membership boundaries have resulted in unrealized opportunities to impact the rate of suicide. Dr. Edwin Shneidman, stated in Albert Cain's 1972 landmark book Survivors of Suicide that “post-vention is prevention for the next generation” (p. x). The ability to design, implement, and study an effective model of postvention is within the considerable talents of our membership; however, doing so will require the commitment and flexibility of the entire association. By making postvention collaboration a goal of the association we can bring a national focus on suicide that could change the legacy of suicide.