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Reducing Suicide: A National Imperative 8 Programs for Suicide Prevention Over the last 15–20 years, the first two generations of suicide prevention efforts have yielded valuable information on risk and protective factors, empirically based methods for preventing suicidal behavior, and improved research methods (Berman and Jobes, 1995; PHS, 2001). During this time, the following developments have been observed in the area of suicide prevention (1) a proliferation of curriculum-based suicide prevention programs in schools (cf., Garland et al., 1989) accompanied by increased attention and concerns voiced over format, goals, theoretic orientation, and safety issues (Hazell and King, 1996) that led to improved methods and prevention program designs (cf., Breton et al., 1998; Kalafat and Ryerson, 1999; Orbach and Bar-Joseph, 1993); (2) increased efforts to undertake empirical research on suicide prevention, prompted by a 1990 US Congressional mandate, and accompanied by the rapid development of suicidology as a multidisciplinary subspecialty with national and international professional organizations, new journals, and the establishment of centers for the study and prevention of suicide (PHS, 1999; 2001); (3) a new precisely defined prevention framework that places prevention programs on a continuum of universal, selective, and indicated interventions (Gordon, 1987; IOM, 1994); (4) the emergence of research on suicide prevention programs designed to target higher risk populations (e.g., Eggert et al., 1995b; Thompson et al., 2001); (5) improved screening tools and measures of suicide and suicidal behaviors (e.g., Eggert et al., 1994; Pfeffer et al., 2000; Reynolds, 1991; Reynolds, 1998; Shaffer and Craft, 1999; Thompson and Eggert, 1999), and (6) key advances in research methods,
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Reducing Suicide: A National Imperative including improved analytic tools and sophisticated models for measuring change over time in prevention trials (Brown and Liao, 1999). In contrast to clinical approaches that explore the history and health conditions leading to suicide in the individual, the public health approach to suicide prevention focuses on identifying broader patterns of suicide and suicidal behavior throughout a group or population. The public health approach to suicide prevention is also reflected in an organized five-step process that has been developed for ensuring the effectiveness of preventive efforts (PHS, 2001:11). This chapter will describe the current public health preventive framework and then review some of the interventions for preventing suicide at each level. The focus will be primarily on school-based programs. As with all other behavioral interventions, the best effects are most likely to be achieved with multidimensional interventions (IOM, 2001), given the overlapping nature of risk and protective factors across domains of influence. The chapter then explores examples of programs targeting specific populations and concludes with an analysis of an integrated approach for reducing the incidence of suicide in the broad population. FRAMEWORK FOR PREVENTION The prevailing prevention model in the interdisciplinary field of prevention science is the Universal, Selective, and Indicated (USI) prevention model. This USI model focuses attention on defined populations—from everyone in the population, to specific at-risk groups, to specific high-risk individuals—i.e., three population groups for whom the designed interventions are deemed optimal for achieving the unique goals of each prevention type. Universal strategies or initiatives address an entire population (the nation, state, local county or community, school or neighborhood). These prevention programs are designed to influence everyone, reducing suicide risk though removing barriers to care, enhancing knowledge of what to do and say to help suicidal individuals, increasing access to help, and strengthening protective processes like social support and coping skills. Universal interventions include programs such as public education campaigns, school-based “suicide awareness” programs, means restriction, education programs for the media on reporting practices related to suicide, and school-based crisis response plans and teams. Selective strategies address subsets of the total population, focusing on at-risk groups that have a greater probability of becoming suicidal. Selective prevention strategies aim to prevent the onset of suicidal behaviors among specific subpopulations. This level of prevention includes screening programs, gatekeeper training for “frontline” adult caregivers
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Reducing Suicide: A National Imperative and peer “natural helpers,” support and skill building groups for at-risk groups in the population, and enhanced accessible crisis services and referral sources. Indicated strategies address specific high-risk individuals within the population—those evidencing early signs of suicide potential. Programs are designed and delivered in groups or individually to reduce risk factors and increase protective factors. At this level, programs include skill-building support groups in high schools and colleges, parent support training programs, case management for individual high-risk youth at school, and referral sources for crisis intervention and treatment. UNIVERSAL PREVENTIONS Using health promotion strategies to combat symptoms of mental illness, including suicidality, represents a primary aspect of many universal suicide prevention programs. Although the field has traditionally separated health promotion from prevention (IOM, 1994), preventionists in the United States and abroad have increasingly turned to mental health promotion as a means of universal prevention (Beautrais, 1998; Cowen, 1994; Durlak, 2000; Waring et al., 2000). Reviews (Cowen, 1994; NRC, 2002) and at least one meta-analysis (Durlak, 2000) demonstrate that school-based programs employing such a health promotion approach can effectively prevent and/or reduce suicide risk factors and correlates like adolescent pregnancy, externalizing disorders (such as delinquency and substance abuse), and depression. These programs also promote protective factors against suicide including: self-efficacy, interpersonal problem solving, self esteem, and social support (see Chapters 3 and 6). Furthermore, throughout the 1990s, the World Health Organization developed evidence-based policies and recommendations for how schools can effectively engage in health promotion using a four-level model (see, WHO, 2002). The WHO model promotes universal prevention, targeting environmental conditions and mental health education for all students, as well as selective and indicated prevention, providing psychosocial interventions and professional treatment for those with mental illness or at significant risk (see also Waring et al., 2000; WHO, 1999; 2000a). As mentioned in Chapter 3, the U.S. Surgeon General (PHS, 2001), the United Nations (1996), and the World Health Organization (1999) have endorsed promoting mental health/resiliency as part of universal suicide reduction strategies. Population-based prevention programs with a school or community focus have an important advantage over those aimed at individuals. There is usually a high participation rate in such programs because all students are exposed, for instance, to a teacher’s classroom management practices
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Reducing Suicide: A National Imperative and control of aggressive behavior (Kellam et al., 1998) or to a middle school drug prevention program (Botvin et al., 1995). These programs also have the advantage, because of inoculation, of having potential impact on not only those who are currently at risk, but also those whose risk status changes after the intervention takes place. Finally, many of these broad prevention programs target multiple outcomes, so overall risk for suicide may be reduced by diminishing developmental risk through multiple pathways. Policy changes represent another universal strategy for reducing suicide. For example, Birckmayer and Hemenway (1999) conclude in their review of minimum drinking age policies in each state from 1970 to 1990 that increases in the legal drinking age reduce not only motor vehicle deaths but also suicides. Media Campaigns A traditional universal public health approach to behavior-related problems has been widespread education through mass-media campaigns. This technique has been used with varying levels of success for smoking, AIDS, and coronary heart disease (see IOM, 2002). A few countries, including the United Kingdom and Norway, have implemented such mass-media campaigns for suicide prevention as part of overall mental health promotion; evaluations of results are not yet available. Extensive media campaigns for suicide prevention are not common, largely due to fear of engendering suicide imitation. Media initiatives more often have focussed on modifying portrayals of suicide to reduce the likelihood of imitation. Since data are limited on use of media for education, this section discusses what is known about suicide imitation through the media, followed by a description of efforts to address this problem and the evidence for their effectiveness. The Evidence for Imitation Throughout history, people have expressed concern about suicide imitation, and have seen the opportunity for intervention in such matters, as evidenced by various anecdotal accounts in the literature of suicide imitation and clustering. For example, Goethe’s 1774 novel The Sorrows of Young Werther, in which the title character shoots himself after a failed love affair, was banned in Denmark, Saxony, and Milan in order to prevent further suicides that were thought to be a result of young men imitating the behavior of Werther (Phillips, 1974, 1985). These events led to the term the “Werther Effect” being used to describe imitation of this sort.
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Reducing Suicide: A National Imperative Today this effect is referred to as either suicide contagion or suicide imitation/modeling. Although they are often used interchangeably, each is based on a different theoretical framework. Each theoretical framework is useful, but Schmidtke and Schaller (2000) propose that the language of imitation and modeling is preferable to the language of a contagious process because it relies on active learning processes that do not imply the exclusion of individual volitional factors. Imitation and modeling, which play a role in other harmful behaviors such as drug use and bullying, occur with suicide in several circumstances, such as in the case of temporal clusters of suicides in a particular community or culture (see Chapter 2), suicide among family members (see Chapter 5), and suicide following exposure to a media1 presentation of a real or fictional suicide. Research shows that suicide contagion through the media is real (for review, see Gould, 2001a; 2001b). Recent meta-analyses report that studies conducted by clinically oriented investigators yield the strongest support for suicide imitation (cited in Schmidtke and Schaller, 2000). However, many of the studies of suicide imitation are beset with methodological problems; for example, many are based on aggregate-level data, which preclude the possibility of ruling out the influence of other factors. Imitation can be linked to newspaper accounts of suicide (for review, see Gould, 2001b; Hassan, 1995; Phillips, 1974; Stack, 1996). Newspaper coverage of suicide is related to an increase in the rate of suicide, and the magnitude of the increase is proportional to the duration, prominence and amount of media coverage (Gould, 2001a). There has been less conclusive research on the consequences of television news programs on suicide imitation. Kessler et al. (1988; 1989) found no association over an 11 year period in the United States, but recent studies suggest imitation in specific groups (e.g., in the elderly, see Stack, 1990). The influence of fictional presentations of suicide on imitation is less clear. Research into fictional portrayals has examined attempts or other suicidal behavior (such as ideation) rather than just rates of completed suicides, which allows for actual measurement of exposure. Some studies indicate that imitation occurs (e.g., Gould et al., 1988; Hawton et al., 1999); others do not (e.g., Phillips and Paight, 1987); still others are inconclusive (Berman, 1988). Aspects of both the media presentation and the individual interact to produce imitation. The person who is likely to imitate a suicidal behavior 1 Media refers to literature, the press, music, broadcasting, films, TV, theater, and the Internet.
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Reducing Suicide: A National Imperative has underlying vulnerabilities. A healthy person is not likely to kill him-or herself as a result of seeing an example of suicide. Different media (e.g., book vs. television) are likely to exert differential effects on different populations. Both the form (headline, placement) and content (celebrity, mental illness, murder-suicide) of suicide coverage clearly impact the likelihood of imitation. Attractive models are more likely to cause imitation. Similarities between a vulnerable person and the reported suicide victim increase the likelihood of contagion. This has been shown with age effects in both the young (Phillips and Carstensen, 1988) and the elderly (Stack, 1999, cited in Schmidtke and Schaller, 2000). Similarly, ethnicity is an important factor; Stack (1996) found that suicides of foreigners did not cause imitation among native populations. Encouraging Responsible Coverage of Suicide Many elements of media presentations influence the likelihood of imitation, and these all provide opportunities for prevention. In efforts to prevent contagion, several countries (including Australia, Austria, Canada, Germany, Japan, New Zealand, and Switzerland) and organizations, including the World Health Organization (United Nations, 1996; WHO, 2000b) have formulated guidelines for media coverage of suicide. The National Strategy for Suicide Prevention in the United States includes as one of its major goals improving “the reporting and portrayals of suicidal behavior, mental illness, and substance abuse in the entertainment and news media” (PHS, 2001). To advance that goal, guidelines for media coverage of suicide were formulated by the Annenberg Public Policy Center of the University of Pennsylvania, the American Association of Suicidology (AAS) and the American Foundation for Suicide Prevention (AFSP) in collaboration with several government agencies (CDC, NIMH, Office of the Surgeon General, Substance Abuse and Mental Health Services Administration [SAMSHA]), the WHO, and other international suicide prevention groups. They were released in August 2001, and the full text of these guidelines can be found on the sites of the partner organizations that developed them, including www.appcpenn.org and www.afsp.org. These guidelines, “Reporting on Suicide: Recommendations for the Media” update those developed in 1989 at a national consensus conference on the topic. The media guidelines include the stipulation that media accounts of suicide should neither romanticize nor normalize suicide; that is, individuals who kill themselves should not inadvertently be idealized as heroic or romantic. They also urge the inclusion of factual information on suicide contagion and mental illness, provide suggestions for questions to ask of relatives and friends of the victim, and suggest that information on
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Reducing Suicide: A National Imperative treatment resources be included. The guidelines also address issues of language such as the use of terms like “a successful suicide,” and speak to special situations that may arise such as a celebrity death by suicide. Finally, they suggest that media professionals address suicide as an issue in its own right, reporting on stigma, treatments, and trends in suicide rates, rather than only in response to a tragedy (AFSP, 2001). With shifts in focus and inclusion of educational material, the same articles that report on an unfortunate event can become part of universal preventive measures. This echoes other areas in the injury prevention field (Hemenway, 2001). The media now indicate the status of smoke detectors when a fire is reported, for example. Likewise, helmet use is indicated when reporting a bicycle accident. Currently, many comprehensive suicide prevention programs include components to improve media response to suicide, including the Finland National Program, Maryland (see later in this chapter) and the Washington State Youth Suicide Prevention Program (Eggert et al., 1997), with the state programs often utilizing the nationally formulated guidelines. The Washington program included a media education component that was designed to impact reporting practices by (1) educating media personnel in ways to report youth suicide stories that prevent potential contagion effects and (2) educating select personnel such as crisis line workers, gatekeepers, and school personnel in how to respond to media requests for information and stories related to youth suicide and suicide prevention. It also focused on ensuring that the youth suicide prevention message was “in the news” by providing information to the media and encouraging ongoing and responsible coverage of suicide and suicide prevention. Despite such efforts to shape discussion of suicide in the media, very little evidence exists to show that initiatives to promote responsible reporting in the media have a direct, significant effect on suicide rates. In Switzerland, implementation of media guidelines did increase responsible reporting of suicides; less sensational and higher quality stories resulted (Michel et al., 2000). But this has not yet been related to changes in suicide rates. An evaluation of media guidelines in Austria showed significant success in reducing suicides. The guidelines in that country were specifically formulated to address concerns that the increase in the number of suicides and suicide attempts on the subway in Vienna was related to the highly publicized and dramatic accounts of the deaths. Subsequent to the release of the guidelines, newspaper reporting of subway suicides decreased greatly and what was reported was much less prominent. The number of subway suicides significantly decreased in the second half of the year after release. In the 4 years following, the overall suicide rate decreased by 20 percent and the rate of subway suicides decreased by 75
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Reducing Suicide: A National Imperative percent with no substitution of method (Etzersdorfer and Sonneck, 1998; Etzersdorfer et al., 1992; Sonneck et al., 1994). Reducing Access to Means Universal measures can be used to reduce the availability of common tools for suicide. More restrictive legislation regarding firearms, barriers on bridges, or blister packs for medications are interventions that may be effective in reducing suicide or suicide attempts. This section focuses on the role of availability of methods of suicide, including the role that method availability and barrier restrictions may play in suicide by firearms, acetaminophen overdose, prescription drugs, jumping from buildings or bridges, domestic gas, automobile carbon monoxide, and railway suicides. Much of the research discussed has been done in Western societies, but suicide in rural Asian societies has been largely linked with availability of insecticides (Van der Hoek et al., 1998; Yip et al., 2000). Research is limited, but this underscores the need for implementing safe storage of agricultural poisons and using safety caps to reduce impulsive swallowing. Firearms2 Epidemiological studies have consistently shown that firearms are most common method of suicide for all demographic groups in the United States (CDC, 1994). The association between suicide and firearms in the home is strong across all age groups, but is particularly high in the 24 and younger group (Odds Ratios3 [ORs] of 10.4 vs. 4.0–7.2 for those 25 and older) (Kellermann et al., 1992). The dramatic increase in the American youth suicide rate since 1960 is primarily attributable to an increase in suicide by firearms (see Figure 8-1a,b; Boyd, 1983; Boyd and Moscicki, 1986). In one study of youth suicide in Allegheny County from 1960–1983, the rate of suicide by firearms increased 330 percent, but the rate of suicide by other means increased only 150 percent (Brent et al., 1987b). The more recent increase in the suicide rate by African American males is also attributable primarily to an increase in suicide by firearms. 2 This section was abstracted from Brent DA. 2001. Firearms and suicide. Annals of the New York Academy of Sciences, 932:225240. Reprinted by permission of the New York Academy of Sciences. 3 The Odds Ratio is the ratio of the odds of an outcome (suicide) for the experimental group relative to the odds of the outcome in the control group.
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Reducing Suicide: A National Imperative FIGURE 8-1a Rates of suicide by firearm in the first year after purchase among persons who purchased handguns in California in 1991. The horizontal line indicates the age- and sex-adjusted average annual rate of suicide by firearm in California in 1991 and 1992 (11.3 per 100,000 persons per year). SOURCE: Wintemute et al. 1999. Copyright © 1999 Massachusetts Medical Society. All rights reserved. FIGURE 8-1b Rates of suicide by firearm during the six years after purchase among persons who purchased handguns in California in 1991. The horizontal line indicates the age- and sex-adjusted average annual rate of suicide by firearm in California in 1991 through 1996 (10.7 per 100,000 persons per year). SOURCE: Wintemute et al. 1999. Copyright © 1999 Massachusetts Medical Society. All rights reserved.
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Reducing Suicide: A National Imperative Ray, age 14, had made three suicide attempts prior to completing his suicide. Each time there had been someone there to stop him. He communicated often about his intent, remarking that “Life’s a bitch” and asking others about which way they thought it would be better to kill oneself. The day before his death, he asked his mother whether it would be better to stick a gun “in your mouth or in your temple?” He chose the latter, using a .357 Magnum that had been kept fully loaded, in his mother’s nightstand (Berman & Jobes, Adolescent Suicide: Assessment and Intervention, 1991:189). Alcohol and illicit drug abuse in the home greatly increase the risk of violent death, including suicide (Rivara et al., 1997). Youth who were drinking at the time of their suicide were much more likely to use a gun than were youth who were not drinking (Brent et al., 1987b; Brent et al., 1993; Hlady and Middaugh, 1988). The increase in youth alcohol abuse and in firearms availability over the past 3 decades may be related to the increase in youth suicide in general, and in youth firearms suicide in specific. However, it is important to note that youth suicide has also dramatically increased in geographic regions where firearms ownership and firearms suicides are relatively rare (e.g., New Zealand; Beautrais et al., 1996). Therefore, it would be an oversimplification to say that the increase in youth suicide, in the United States, or anywhere else in the world, is solely a function of increased firearms availability. Several studies (Beautrais et al., 1996; Brent et al., 1991; Brent et al., 1988; Kellermann et al., 1992) have demonstrated that the presence of a gun in the home is highly predictive of its use for completed suicide (see Table 8-1). Firearms were between 31.1 and 107.9 times more likely to be used for the suicide if a gun was already in the home. This was even true in New Zealand, where firearms is a much less common method choice TABLE 8-1 Case-Control Studies: Guns in the Home and the Method of Suicide Brent 1993 Kellerman 1992 Beautrais 1996 Use of gun if kept in home 87.8% 88% 33% Use of gun if not kept in home 18.8% 6% 0.5% Guns in home and firearms as method (Odds Ratio [OR]) 31.1 69.5 107.9 Firearms and alcohol use (OR [95%CI]) 7.3 — — Bought gun within two weeks of suicide — 3% —
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Reducing Suicide: A National Imperative for suicide than in the United States (14 percent vs. 55–60 percent, Beautrais et al., 1996). Conversely, if a gun was not in the home, it was used as a method of suicide quite infrequently. Furthermore, in a study by Kellermann et al. (1992), only 3 percent of those who completed suicide had bought a gun within 2 weeks of the suicide. Wintemute et al. (1999) examined the standardized mortality rates (SMRs) of purchasers of handguns in California, who are registered by state law, and found an extremely high rate of suicide right after purchase. However, the rates remained elevated for the 6 years of analysis. This suggests that firearms are purchased for the purpose of completing suicide even though most of the suicides occurred some time after the purchase. Together, these data strongly suggest that it is the immediate gun availability that conveys the risk for firearms suicide, and supports method restriction as one means to prevent firearms suicide. Method of storage and the type and number of guns modify suicide risk substantially. Higher risk is associated with handguns than with long guns, loaded guns than unloaded guns, and unlocked than locked guns (see Table 8-2, Brent et al., 1993; Kellermann et al., 1992). Long guns convey an increased risk to males, but not females, and handguns convey a particularly increased risk for females (Brent et al., 1993). Furthermore, in adolescents, long guns, but not handguns, convey an increased risk in rural areas (OR’s 4.5 vs. 1.0), while in urban areas, this situation is re- TABLE 8-2 Risk of Suicide in the Home in Relation to Various Patterns of Gun Ownership Variable Adjusted Odds Ratioa 95% Confidence Interval Type of guns in the home One or more handguns 5.8 3.1–4.7 Long guns only 3.0 1.4–6.5 No guns in the home 1.0 — Loaded guns Any gun kept loaded 9.2 4.1–20.1 All guns kept unloaded 3.3 1.7–6.1 No guns in the home 1.0 — Locked guns Any guns kept unlocked 5.6 3.1–10.4 All guns kept locked up 2.4 1.0–5.7 No guns in the home 1.0 — SOURCE: Kellermann et al., 1992. Copyright © 1992 Massachusetts Medical Society. All rights reserved.
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Reducing Suicide: A National Imperative Encompass’d with a thousand dangers, Weary, faint, trembling with a thousand terrors… I … in a fleshy tomb, am Buried above ground. —WILLIAM COWPER (1731-1800) From the poem “Lines Written During a Period of Insanity”. Cowper on several occasions tried to hang, poison, or stab himself. The lines above were composed after one of his suicide attempts.
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