11
Findings and Recommendations

ENHANCING THE INFRASTRUCTURE

Over 80 million people in the United States are at risk for suicide due to mental illness and substance use disorders; about 30,000 Americans each year die by suicide. It is estimated that the cost to society in lost productivity each year is approximately $11 billion. Yet, suicide has a low base-rate, approximately 11 individuals per 100,000 per year, which makes clinical investigation difficult. While this report discusses the wealth of knowledge about the risk and protective factors for suicide and promising treatments and prevention programs, important research gaps exist in the understanding of suicide and suicidal behavior. Most studies are cross-sectional or retrospective. Data are weakened by the constraint of using proximal endpoints instead of completed suicide and by inaccurate reporting of suicide and suicide attempts. The low base rate of suicide necessitates studies in large sub-populations to have adequate power to provide significant results. Most efforts to date have been disciplinary, single level approaches, limited by funding. To make fundamental advances requires a different scientific approach that will ensure a higher level of scientific rigor, integrate multiple levels of research, provide reliable national and international data on current rates of suicidal behavior and key risk and protective factors, and create the infrastructure for testing treatment and preventive interventions and implementing and institutionalizing the effective strategies. The following sections will briefly



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Reducing Suicide: A National Imperative 11 Findings and Recommendations ENHANCING THE INFRASTRUCTURE Over 80 million people in the United States are at risk for suicide due to mental illness and substance use disorders; about 30,000 Americans each year die by suicide. It is estimated that the cost to society in lost productivity each year is approximately $11 billion. Yet, suicide has a low base-rate, approximately 11 individuals per 100,000 per year, which makes clinical investigation difficult. While this report discusses the wealth of knowledge about the risk and protective factors for suicide and promising treatments and prevention programs, important research gaps exist in the understanding of suicide and suicidal behavior. Most studies are cross-sectional or retrospective. Data are weakened by the constraint of using proximal endpoints instead of completed suicide and by inaccurate reporting of suicide and suicide attempts. The low base rate of suicide necessitates studies in large sub-populations to have adequate power to provide significant results. Most efforts to date have been disciplinary, single level approaches, limited by funding. To make fundamental advances requires a different scientific approach that will ensure a higher level of scientific rigor, integrate multiple levels of research, provide reliable national and international data on current rates of suicidal behavior and key risk and protective factors, and create the infrastructure for testing treatment and preventive interventions and implementing and institutionalizing the effective strategies. The following sections will briefly

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Reducing Suicide: A National Imperative review the scientific gaps that are discussed throughout the report and will present a vision for a solution. Magnitude of the Problem Yearly, there are almost 30,000 reported suicides in the United States and a million worldwide. However, suicide rates are underestimates because of the lack of internationally accepted case definition and uniform ascertainment methods. Moreover, data are lacking on changing profiles of mental disorders and social factors associated with changes in suicide rates over time. Suicide attempt prevalence has been determined in some national epidemiological studies, but no data on changing rates are available in the United States. Suicide attempt rates estimated from cases presenting to emergency rooms or health care professionals are a significant underestimate of true rates. Because longitudinal studies are lacking, incidence cannot be estimated from existing data sets. Thus, accurate rates of suicide and particularly suicide attempts are not available at a national level. Data gathering must consider ethnic and social subgroups, including cross-cultural groups, in which rates may be strikingly different and where risk and protective factors may differ in relative importance. Risk and Protective Factors Biological, psychological, and cultural factors all have a significant impact on the risk of suicide in any individual. Risk factors associated with suicide include serious mental illness, alcohol and drug abuse, childhood abuse, loss of a loved one, joblessness and loss of economic security, and other cultural and societal influences. Resiliency and coping skills, on the other hand, can reduce the risk of suicide. Social support, including close relationships, is a protective factor. However, knowledge regarding the relative importance of risk and protective factors is limited, and we are far from being able to integrate these factors in order to understand how they work in concert to evoke suicidal behavior or to prevent it. Where such knowledge is emerging, the results are difficult to generalize because of a lack of population level data. Without a combination of a population-based approach and studies at the level of the individual patient within higher risk sub-groups, macro-social trends cannot be related to biomedical measures. Most existing studies are retrospective or cross-sectional, involve a few correlates, and do not address prediction of risk. Without specific data from well-defined and characterized populations whose community level social descriptives are well-known, normative behavior and abnormality cannot be estimated.

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Reducing Suicide: A National Imperative Treatment and Prevention Pharmacotherapy and psychotherapy can be effective in preventing suicide. Continued contact with a health care provider has been shown to be effective in reducing the risk of suicide, especially in the early weeks after discharge from a hospital. However, psychological autopsy studies and toxicological analyses indicate that many people who complete suicides are not under treatment for mental illness at the time of death. Accurate information on treatment utilization by persons at risk for suicidal behavior, efficacy or effectiveness of existing interventions and cost of treatment are not possible without accurate assessment of suicidal behaviors. Data on the reasons for under-treatment must be used to design corrective programs. Several prevention programs have been developed that look promising. However, many prevention programs do not have the long-term funding that would allow them to assess reduction in the completion of suicide as an endpoint. The low base rate of suicide, combined with the short duration of assessment and the relatively small populations under study make it difficult to acquire sufficient power for such trials. As described in Chapter 10, to assess the incidence of suicide in a general population where the rates are between 5 and 15 per 100,000 with a 90 percent confidence requires almost 100,000 participants. These populations can only be recruited through large nationally coordinated efforts. Population Perspectives Extensive epidemiological data describe the suicide rates among various populations. The rates of suicide in the United States are exceptionally high in white males over 75 years of age, Native Americans, and certain professions, including dentists. Studies from across the world find higher rates of suicide in rural areas as compared to urban ones. Much is known about the general trends, but no data set provides a picture of evolving risk and protective factors at the national level. Globally, a million suicides are estimated to occur each year, but there is no coordinated effort to understand responsible factors or reduce the death toll. Major changes in rates of youth suicide remain unexplained. Population laboratories could provide data on a much larger population. While each center might be able to obtain a sufficiently large sample for studies in the general population, a consortium of centers will be necessary to fully explore differences based on region, economic environment, culture, urbanization, and other factors that vary across the country. Furthermore, certain subpopulations may be sufficiently small or low risk to require broader recruitment than one center could access. For these

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Reducing Suicide: A National Imperative reasons, multiple centers would be optimal to enhance the science of suicide. The integration of data across laboratories can provide an ongoing picture of the key factors influencing national suicide rates such that studies of risk and protective factors can be optimized, and permit rational prevention and treatment planning. The national impact of treatment and prevention interventions shown to be effective within a network can be estimated. This will permit translation into national implementation, and with systematic cross-cultural comparisons, global extension of United States studies would become more feasible. Vision for a Solution: National Network of Population Laboratories To obtain optimal data for the understanding, prevention, and treatment of suicide and suicidal behavior, a large population base is essential. The committee proposes a coordinated network of Population Laboratories that would allow stratified and repeated longitudinal surveys to provide more accurate data on rates of suicidal behavior, as well as long-term data on ethnographic, social, psychiatric, biological, and genetic measures necessary for increased success in prevention. Data on diagnoses associated with suicides would be obtained through the psychological autopsy method by the population laboratories for all suicides within their population, which would be enriched by highly focused ethnography. Similarly, data would be obtained on suicide attempts in the course of stratified population surveys that would be more complete than that obtained from reports generated from emergency rooms or health care providers. Thus, the population laboratory rates would correct underestimations of national rates through these registries of suicides and attempted suicides. The population laboratories would be the source of data on rates of suicidal ideation. Accurate ascertainment is essential for measurement of relative impact of risk and protective factors, and of preventive interventions. Drawing smaller samples from these large population centers will allow the examination of risk and protective factors in far greater specificity. Multiple risk factors must be measured in the same high-risk group by multi-disciplinary groups of scientists to determine their interaction as well as their relative importance. This differs from the overwhelmingly typical approach of measuring only a few risk or protective factors in unrepresentative convenience samples. Sampling from within population laboratories allows measurement of generalizability. Deliberate sampling within ethnic and social subgroups as well as from groups with specific mental disorders can generate data applicable to at-risk groups all over the United States. In the course of obtaining data on completed suicides, the population laboratories can collect tissue samples from each indi-

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Reducing Suicide: A National Imperative vidual that can be used for toxicological screens, biochemical analyses, and genetic research. Finally, data on treatment utilization and barriers to treatment can be obtained at a population level and related to those considered to be at risk for suicidal behavior. A longitudinal data gathering strategy will be more powerful than a cross-sectional approach. A population-based approach is well suited for testing public health interventions. A sub-population high-risk group is best suited for randomized treatment studies that test efficacy at the level of the individual patient, and such studies can be feasibly extended to comparison studies in the developing world. To address the problem of suicide effectively will require an integrated approach in which experts from many disciplines come together to tackle the problem. Only with such an interdisciplinary effort can a full understanding of the complex nature of suicide be obtained. And only through this full understanding can effective interventions be designed. A coordinated network of laboratories provides the infrastructure in which the many disciplines can be united. An interdisciplinary center also provides a) opportunities for training new scientists to think broadly about suicide and b) incentives to recruit established scientists to apply their expertise to this important area. Because of the multidisciplinary nature of research on suicidal behavior, multiple federal agencies, foundations, and the pharmaceutical industry have a stake in enhancing the science and reducing the risk of suicide. The public health significance of suicidal behavior has been underscored by the World Health Organization and the United States Surgeon General and validates a substantial financial commitment to fostering biomedical research and improving the health of the public. The nation’s experience and benefit from funding multiple Alzheimer Disease Research Centers, as well as centers of excellence in cancer, provides a useful precedent and analog for this initiative. The committee believes that, to have a large public health impact, a network of Population Laboratories in the United States will be necessary. The longitudinal dimension of the proposed studies, necessary to provide a picture of the evolving rates of suicidal behaviors and of risk and protective factors, requires a 10-year funding period. The committee believes that population laboratories will eventually provide models of “reduced-suicide zones” that will have great benefit to public health. Recommendation 1 The National Institute of Mental Health (in collaboration with other agencies) should develop and support a national network of suicide research Population Laboratories devoted to interdisciplinary research

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Reducing Suicide: A National Imperative on suicide and suicide prevention across the life cycle. The network of Population Laboratories should be administered by NIMH and funded through partnerships among federal agencies and private sources, including foundations. Very large study samples of at least 100,000 are necessary because of the relatively low frequency of suicide in the general public. A number of Population Laboratories (e.g., 5–10) are necessary to capture the data for numerous and complex interacting variables including the profound effects of demographics, region, culture, socioeconomic status, race, and ethnicity. Extending the efforts into the international arena where cultural differences are large may provide new information and can be fostered and guided by such global organizations as the World Health Organization and the World Bank and by the Fogarty International Center at NIH. The network should be equipped to perform safe, high-quality, large-sample, multi-site studies on suicide and suicide prevention. Each Laboratory would have a population base of approximately 100,000. At a base-rate of 10–12 suicides per 100,000 people, this population base of the network would significantly improve the available data for estimates of suicide incidence, capacity for longitudinal studies, development of brain repositories, access to representative samples for prevention and intervention studies, and studies of genetic risk for suicide. Several such laboratories would provide adequate data to assess the numerous and complex interacting variables including the profound effects of demographics, regions, culture, socioeconomic status, race, and ethnicity. Coordination and collaboration among centers should be encouraged to further enhance the breadth of the database. The laboratories would cover an ethnically and socially diverse and representative population and would recruit higher risk individuals and subgroups in communities within the population laboratories for longitudinal and more detailed studies. Treatment and prevention studies would be carried out in high-risk patients recruited from within the population laboratories. With these defined populations, the centers would conduct prospective studies—integrating biological, psychosocial, ethnographic, and ethical dimensions—that would be of great importance in advancing science and meeting public health needs. These studies would include such initiatives as identified in the committee report: Intervention and Prevention Research Testing of promising programs at multiple sites with long term follow-up. It is critical to determine whether an intervention can be gen-

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Reducing Suicide: A National Imperative eralized to other sites. Long-term assessments are important for evaluation of the impact of interventions on suicide and suicide attempts rather than more proximal measures. Intervention studies to evaluate means and effectiveness of promoting greater continuity of care, treatment adherence, and access to emergency services because patients recently discharged from inpatient care are among those at highest risk for suicide. Descriptive studies to identify markers for increased risk should aid in the design of intervention studies to decrease risk. Psychological Risk and Protective Factors Clinical trials on the specific effects of reducing hopelessness on suicide. Hopelessness is related to suicidality across age, diagnoses, and severity of disorder, yet the field lacks research on the pathways to hopelessness, interrelationships between hopelessness and other psychological aspects of suicide risk, and on the specific effects of reducing hopelessness on suicide. Treatment Research Carefully designed trials to understand the potential of pharmacotherapies to reduce suicidal behavior. Studies should include the antidepressants, anticonvulsants, lithium, and clozapine. The lack of long-term assessment of therapeutic strategies and the exclusion of high-risk patient from clinical trials represent critical gaps in the field. Controlled clinical trials to determine the types and aspects of psychotherapy that are effective in reducing suicide for diverse individuals. Current evidence suggests that continued contact with a psychotherapist is critical. This needs to be rigorously evaluated. Neurobiology Longitudinal, prospective studies of the influence of HPA axis function on suicidality. The utility of assessing HPA axis function as a physiological screening tool for suicide risk should be explored. Medical and psychosocial treatments that attenuate HPA dysregulation should be further developed and tested for their efficacy in reducing suicide. Biological predictors of suicidal behavior should be sought through brain mapping studies. Prospective, rather than cross-sectional studies, are crucial. Analyses in vivo would allow the examination of changes over time to elucidate response to treatment and remission from episodes of mental illness. Moreover, brain mapping studies may help to identify individuals at risk for suicidal behavior.

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Reducing Suicide: A National Imperative Molecular and Population Genetics Genetic samples from psychiatric populations should be studied to examine the relationship between genetic markers and suicidal behavior. Genetic isolates (i.e., populations that have had few or no new genes added from outsiders for many generations) with a high rate of suicide and suicidal behavior should be identified for linkage studies. Studies searching for genes associated with suicidal behavior should be undertaken. The relationship between suicide and aggression/impulsivity requires additional attention, particularly regarding its developmental etiology and genetic linkages. Genetic markers that have functional significance and correlate with impulsive aggression and suicidal behavior cross-sectionally may have the potential to identify individuals at risk and to suggest new molecular targets for treatment. Clinical Epidemiology Prospective studies of populations at high risk for the onset of suicidal behavior, such as the offspring of suicide completers or attempters, can allow for studies of neurobiologic, genetic, and non-genetic factors that predict the onset of suicidal behavior. Interdisciplinary research that weaves together biological, cognitive, and social effects of trauma to elucidate the complex pathways from childhood trauma to mental illness and/or suicidality and thereby elucidate multiple possibilities for intervention. Services Research Research on the peri-hospital period to assess the risk and protective effects of hospitalization, the relationships between length of stay and outcomes, and the factors post-hospital that account for the increased risk for suicide would provide critical information for suicide reduction strategies. The efficacy of different approaches to follow-up care in reducing suicide across populations must also be established, and successful interventions should be replicated and widely disseminated. Longitudinal research to assess outcomes of prophylactic/short-term versus maintenance/long-term treatment for suicidality. The course of suicidality across the life span suggests it may at times represent a lifelong condition requiring sustained treatment; further life-course research is required to verify this.

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Reducing Suicide: A National Imperative Economic and Cultural Studies Interactions of genetics, psychosocial, socio-political, and socioeconomic context. The field requires interdisciplinary, multi-level research on the impact of individual and aggregate level variables on suicide. Contrasts among international suicide data also offer important insights into the influence of cultural/macro-social contexts on suicide. Ethnographic research and other qualitative methods to obtain greater detail about the setting, conditions, process, and outcome of suicide. These approaches should be developed to deepen and to increase the validity of psychological autopsy studies and prevention outcome studies. Funding should be provided for the necessary infrastructure for these centers. This should include support for dedicated full time staff at NIH to provide long-term (at least 10 years) continuity and consistency in these efforts. Furthermore, funding for centers should include support for the following: Population cores to coordinate the social science, ethnographic data and to maintain registries of deaths by suicide and suicide attempts. Pathology cores to maintain the repositories for tissue samples from suicide victims. Statistical cores to manage the databases on risk and protective factors including genetic markers and cultural contexts. Clinical cores to recruit patients and to ensure their safe and ethical treatment. Research efforts that encompass both program projects and individual projects. Centers should encourage collaborations across the centers and facilitate the sharing of data maintained by the cores. In an effort to recruit excellent scientists to research in suicide, supported sites should develop training programs, to provide local and distance mentoring, to attract new investigators from a wide variety of disciplines into the field, and to form research and research training partnerships with developed and developing countries. ENHANCING THE DATABASE ON SUICIDE Because suicide is a low base-rate event, special efforts are needed to ensure collection of sufficient data to allow meaningful analysis of risk factors and interventions. Long-term studies of suicidal behavior are potentially uniquely informative. Long-term studies such as the Framingham study offer populations that are studied over a long dura-

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Reducing Suicide: A National Imperative tion and from a variety of biological, behavioral, and sociological perspectives. Studies such as these provide an ideal opportunity to explore suicidal behavior prospectively if the correct measures and outcomes are incorporated. Managed care databases also offer unique opportunities to examine the development of suicidal behavior and the relationship between health behaviors, practice variation, and suicidal outcomes. Suicidal behaviors are likely much more common than generally thought, as found with child abuse and neglect (National Research Council report on Understanding Child Abuse and Neglect, 1993). Including measures of suicidality in ongoing long-term studies will broaden the understanding of the dimensions of the problem. Furthermore, addressing suicidality in these large studies would benefit the public by directing at-risk individuals to appropriate care. As described in Chapter 10, exclusion of suicidal patients from clinical trials has serious repercussions. Analysis of the few trials that include suicidal participants reveals that only those studies that included high risk patients were able to demonstrate significant effects of an intervention. Currently, clinical trials exclude participants who exhibit suicidality. Suicidal participants can be included in clinical trials with appropriate safeguards consistent with the highest standards of human subjects’ protection. Including suicidal participants in clinical trials is a critical step to improving the outcome of suicidal individuals by providing an evidence-base for treatment protocols. Such studies should be conducted with research designs and measures that touch on the etiopathogenesis of suicidal behaviors, as described throughout this report. Surveillance is a cornerstone of public health, allowing realistic priority setting, the design of effective prevention initiatives, and the ability to evaluate such programs (Institute of Medicine report on Reducing the Burden of Injury, 1999). Non-uniformity in reporting suicide across jurisdictions introduces inaccuracies into data on prevalence and confounds the analysis of risk and protective factors. Ideally, coroners and medical examiners should receive uniform training to standardize diagnosis and information about suicide. However, given the limitations of funding, jurisdictional purview, and the influences of stigma and religion, the committee recognizes that this is unlikely to happen soon. The quality of data for suicide attempts is even less reliable than for completed suicides. The need for improved and expanded surveillance systems for suicide is highlighted as one of the central goals of the National Strategy for Suicide Prevention. National surveillance programs for HIV/AIDS and for motor vehicle deaths are currently in place and provide nationwide data that help form policies for prevention (see Chapter 10). Currently no such national program for suicide deaths or attempts exist. The National Vio-

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Reducing Suicide: A National Imperative lent Death Reporting System provides a promising framework that might be expanded into a national program that would provide the database for suicide deaths. The Oregon State Adolescent Suicide Attempt Data System is one of a few mechanisms that might inform the creation of a national system for reporting suicide attempts. Issues of confidentiality are a concern for surveillance of suicide as they are for HIV/AIDS. However, CDC found that reporting through a name-based system did not impact rates of testing for HIV/AIDS. As state and pilot programs have shown, there are options available that are sensitive to confidentiality yet allow the benefits of a reporting system (see Chapter 10). The committee is strongly committed to the principle of confidentiality and would urge that implementation of surveillance programs be done in a manner that respects the privacy of the individual and their families and communities. Yet examples exist of reporting systems that deal effectively with this issue. Consequently the committee sees no fundamental reason why these approaches cannot be applied to the reporting of suicide and suicide attempts. Recommendation 2 National monitoring of suicide and suicidality should be improved. Steps toward improvement should include the following: Funding agencies (including NIMH, NIA, NICHD, NIDA, NIAAA, CDC, SAMHSA and DVA) should encourage that measures of suicidality (e.g., attempts) be included in all large and/or long-term studies of health behaviors, mental health interventions, and genetic studies of mental disorder. Funding agencies should issue program announcements for supplements to ongoing longitudinal studies to include the collection and analysis of these additional measures. Suicidal patients should be included in clinical trials when appropriate safeguards are in place. A national suicide attempt surveillance system should be developed and coordinated through the CDC. It might be developed as part of a broader injury reporting database. Modeled after Oregon’s program for the reporting of adolescent suicide attempts and the HIV/AIDS registry, pilot programs should be developed, tested, and implemented as soon as feasible. State participation should be encouraged by requiring reporting as a prerequisite for receiving funding for related programs. Federal funding should be provided to support a surveillance system such as the National Violent Death Reporting System that includes

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Reducing Suicide: A National Imperative data on mortality from suicide. The system should have sufficient funding to support a national effort. CDC would be the most appropriate agency to coordinate this database given their experience with HIV/AIDS surveillance. Efforts to create such registries in other countries should be encouraged and, where feasible, assisted. ENHANCING IDENTIFICATION OF THOSE AT RISK FOR SUICIDE In the United States, over 90 percent of completed suicides are associated with psychiatric diagnoses, yet single psychiatric diagnoses have low relative risk for suicide. Converging data indicate that some portion of risk for suicide is separable from these disorders. These data include: differential treatment effects for other symptoms associated with the disorder versus suicidality, differential heritability, ante- and post-mortem biological markers associated with suicide across psychiatric diagnoses, and psychological factors associated with suicidality across diagnoses. Converging evidence across disciplines indicates that suicide is related to stress: developmental and adult trauma; cumulative stressors, including multiple morbidities; acute and chronic social and cultural stressors; and capacity to cope with stress. Suicide can be considered an expected outcome of a significant subgroup of mentally ill patients who experience accumulative life stresses, just as cardiac infarction is an expected outcome of untreated high blood cholesterol. The committee finds that mental illnesses are potentially fatal and that suicide is the most common cause of premature mortality in this group. This context for death from suicide conveys less blame for the physician and might be expected to lower the barriers to aggressive treatment, prevention, and reporting of suicide and its risk factors. While much more needs to be learned about the processes leading to suicide detection and prevention, it is clear that existing knowledge and new findings are not adequately disseminated and practiced in the primary care and mental health professions. Case identification and treatment for those at risk of suicide is a serious problem. Although suicides in the United States are associated with a diagnosis of a mental illness, only about a third of those with mental illness receive services. The committee recognizes that several barriers exist to obtaining such treatment, including stigma, limited insurance coverage, and fragmentation of services. On the other hand, a significant proportion of those who do complete suicide visit a non-mental health clinician within the last month or even week of their lives. The committee finds that there is an important role for the primary care and mental health care providers as well as providers for special high-risk populations (e.g., aged, adolescents, and incarcerated

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Reducing Suicide: A National Imperative individuals) in the identification and referral of patients with suicidal intent. Many risk factors for suicide can be uncovered during a visit with a primary care physician. Depression is associated with a significant risk of suicide. Substance abuse, history of physical or sexual abuse, conduct disorder, and aggression/impulsivity also suggest greater risk of suicide, especially in combination. In addition, social and cultural contexts, such as family discord, economic hardship, and social isolation, deserve attention. Multiple concurrent risk factors increase the risk of suicide and should be heeded. Access to the means for suicide should also be noted. Screening for suicidality would benefit from improved assessment tools. Currently available tools are inadequate to determine acute suicide risk or to predict when a person will attempt or complete suicide (see Chapter 7). Assessment tools may be specific only for the populations for which they were developed. Despite the limitations, tools for detection or risk assessment can be an important component of treatment when used appropriately. Recommendation 3 Because primary care providers are often the first and only medical contact of suicidal patients, tools for recognition and screening of patients should be developed and disseminated. Furthermore, since over half of suicides occur in populations receiving treatment for mental disorders, it is critical to enhance the capacity of mental health professionals to recognize and address both chronic and acute suicide risk factors. NIMH and other funding agencies should provide funds to clinical researchers to develop and evaluate screening tools that assess risk factors for suicide such as substance use, history of abuse and/or trauma, involvement with the criminal justice system, mental illness, psychological and personality traits such as impulsivity and hopelessness, abnormal neurobiology or genetic markers, employment problems, bereavement and other relationship stresses, etc. Funding agencies should issue program announcements to encourage efforts in this area. Physicians should refer patients with multiple risk factors to consultation with a mental health professional. This should be standard in the same way finding high blood cholesterol levels dictates further medical and behavioral interventions. This will only be effective if the issue of parity is addressed and insurance benefits are expanded adequately to cover mental health care.

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Reducing Suicide: A National Imperative Professional medical organizations should provide training to health care providers for assessment of suicide risk and provide them with existing tools. Mental health professional associations should encourage (or require, when appropriate) their memberships to increase their skills in suicide risk detection and intervention. National, state, county, and city public health organizations should build on their existing infrastructure to facilitate suicide screening especially in high-risk populations. Medical and nursing schools should incorporate the study of suicidal behavior into their curricula or expand existing education. NIMH and Agency for Health Care Research and Quality (AHRQ) should work with physician associations including American College of Physicians, American College of Family Physicians, American Academy of Pediatricians, American Society of Internal Medicine to implement these recommendations. In addition, through their health services research funds they should support efforts to improve approaches to identifying and treating those at risk. ENHANCING PREVENTION AND INTERVENTIONS As the Surgeon General’s Call to Action states, prevention of suicide should be a national priority. The severity of the suicide problem nationally and globally demands that prevention programs be developed. Research is needed to rigorously test approaches at all levels of intervention. Successful experimental programs need to be expanded to larger populations. And effective approaches need to be implemented. There are examples of promising universal, selective, and indicated interventions. Programs that integrate prevention at multiple levels are likely to be the most effective. Comprehensive, integrated state and national prevention strategies that target suicide risk and barriers to treatment across levels and domains appear to reduce suicide. Evaluation of such programs remains challenging given the multitude of variables on the individual and aggregate levels that interact to affect suicide rates. The value of intervention programs is frequently difficult to assess because of their short duration, inadequate control populations, and limited long-term follow up. Lack of adequate planning and funding for evaluation have seriously hampered prevention efforts. Universal programs broadly blanketing a school or community have been shown to be effective in reducing suicide rates. For example, the Air Force’s prevention program removed barriers; increased knowledge, attitudes, and competencies within that community; and increased access to

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Reducing Suicide: A National Imperative help and support with a consequent decrease in suicide rates. Reducing the availability or the lethality of a method (such as using blister packs for pills or enacting stricter gun control laws) results in a decline in suicide by that method; method substitution does not invariably occur. Education of the media regarding appropriate reporting of suicides can change reporting practices. Such changes seem to reduce suicide in certain contexts but the data are limited. Interventions that target groups with a greater likelihood of suicide (selective prevention measures) have also been shown to be effective. Screening programs, gatekeeper training programs, support/skills training groups, and school-based crisis response teams/plans can create a coordinated effort that identifies youth at suicide-risk and provides individual follow-up. Indicated interventions directed toward individuals at high risk for suicide include medical and psychosocial approaches. Suicide is far more likely to occur in the first month after discharge from a psychiatric hospital than subsequently. Low treatment adherence poses a major risk factor for suicidal individuals. Long-term follow-up care of discharged suicidal individuals holds promise for reducing suicide. Controlling the underlying mental illness through pharmacology and psychotherapy is an important indicated prevention approach. Medication alone is not sufficient treatment for suicidality. Psychotherapy provides a necessary therapeutic relationship that reduces the risk of suicide. Cognitive-behavioral approaches that include problem-solving therapy appear to reduce suicidal ideation and attempts. However, major obstacles to utilizing these resources exist, including doctor–patient communication barriers, limitations on insurance or financing, and stigma of mental illness. Providing skills and support for youth at risk through school programs appears to show promise. Optimism and coping skills, which enhance both mental and physical health, can be taught. Universal, selective, and indicated prevention programs that provide skills training reduce hopelessness. School-based programs employing a health promotion approach have been shown to effectively prevent and/or reduce suicide risk factors and correlates like adolescent pregnancy, delinquency, substance abuse, and depression. These programs also promote protective factors against suicide including self-efficacy, interpersonal problem solving, self-esteem, and social support. The data are limited, however, on the effectiveness of these programs to reduce completed suicides. Yet the known benefits and the links between these skills and suicide provide a logical rationale for recommending pilot studies in this area. Some international programs (see Chapter 8) have implemented similar efforts and it will be important to learn from their experiences.

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Reducing Suicide: A National Imperative Recommendation 4 Programs for suicide prevention should be developed, tested, expanded, and implemented through funding from appropriate agencies including NIMH, DVA, CDC, and SAMHSA. Partnerships should be formed among federal, state, and local agencies to implement effective suicide prevention programs. Collaboration should be sought with professional organizations (including the American Psychiatric Association, the American Psychological Association) and non-profit organizations dedicated to the prevention of suicide (such as the American Foundation for the Prevention of Suicide or the American Association of Suicidology). NIMH and SAMHSA should work with the Department of Education and the Administration on Aging to encourage national programs for youth and elderly populations. Programs that have shown success within select populations should be expanded. For example, the Air Force program should be adopted by hierarchical organizations that employ groups with increased suicide rates, including police and rescue workers. Gatekeeper training programs and screening programs for youth and elderly should be implemented more broadly within work and educational settings to identify and intervene with those at suicide-risk. There should be a systemic identification of high suicide risk groups for targeted intervention.