Reducing Suicide A National Imperative (2002) / Chapter Skim
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8 Programs for Suicide Prevention
8 Programs for Suicide Prevention
Pages 273-330
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From page 273... ...
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)
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. 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.
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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)
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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.
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Aspects of both the media presentation and the individual interact to produce imitation. The person who is likely to imitate a suicidal behavior 1 J 1Media refers to literature, the press, music, broadcasting, films, TV, theater, and the Internet.
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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)
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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.
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(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-la,b; Boyd, 1983; Boyd and Moscicki, 1986~.
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o 1 2 3 4 5 6 Years FIGURE 8-lb 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)
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From page 282... ...
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~.
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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~.
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Quasiexperimental studies suggest that greater restrictiveness in gun control laws is associated with declines in firearms suicide, sometimes without compensatory method substitution (Loftin et al., 1991~. In a particularly elegant cross-country comparison, the suicide rates were compared in two similar cities, Seattle and Vancouver.
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found a significant reduction in suicide rates following enactment, their breakdown by age and their choice of duration of analysis may be problematic (Kleck and Marvell, 2000; Loft, 2000~. Given the complexity of gun availability and fluctuations of these relatively infrequent events over time, a final judgement on the effectiveness of this legislation in reducing suicide is unlikely to happen soon.
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, with similar correlations between sales and completed suicide (Gunnel!
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While interictal psychopathology related to epilepsy seems to be an important risk factor for suicidal behavior (Mendez et al., 1989) , phenobarbital may be an iatrogenic cause of depression and suicidal behavior in epilepsy (Brent, 1986; Brent et al., 1990; Brent et al., 1987a; Ferrari et al., 1983~.
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From page 288... ...
, but not Japan (Lester and Abe, 1989~. Therefore, in some locales, the detoxification of domestic gas has had a lasting effect, and even in Great Britain, where method substitution did eventually take place, this occurred after a reduction in the suicide rate which lasted for a 15-year period.
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From page 289... ...
However, among cities internationally, there are marked variations in the suicide rate per passenger. Rates are extremely low in Singapore, Tokyo, Budapest, and Hong Kong but much higher in London, Barcelona, Rio de laneiro, and Paris (O'Donnell et al., 1994~.
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, which may limit the potential usefulness of hotlines in reducing suicide rates. Demographics of hotline use may be changing with an increase in usage by middle aged individuals (Scott, 2000~.
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These data and other anecdotal accounts indicate that no-suicide contracts are a widely used intervention, but the precise prevalence rates of use are not known. No-suicide contracts should never be used in place of appropriate suicide risk assessment and treatment (Miller, 1999; Simon, 1999~.
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It should be recognized that suicide prevention contracts do not provide protection from lawsuits (and may have the opposite effect if it is determined that the contract took the place of a thorough assessment; Miller, 1999~. As discussed in Chapter 10, suicide can be considered an expected outcome of some mental illnesses, and is very difficult to predict.
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. As would be expected with a universal program assessed shortly after its completion, the changes in suicidal behaviors and related risk factors have generally been promising yet modest.
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Skills training as described was quite variable: a single session on active listening and other social skills for supporting a peer (Overholser et al., 1989~; positive self-talk, situational analysis, empathy training, role playing, biblioguidance, interrupting automatic thoughts, rehearsal and skills strengthening (Klingman and Hochdorf, 1993~; roleplay with a suicidal peer emphasizing help-seeking (Kalafat and Elias, 1994~; suicide-specific content included in the context of a 10th grade semester-long mental health course entitled "Life Management Skills" (Zenere and Lazarus, 1997~; and a suicide intervention workshop, media training, and script writing and role-playing steps to helping a suicidal peer (Eggert et al., 1999~. Such programs increased adaptive coping skills (Klingman and Hochdorf, 1993; Overholser et al., 1989)
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analyzed the county data in comparison to state and national suicide rates from 9 years before to 7 years after the initial program implementation and found a consistently lower post-program rate of completed suicide. The current data support the importance of longer-term and skillstraining prevention programs for schools that include accessible services.
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From page 296... ...
, New Zealand, Australia, and Sweden have developed mental health promotion curricula as components of their comprehensive suicide prevention strategies (Beautrais, 1998; Ramberg, 2000; Waring et al., 2000~. Following WHO philosophy, their approach focuses on influencing health-related behaviors via knowledge, skills, attitudes, and support; creating conditions in the school and community that are conducive to health; and preventing leading causes of death, illness, and disability, including suicide.
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The evidence reviewed here supports carefully designed, sciencebased programs, particularly longer-term approaches couched in a broader context of teaching skills and establishing appropriate followthrough and services, as part of an effective armamentarium against suicide. Brief, didactic suicide prevention programs with no connection to services should be avoided.
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From page 298... ...
Information provided by program participants suggested that participants in SOAR performed at a level above the national average based on a national survey (King and Smith, 2000~. The two programs demonstrated that motivated adult helpers/professionals have little difficulty learning critical facts regarding suicide and the associated warning signs/risk factors when delivered as part of a gatekeeper-training curriculum.
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medications. When compared to suicide rates of the preceding 4 years, Rutz and colleagues (Rutz et al., 1989)
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Results also point to the critical nature of leader support in building a positive peer culture and creating a context in which effective skills training occurs. INDICATED PREVENTION Programs for Youth Youth identified as being at risk, evidencing early warning signs of suicide risk, need indicated suicide prevention.
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. Growth curve analyses showed significant rates of decline in suicidal behaviors including suicidal ideation in both programs.
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An NIMH-supported study on Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT; Bruce and Pearson, 1999) is testing the effectiveness of placing depression care managers in primary care practices in preventing and reducing suicidal ideation and behavior, hopelessness, and depressive symptomatology.
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Many of these programs also establish improved data-gathering and surveillance systems. Although some comprehensive suicide prevention programs appear to reduce rates of suicide, evaluation of such programs remains challenging given the multitude of variables on the individual and aggregate level that interact to affect suicide rates.
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. A significant aspect of Maryland's youth suicide prevention plan involves funds for schools to develop prevention programs.
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Given the research on overlapping risk factors for suicidality, the Air Force recognized a need to coordinate its mental health and social services. The suicide prevention program established a collaboration among six agencies: chaplains, child and youth programs, family advocacy, family support, health promotion/health and wellness centers, and mental health clinics.
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After implementing its comprehensive suicide prevention program, the Air Force saw a significant decrease in suicide rates among its activeduty personal, from 16.4 per 100,000 to 9.4 per 100,000 (p< 0.002) between 1994 and 1998 (Litts et al., 2000~.
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The Department of Defense is currently implementing the LINK model, which should yield more information about its effectiveness in reducing suicide. Suicide Prevention Programs for Rural American Indian Communities Integrated approaches to suicide prevention have been used effectively in several American Indian reservation communities in the United States and Canada for at least three decades.
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As a result of this partnership, this Jicarilla Apache community has had a comprehensive youth suicide prevention program since 1989 targeting 15-18 year olds in school and in the community with a variety of measures including public education, risk assessment, counseling, and alcohol abuse prevention initiatives (Serna et al., 1998~. Like the Shoshone-Bannock community program, the licarilla Apache program emphasized the use of "Natural Helpers" (local, indigenous persons trained to recognize symptoms of self-destruction and perform lay counseling)
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A number of risk factors and possible solutions were identified from survey research among the students, teachers, tribal leaders, and others within the community. The research at Zuni pinpointed correlates of suicide specific to this community that identified high risk youths as having experience similar to that of other populations (e.g., suicide ideation, depression, poor social support, and hopelessness, among others)
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In addition, the overall violent death rate dropped from 253 per 100,000 to 109 (Fox et al., 1984; Ward, 1984~. For a critical review of these and other suicide prevention programs among American Indians and Alaska Native communities, see Middlebrook et al., 2001.
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Published results of a national psychological autopsy study alone brought suicide to the national consciousness in Finland and evoked willingness among professionals to tackle the problem. Ignoring other research paradigms, however, hampered evaluation efforts, for example, and made determining whether the prevention program accounts for the reduction in suicide rates virtually impossible.
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New Zealand's youth suicide prevention program incorporates virtually the same elements, including the parenting interventions (Beautrais, 1998~. Sweden's program is very similar (Ramberg, 2000; The National Council for Suicide Prevention, 1996~.
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Although each of these programs based their strategy on the scientific literature regarding suicide, they lack the means to determine accurately whether their methods have specifically affected suicide rates. Suicide prevention researchers therefore have voiced concern about how funders and scientists have poured the bulk of their resources into more well-developed fields while communities continue to establish prevention efforts whose true effects remain largely unknown.
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314 ._, u cr~ ¢ bC u 5o V)
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Various technologies currently exist to improve participation in prevention programs and through higher utilization increase hotline effectiveness; the analysis here uses 5 percent. Even with the assumption of a very liberal relative risk of 2.5-10 for TABLE 8-4 PAR and PPE for Alternative Population-Based Prevention Programs p(X)
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From page 316... ...
Education of media professionals can change reporting practices and such changes seem to reduce suicide in certain contexts but the data are limited. Long-term public education campaigns and media training should be evaluated for their effectiveness both to change the public's knowledge and attitudes and to reduce suicide and suicidal behav~ors.
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Evaluation of such programs remains challenging given the multitude of variables on the individual and aggregate level that interact to affect suicide rates. Lack of adequate planning and funding for evaluation have seriously hampered prevention efforts.
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1990. Suicide rates, handgun control laws, and sociodemographic variables.
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1992. Youth Suicide Prevention Programs: A Resource Guide.
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Washington State Youth Suicide Prevention Program: Pathways to Enhancing Community Capacity in Preventing Youth Suicidal Behaviors. Final Report.
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Garland A, Shaffer D, Whittle B.1989. A national survey of school-based, adolescent suicide prevention programs.
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1999. The implementation and institutionalization of a school-based youth suicide prevention program.
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1992. The effect of access to lethal methods of injury on suicide rates.
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1984. An analysis of the effects of suicide prevention facilities on suicide rates in the United States.
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2000. Presentation of a Youth Suicide Prevention Programme.
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1990. Adolescent suicide attempters: Response to suicide-prevention programs.
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2001. Evaluation of the National Model Adolescent Suicide Prevention Project: A Comparison of Suicide Rates Among New Mexico American Indian Tribes, 1980-1998.
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2000. Urban/rural and gender differentials in suicide rates: East and west.
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The lines above were composed after one of his suicide attempts.
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Study designs frequently compare suicide, or suicide attempts, or suicidal ideation as an outcome in two groups of individuals. Several factors affect the necessary sample size.
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