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The Link Between Substance Abuse and Suicide

(6 hours)

This text is taken from the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Mental Health Information Center, Center for Mental Health Services

 

Suicide as a Public Health Crisis

"When I was 16 I tried to kill myself. Later, in the hospital, I had to drink this horrible charcoal to get the pills I had used out of my system. As anyone who has suffered through this horrible procedure knows, the charcoal ends up coming out of every orifice. It's disgusting!

I'm 35 years old and, so far, I have survived five episodes of being suicidally depressed.

All of us have had days when we feel down. But when you are blue, you still have your favorite things, you don't just abandon everything. When you are deep-down suicidally depressed, there is nothing, absolutely nothing that makes you feel better. Not even your child bringing you breakfast makes you feel worthy of getting out of that deep darkness. You stop brushing your teeth, showering, wearing makeup. . . doing things. Within a couple of days, you just shrink into this nothingness. You try to continue but you get worse and worse.

The pain is excruciating, but it isn't physical, it's emotional. In fact, physical pain--self-inflicted wounds and suicide attempts--can become a way to escape from the emotional pain.

People who have never had these feelings--feelings of not wanting to associate with anyone or anything, of being unworthy of life, of being suicidally depressed--may have a hard time understanding. But they must understand. It happened to me. It can happen to someone you know; your friend, your neighbor, your spouse, your child. It can happen to you!" -- The words of a suicide attempt survivor

Joey. Garrett. Jane. Scott. Louise. Bill. These are the names of six people who have been among the more than 30,000 people per year who die by suicide. Some of these people are adolescents or young adults. Some are elderly. Others are in the prime of life. They are sons, daughters, mothers, fathers, grandfathers, doctors, homemakers, artists, police officers, and members of the military. Some live in million dollar homes. Others are homeless. Some are athletes and in top physical shape. Others may be coping with disease or physical impairments.

Although some populations of people are more at risk than others, people who die from suicide come from every walk of life, gender, ethnicity, religion, and socio and cultural affiliation.

For the loved ones affected by individual suicide, the grief is immense. The questions are endless. How could this have happened? Why did this happen? And, perhaps the most painful question of all: What could I have done to prevent this?

The Cost of Suicide

Worldwide, suicide is the cause of almost half of all violent deaths -- more than wars and homicides put together.

Family and friends coping with the aftermath of a suicide or a suicide attempt often find themselves dealing with a double blow from the stigma associated with suicide. In reality, they are not alone in their grief. Suicide is the eleventh leading cause of death among the general population and is even higher among other select groups and regions of the country. It is the third leading cause of death among young people aged 15 to 24 and is the eighth leading cause of death for men--most of whom die from firearm injuries.

In fact, more lives are lost annually to suicide than are lost to AIDS or homicide. In 2002, suicide was the third leading cause of death for people in the 10-30 age group, following unintentional injuries (first) and homicide (second). This amounted to 7,199 deaths for this age group alone. These statistics don't take into account the loss to family, friends, and communities from suicide. Every suicide affects from 6 to 8 individuals who are closely associated with the person who has died.

Experts agree that suicide remains an underreported cause of death, in part because of differing case reporting requirements and definitions across the country and from suicides that are misidentified as unintended injuries or homicides. Drug overdoses are also difficult to understand: was the overdose intentional, unintentional, or accidental?

In addition to the tens of thousands of people in this country who die by suicide each year, another 650,000 people receive emergency care after they attempt it. It is estimated that there are from 8 to 25 attempted suicides for every one death by suicide--but no national data on attempted suicides are available. Countless others have suicidal thoughts (known as suicide ideation).

Public Health Responses

The rates of completed suicides have decreased about 6 percent during the past decade. However, given the major inroads in treatment options for mental health disorders over the past decade, it is difficult to understand why suicide rates haven't declined even more. Meanwhile, although deaths by suicide have declined, research indicates that other suicidal behaviors have not. A report comparing the results of surveys taken in 1990-1992 and in 2001-2003 found no significant differences in suicidal behaviors, such as ideation, plans, or attempts.

Suicide is not classified as a mental disorder, such as depression. Rather, it is a complex set of behaviors usually caused by a combination of factors. According to a ground-breaking U.S. Surgeon General's report, society must respond to suicide at the individual level--taking a clinical/medical approach to determine the history and health conditions resulting in suicidal behavior--and at the societal level with a public health approach. A public health approach seeks to prevent suicidal behaviors well before an individual is imminently at risk for taking his or her own life.

Thus, the public health approach focuses on identifying and understanding patterns of suicide and suicidal behavior throughout a group or population. The steps in this process include:

  • Defining the problem
  • Identifying risk factors and causes of the problem
  • Developing interventions evaluated for effectiveness
  • Implementing such interventions in a variety of communities  

Suicide "is a huge but largely preventable public health problem," according to the World Health Organization (WHO). Suicide results in nearly one million fatalities every year and billions of dollars in economic costs. The National Institute of Mental Health's Frequently Asked Questions About Suicide summarizes current findings about those populations at greatest risk and addresses other topics of concern.

Substance Abuse, Mental Illness, and Suicide

"Suicide is a huge but largely preventable public health problem."

In many cases, people who die from suicide are either under the influence of drugs or alcohol or have a substance abuse problem. Substance abuse is defined as "a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to repeated use; includes maladaptive use of legal substances such as alcohol; prescription drugs such as analgesics, sedatives, tranquilizers, and stimulants; and illicit drugs such as marijuana, cocaine, inhalants, hallucinogens and heroin."

In fact, research shows that alcohol is the substance most frequently associated with suicide risk.

Alcohol and Suicide

This alcohol/suicide association is based on a number of factors:

  • Alcohol is easily available, since it is legal, and affordable.
  • Alcohol use may reduce a person's inhibitions and also impair judgment.
  • Alcohol abuse frequently leads to impulsive, aggressive behavior.
  • Alcohol is a central nervous system depressant.

Alcohol is rapidly absorbed into the body, and with its continued use, alcohol reduces reaction time, leads to difficulty walking, and impaired judgment. In large doses, when consumed rapidly, alcohol can result in coma and death.

In addition to its link to substance abuse, suicide may occur with mental illness, particularly depression. For example:

  • At least 90 percent of all people who kill themselves have a mental or substance abuse disorder, or a combination of disorders.  
  • In a study of adults who drank alcohol, suicide ideation was reported among persons with depression. Another survey reported that persons who had made a suicide attempt were more likely to have a depressive disorder, and many also had an alcohol and/or substance abuse disorder.  
  • Among youth ages 12-19, males with hallucinogen use disorders, inhalant use disorders, and sedative-hypnotic use disorders had a higher risk for attempting suicide, and females with substance abuse disorders other than marijuana use had higher odds for attempting suicide.  

Substance Abuse and Mental illness

90 percent of people who die by suicide have a diagnosable mental illness or substance abuse disorder.

Substance abuse and mental illness have their own interconnection. A substance abuse problem, whether it stems from alcohol or other drugs, is often associated with a mental health problem.

The Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocol (TIP) No. 42, Substance Abuse Treatment For Persons With Co-Occurring Disorders describes the treatment challenges and techniques for working with a dually diagnosed or co-occurring disorder population. It is available at no charge through the National Clearinghouse for Alcohol and Drug Information.

Module 3 goes into greater detail about the connection between substance abuse, mental illness and the continuum of suicide risks.

National Strategy for Suicide Prevention

Despite the high death toll suicide has exacted through the ages, society has failed to address the problem as a public health concern. Many people view suicide purely in terms of its tragic consequences for individuals, not as a problem plaguing society as a whole. Complicating the issue is the stigma society has traditionally attached to suicide and to mental illness in general. As a result, those people contemplating suicide and their families may be reluctant to seek help. Community members may be apprehensive about taking a proactive stance towards the problem.

Suicide has lagged behind other social problems, such as child abuse and domestic violence, in gaining recognition as an issue that deserves public attention from individuals, organizations, and society. This kind of public attention is essential in order to identify or create the tools and knowledge to prevent suicide and save lives.

However, there are hopeful signs that suicide prevention is getting deserved attention. The World Health Organization (WHO), with input from leading experts, developed guidelines to help identify gatekeepers (health workers, teachers, prison officers, members of the media, and others) to identify those at risk, reduce stigma, and take other measures to deter and prevent suicides.

Boosted by calls to action by WHO, leaders in government and nongovernmental associations (NGOs), and suicide survivors (persons close to someone who completed suicide), suicide attempt survivors, and community activists, the Federal government developed a National Strategy for Suicide Prevention: Goals and Objectives for Action.

National Strategy Goals

"Mental illnesses are shockingly common; they affect almost every American family"

The National Strategy for Suicide Prevention is a Federal collaborative effort that brought together many of the best and brightest minds to focus on suicide prevention in the United States. Researchers, suicide survivors, government officials, nonprofit organizations, and advocacy groups, came together to produce a comprehensive document that provides direction and clarity for suicide prevention.

The Goals of the National Strategy for Suicide Prevention range from promoting awareness that suicide is preventable to improving access to mental health services and reducing the stigma of mental illness and substance abuse. This course is designed to help advance the goals of the National Strategy, including those of increasing awareness of suicide and decreasing the stigma of mental illness. To reduce the toll from suicide, experts identified Key Elements of a Planned National Strategy.

The Federal Steering Committee that helped develop the National Strategy and is overseeing its implementation includes representatives from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the Office of the Surgeon General (OSG). SAMHSA is acting as a link between the Federal efforts, States, and local communities.

SAMHSA is supporting the Suicide Prevention Resource Center (SPRC) and a National Suicide Prevention Lifeline (1-800-273-TALK). Calls made to the 1-800-273-8255 are automatically routed to the nearest suicide hotline at the local level. SPRC features an online registry of Evidence-based Practices in Suicide Prevention Programs. SPRC offers technical assistance and resources to states and communities to promote the National Strategy for Suicide Prevention (NSSP).

The Centers for Disease Control (CDC) has a systematic process for addressing suicide as a public health problem. CDC Activities highlight steps the CDC is taking to define the problem, identify risk and protective factors, develop and test prevention strategies, and assure widespread adoption of prevention principles and strategies.

A number of these resources and programs are described in more detail throughout this course.

In addition to the National Strategy for Suicide Prevention, The President's New Freedom Commission on Mental Health, which reviewed the mental health service delivery system in order to make recommendations related to improved access to services for people with disabilities, released a groundbreaking report calling for "a fundamental transformation of the Nation's approach to mental health care."

The commission recommended a national campaign to (1) reduce the stigma of seeking care and (2) improve efforts to address mental health "with the same urgency as physical health."

Suicide Across the Life Span

This course pays particular attention to how mental health professionals, prevention specialists, and others can identify the warning signs of suicide within individuals and to prevent problems from occurring within groups.

For professionals in prevention and treatment, it is important to learn the connections linking mental illness, substance abuse, and suicide. Of all the mental illnesses, depression is the most common disorder.

Suicide and substance abuse frequently have a mutually-reinforcing relationship. For a complex set of reasons that vary from person-to-person, suicidal behaviors may worsen substance abuse and substance abuse may intensify suicidal feelings and behaviors.

Modules 2, 3, and 4 discuss different dimensions of this vicious cycle by:

  • Describing the progressive development of suicide along a continuum of increasing risks
  • Focusing on substance abuse as a major contributor to suicide
  • Viewing suicide risks developmentally through the life span

Gatekeepers

At any age and within all socio-demographic groups, suicide and its underlying mental health issues are treatable conditions.

Yet, throughout the life of a person, there are people around who have the potential to impact one's direction in life for the better. Such individuals are sometimes known as community gatekeepers, those people who are in positions to help, due to their professional responsibilities and/or place in the community. Module 5 describes who some of these gatekeepers could be in a community and how their positive impact might help to prevent suicide. In conjunction with gatekeepers, this course lists a number of protective factors, which are areas of help, strength, and resilience.

Protective factors can exist within a person at-risk for suicide, within the strength and abilities of families impacted by suicide risks, and within the larger community and society. An example of a protective factor is reducing the stigma associated with mental illness.

This course presents fictitious scenarios and vignettes showing individuals facing suicidal tendencies. These scenarios and vignettes are based on real-life composites of people who have been at risk for suicide and on research into the complex reality of what it means to be at risk for suicide. There are also quotes at the beginning of most modules from actual suicide attempt survivors.

Suicide Symptoms

What is apparent is that suicide, in all its dimensions and variations, is a lonely and uncertain place. It affects hundreds of thousands of people who struggle with incapacitating feelings of despair and hopelessness or who react impulsively or under the influence of alcohol or other drugs. Those who experience this degree of despondency and crisis may do so in such a private and isolated way that it may be all too easy for those around them to be unaware of the problem. And for those who have never been to such an inner bleak place, it may be hard to empathize with the condition.

Unlike distress signals resulting from physical trauma, such as a heart attack or deadly disease, the pain of people considering suicide may go unrecognized until it is too late. This is why a public health approach to suicide prevention is so important--targeting or identifying at-risk people before they appear in the emergency department of a hospital. Through increasing awareness in the community-at-large, the signs and symptoms of suicide can be recognized and addressed.

Compared to progress over the past decade in identifying treatment for many mental disorders, information about the best methods for addressing suicidal behaviors is just emerging. In addition, researchers and practitioners continue to debate the role, if any, antidepressants may play in suicidality among adolescents. At the same time, at any age and within all socio-demographic groups, suicide and its underlying mental health issues are treatable conditions.

The advent of mood stabilizing medications, cognitive behavior treatment, and other therapies, and/or a combination of these interventions, have enhanced the quality of life for thousands of people. Other promising practices offer hope for many others. Effective treatment is also available for individuals who need help for substance or alcohol abuse.

The Warning Signs of Suicide

All members of a community owe it to their families and other loved ones and to society to learn the warning signs of suicide.

The National Suicide Prevention Lifeline recommends contacting a mental health professional or calling 1-800-273-8255 for a erral if someone exhibits one or more of the following:

Warning Signs for Suicide:

  • Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself
  • Looking for ways to kill oneself by seeking access to firearms, available pills, or other means
  • Talking or writing about death, dying, or suicide when these actions are out of the ordinary for the person
  • Feeling hopeless
  • Feeling rage or uncontrolled anger or seeking revenge
  • Acting reckless or engaging in risky activities--seemingly without thinking
  • Feeling trapped--like there's no way out
  • Increasing alcohol or drug use
  • Withdrawing from friends, family, and society
  • Feeling anxious, agitated, or unable to sleep or sleeping all the time
  • Experiencing dramatic mood changes
  • Seeing no reason for living or having no sense of purpose in life

At-Risk Populations

The warning signs of suicide may differ among age groups and other populations. Module 5 of this course addresses some special populations who may either be more at-risk for suicide and/or have under-recognized and under-treated mental health concerns. These populations include: African Americans; American Indians and Alaska Natives; Hispanics and Latinos; Asian Americans and Pacific Islanders; the Gay, Lesbian, Bisexual and Transgender (GLBT) population; Veterans and Active Duty Military Personnel; and the Severely and Persistently Mentally Ill (SPMI) population.

For many individuals, suicide is the last step on a continuum of pain. Crisis intervention is essential in order to help individuals find alternatives and hope before taking this final action. But, reducing suicide's destructive influence on populations and communities involves more than medical or psychological interventions at a point of crisis.

As individuals, community members, professionals, and as a society, we can change our behaviors and our systems to reduce the risk of suicide, whether it is linked to substance abuse, mental illness, or other risk factors.

By taking these steps, we can help the Joeys, Janes, Scotts, and Louises, and many others from getting to the place where there is no turning back.

Summary

  • Suicide is a public health crisis that can impact anyone, regardless of age, race, gender, religion, socioeconomic status, or geographic area.
  • Suicide is primarily connected to mental illness, but not always. Substance abuse also has an enormous negative effect on suicidal behaviors.
  • There are many governmental and nongovernmental programs and initiatives to address suicide prevention.
  • Recognizing warning signs can help in identifying those with suicidal behaviors in need of help.

Module 2: Recognizing the Progressive Development of Suicide

The Progression of Suicide

"Suicidal thoughts can come on suddenly and abruptly. What you need in that instance is for the person in your life to know the signs and not let you climb into bed at 7:00 p.m., then at 6:00 p.m., then earlier, and eventually not go to work at all.

You need an emergency preparedness plan for suicide. You lose it so quickly and completely, there is not even an ounce of you left that wants to hang on. At that time, you need to be able to call in the troops--friends who can help with dinners for your family or take the kids to soccer practice.

What can you say to a person with suicidal behavior? Be consistent and persistent and remind that person that it is temporary. Acknowledge the reality of what the person is feeling and put it in clinical terms when it is appropriate, but, also in loving terms when appropriate. You can't let yourself be sucked into the self-pity and guilt that the person might make you fall into.

Being able to let yourself go into someone else's protective care is the only thing that can save you.

When the suicidal thoughts finally do break--and they will--your senses come back to life. You can taste your food again... feel the texture of a warm blanket... see the fall trees and their beautiful colors. You can feel love again."

-- The words of a suicide attempt survivor

Among the after-effects of a suicide is the feeling of disbelief among family, friends, and other loved ones. How could she/he have done this horrible thing? I can't believe that someone I know would do such a thing.

Impulsive Suicide

Some completed suicides are the result of impulsive actions. Impulsiveness is the tendency to act without thinking. It has implications for both a plan of action and its consequences. Impulsiveness has been linked to suicidal behavior, typically through its connection to mental disorders and substance abuse. Some mental disorders contain impulsiveness as one of their diagnostic criteria. Those disorders that are the most linked to suicide include borderline personality disorder among young females, conduct disorder among young males and antisocial behavior in adult males, and alcohol and substance abuse among young and middle-aged males. It is less of an indicator for suicide in older adults. Impulsiveness, with and without aggression or violence, has been found to add to the risk of suicide.

Planned Suicide

However, for many people, death by suicide is not a rash decision. The decision to end one's life can involve years of thinking and planning. In recent years, researchers have gained new knowledge about suicide victims by conducting psychological autopsies. A psychological autopsy is a post-mortem investigation into the cause of a person's death. It is particularly useful in suicide and homicide cases, because there can be so many unanswered questions concerning the who, what, when, where, how, and why of a person's death.

Findings from psychological autopsy studies have identified a pattern among many suicide victims of progressively more serious acts of self-harm--culminating in death.

Suicidal Behaviors (Risk Factors)

Experts are moving away from looking at suicide merely as the act of killing one's self and instead er to a cluster of suicidal behaviors, beliefs, and/or life experiences and situations (past, present, and anticipated) known as risk factors that may eventually lead to suicide. Family members, friends, and professionals in mental health and other fields who have a clearer understanding of these suicidal risk factors are in a better position to provide early intervention to save lives.

This module introduces case examples to show individuals at various stages in the suicide continuum, from thinking of suicide to a suicide attempt.

Suicidal Ideation

Suicidal ideation occurs when a person thinks about suicide or about wanting his/her life to end. Individuals exhibiting suicidal ideation usually do not have a plan to commit suicide or end their lives. Suicidal ideation is a common occurrence for people from adolescence onward, at some point in life. However, for some people suicidal thoughts become more intense and frequent and lead to suicidal plans.

Teenagers are the most likely to have had some thoughts of suicide. Most of what we know about adolescent self-reported tendencies toward suicide and other health issues comes from the Centers for Disease Control and Prevention's Youth Risk Behavior Surveillance (YRBS). According to the YRBS nationwide survey of high school students for 2003, 16.9 percent of students had seriously considered attempting suicide during the 12 months preceding the survey.

Example of an Adolescent with Suicide Ideation*

Sean, 15, is in tenth grade and says he "hates" his life. Sean has a hard time opening up, but once he gets started talking, he has a string of complaints about his family, school, and life. "My parents hassle me all the time," Sean says. "They hate my clothes, my music, they hate me."

Sean has been smoking marijuana daily for the past year, along with binge drinking on weekends. Sean is alienated from school and thinks the only good thing about it is "hanging out with my friends, listening to music, just hanging." Sean says getting high and drunk numbs his feelings for awhile, then he crashes and feels worse, and uses some more to get rid of feeling so down and angry."

Sean says "he needs to use more and more to get the same effect and then he feels even worse. To Sean's surprise, now when he smokes pot or drinks alcohol, he still feels really depressed and full of hate, but he doesn't want to stop using. Sometimes Sean hates himself and wishes he weren't around anymore.

"Some of Sean's concerns are particular to adolescence, but his thoughts and feelings also lect problems that exceed typical teenage angst." He is having trouble concentrating and believes that his teachers think he's "stupid." Most of the time, Sean says he is "just out of it." But this also masks his depression and feelings of "being just plain down." When asked to describe this feeling, Sean says it's "like being sad but more so."

*Created for illustrative purposes only, not a real person.

Sean is a representation of thousands of youth with risky behaviors that increase the likelihood of self harm and other violent actions. As this example shows, with applicability to other stages in suicide, using alcohol and other drugs increases Sean's risk of suicide. It also increases the likelihood that Sean's depression will continue and lead to other problems.

Sean is socially isolated and shows tendencies of being both impulsive and emotional. Having access to alcohol and marijuana increases his risks. Sean needs to have people in his life who really know him, care about him, and who he can rely on to take action to help him.

Just how much of a danger does suicidal ideation cause along the spectrum, particularly for adolescents? Research shows why practitioners, parents, and others are concerned about the progression of suicide in youth. An analysis of data from the National Longitudinal Survey of Adolescent Health (ADD Health) of American adolescents in grades 7 through 12 found a number of factors were associated with suicide ideation, including having a gun in the household and lack of engagement in activities with their parents. Other conditions that increased the odds for both boys and girls of having suicidal thoughts included having a friend who attempted suicide in the past year, being depressed, having homosexual romantic attractions, or frequent substance abuse.

Suicide Plan

Having a suicide plan means that the person is thinking about killing himself and has at least one idea about how to go about ending his life.

Example of an Individual with Suicide Plans*

Tanya, 24, is a soft-spoken, shy young woman who graduated from college two years ago. Tanya admits that she lacks confidence. Despite a solid college record, she says she has had only "loser" jobs.

Tanya feels "left behind" compared to her friends who are "getting it together" and moving forward. She is embarrassed about the fact that she's still living at home with her parents. "I don't even have money to party," Tanya says, "It's just pathetic. I'm a total failure..."

When she does get out, Tanya's friend Jimmy buys her some 40-ounce bottles of beer. After a couple of those on Friday nights, "I feel good," she says. She began raiding the medicine cabinet at her friend's house, pocketing large amounts of valium at a time. "My life is a mess, I just want it over," Tanya said. "I'm glad I'm saving them because if things don't get better, I could do it. I really could. This could be it."

*Created for illustrative purposes only, not a real person.

Tanya is obviously experiencing immense distress and believes that her life is out of control. What she has in common with Sean is a strong sense of alienation, a substance abuse problem, and most likely mental health problems. Yet for both of these people, they have not crossed the line to becoming convinced that suicide is the right answer for them.

Suicide Attempt

A suicide attempt is a potentially self-injurious behavior with a nonfatal outcome; suicide attempts may or may not result in injuries. In a suicide attempt there is evidence that the person intended to kill him or herself.

Example of Suicide Attempt*

Frank, nursing his fourth beer of the evening, is slumped in a chair in his living room, fast food packages are strewn across the carpet and the television is blaring.

From the outside, most people think Frank has everything going for him. A nice house, a wife and kids, a well-paying job. But recently, the pressure of work, family conflict, and his own long-term depression are driving Frank to the edge.

From Frank's point of view, his life is a sham and, increasingly, he believes, not worth living.

"I'm scared. If I get laid off, the credit card bills alone could sink us. I'm in way over my head. Without my job, I'm nothing. Just another fat slob trying to hang on. Nothing."

Frank says that increasingly, he can't even get out of bed in the morning. He finds that sleeping just makes it worse. He feels like he's "being eaten up."

Frank is carrying out his plan to "say goodbye to this world" tonight. He has already consumed several pain pills, enough for an overdose, and plans to "finish off the job" with a handgun he has stored away.

"It's almost a relief knowing it's coming," he says. "One quick shot and it's over. Just like that. No more pain."

*Created for illustrative purposes only, not a real person.

Frank's story is similar to countless other people in the real world who are thinking about, planning, or making attempts to end their own life. This course provides suggestions for helping people at every step in the progression of suicide, including those like Frank who are facing the prospect of the last stage.

Suicide

Until this point, there is hope for individuals no matter what stage of the suicide spectrum they are in. In Frank's case, the suicide attempt will act in part as a wake-up call for him, helping him to value life more, but it also puts him at much greater risk for another suicide attempt that could end in death the next time.

Example of a Suicide's Impact on a Community*

On a spring day, near the beginning of the planting season, the generally quiet pace of life in a rural Midwest community was unexpectedly disrupted with the suicide of a popular local newscaster. This charismatic young man in his late 20s was a local celebrity, an active volunteer, and role model who worked with numerous community programs serving youth. Joe's suicide devastated the local community which had assumed that the popular "city boy" had adjusted to the slower pace of life in their area.

Parents and other community members working with the young people who knew Joe held hushed conversations among themselves to discuss responses to the grief-stricken teens. Informally, they agreed that it was better not to discuss the matter until a young person asked for help. Some parents expressed the concern that discussing Joe's suicide would only make things worse.

Joe's suicide made state news. One of the local networks carried extensive coverage of the suicide, providing elaborate details about how Joe died and its effect on the community. There was also a feature story on celebrities who had completed suicide that gave simple and generalized answers about why well-known people take their own lives.

Two days after Joe's suicide, three high school students engaged in copycat suicides. At the scene of the triple suicide, police found several empty bottles of hard liquor and an open container of gasoline that the students had inhaled. There were also three separately written suicide notes indicating that these suicides were done in "tribute" to Joe.

A year later, many people in this community were still upset about the deaths by suicide. Parents and other community members learned the hard way that trying to sweep suicide under the rug doesn't work. It became clear that talking about what happened to Joe out in the open was very important and healing for the young people. This community also learned that sensationalizing suicide stories only makes the situation worse. There are no quick and easy answers to what causes a suicide.

*Created for illustrative purposes only, not a depiction of an actual event.

As the above vignette illustrates, one dimension of suicide is known as suicide clusters, suicide contagion, suicide imitation, or copycat suicide. These terms er to the exposure to suicide or suicidal behaviors within one's family, peer group, community, or even through media reports of suicide. This kind of exposure can result in an increase in suicide and suicidal behaviors, both through direct and indirect contact with a suicide. Teenagers and young adults are the age groups that most often engage in suicide following a suicide.

Media reporting about suicide deaths plays a large role in copycat suicides. When headlines or reporting are dramatic, providing lengthy descriptions, and/or details about the method of suicide, vulnerable people exposed to such reports can react by identifying with the victim and taking their own lives. Inadvertently romanticizing or idealizing a person who kills oneself, or portraying the suicide victim as heroic, can have a devastating effect on others. Likewise, celebrity deaths by suicide are more likely than non-celebrity deaths to yield imitation.

Suicide contagion can be greatly reduced by factual and concise media reports of suicide. When there is not prolonged exposure to reports of suicide, the likelihood of suicide imitation or copying is minimized. Media reports should avoid oversimplification of causes, as well as glorifying the victim.

Suicide should never be depicted as an effective way to achieve a personal goal or solve a problem.

Suicide Survivors

Suicide survivors are defined as those family members, partners, or friends who have survived the suicide death of a loved one. They are the people who are left behind to pick up the pieces; the ones who try to answer questions that may be unanswerable. Being a suicide survivor frequently puts one at risk for suicide, too. When a loved one takes his/her own life, it makes the reality of suicide all the more present in the lives of everyone close to that person.

Example of a Suicide Survivor*

Gayle's husband, Jerry, killed himself two months ago. He had been depressed for many years, and he had resisted getting help. When Jerry began to feel better, he would stop taking his medications. He also didn't like their side effects. Gradually, Jerry stopped going to therapy.

Gayle and Jerry had been through so much together. Gayle believed that if she "hung in there forever," Jerry would change, he would get better. Jerry left Gayle a suicide note. The note thanked her, told her how much he loved her, and said that she had been a great wife and that she should move on in her life. Gayle was having none of that.

She blamed herself and kept wracking her brain for what she could have done differently and better. She kept going over the same scenarios again and again. And, she was so angry with Jerry for not trying harder, for not sticking with his treatment as he should have.

Gayle is still having trouble sleeping at night and she's not eating very well. At first people were supportive, except for her husband's sister Alice, who thinks that Gayle didn't do enough. Other people don't know what to say or do and they have kept away. Her adult children are asking her to get some help, to take the steps that their Dad never did and really take care of herself.

*Created for illustrative purposes only, not a real person.

Suicide Aftermath

Death from a suicide is different from the more typical, involuntary forms of death. As the preceding example shows, among the painful feelings a suicide survivor may feel are guilt, anger, stigma, and disconnection.

The Aftermath of Suicide for Family and Friends

Suicide survivors, or those close to someone who committed suicide, face a painful recovery. They often experience:

Guilt: They may wonder what could have been done differently to save the person; survivors may question whether they are to blame.

Anger: When loved ones choose to end their own lives, they choose to be permanently separated from others rather than leave survivors with the thought that they wanted to remain with them.

Stigma: People may make insensitive remarks, ask inappropriate questions, pass judgment and blame instead of offering compassion and support to survivors.

Disconnection: Survivors may become confused and disconnected from the happy or positive memories of the loved one. They may also feel distant from their friends and family who are alive.

Identifying Risk Factors for Suicide

What puts individuals similar to Sean, Tanya, Frank, Joe, and Jerry at risk for suicide? How can society understand the factors contributing to suicide's progression and conversely find ways to counter them with healthy behaviors?

Researchers and practitioners are examining these and other questions that need to be addressed in order to intervene in individual cases and to prevent suicide among diverse populations. The National Strategy for Suicide Prevention has identified the following factors related to suicide:

Risk Factors (What Makes Suicide More Likely?)

Risk factors are those characteristics present within an individual or group that create the greater potential for suicidal behavior. Risk factors may be present in the individual, in the environment, or within the social and cultural context.

Biopsychosocial Risk Factors
  • Mental disorders, particularly mood disorders (depression, bipolar disorder), schizophrenia, anxiety disorders, and certain personality disorders
  • Alcohol and other substance use disorders
  • Hopelessness
  • Impulsive and/or aggressive tendencies
  • History of trauma or abuse
  • Some major physical illnesses
  • Previous suicide attempt
  • Family history of suicide
Environmental Risk Factors
  • Job or financial loss
  • Relational or social loss
  • Easy access to lethal means
  • Local clusters of suicide that have a contagious influence
Sociocultural Risk Factors
  • Lack of social support and sense of isolation
  • Stigma associated with help-seeking behavior
  • Barriers to accessing healthcare, especially mental health and substance abuse treatment
  • Certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma)
  • Exposure to, including through the media, and influence of others who have died by suicide

Protective Factors (What Helps Prevent Suicide?)

"Suicide is difficult to predict; theore preventive interventions focus on risk factors."

Protective factors are those factors that reduce the likelihood of suicide by enhancing resilience and decreasing risks:

  • Increasing social support
  • Increasing and/or improving coping skills
  • Developing an understanding of mental health
  • Decreasing the stigma associated with seeking help for mental health problems  

Related to the above list of protective factors, but with some important additions, the Suicide Prevention Resource Center (SPRC) lists the following:

  • Effective clinical care for mental, physical, and substance abuse disorders
  • Easy access to a variety of clinical interventions and support for help-seeking
  • Restricted access to highly lethal means of suicide
  • Strong connections to family and community support
  • Support through ongoing medical and mental healthcare relationships
  • Skills in problem solving, conflict resolution, and nonviolent handling of disputes
  • Cultural and religious beliefs that discourage suicide and support self preservation  

Who Are Gatekeepers?

Gatekeepers are individuals trained to identify persons at risk of suicide and er them to treatment or supporting services as appropriate. They include:

  • School health staff
  • Clergy
  • Police
  • Correctional personnel
  • Occupational supervisors
  • Hospice and nursing home staff
  • Volunteers
  • Natural community helpers
  • Healthcare providers
  • Mental health and substance abuse treatment providers
  • Emergency department healthcare workers
  • Divorce, family law, and criminal defense attorneys

Prevention Goals

The National Strategy for Suicide Prevention describes goals and priorities for suicide prevention on an individual, community, and/or national level. The goals and priorities stated below complement the protective factors and help one to see how protective factors can be operationalized.

The National Strategy supports these methods for preventing suicide:
  • Promote awareness of suicide as a public health problem, not merely an individual/family problem.
  • Gather broad-based support for suicide prevention.
  • Identify patterns of suicide and suicidal behavior throughout a group or population.
  • Develop and implement community-based suicide prevention programs.
  • Train professionals and others to recognize at-risk behavior and have adequate treatment available.
  • Establish effective clinical and professional practices for prevention, early intervention, and treatment of suicide.
  • Promote and support research on suicide and suicide prevention.
  • Improve and expand data collection and statistical systems (collect information on completed suicides, precipitating events, adequacy of social support and health services, data on cost of injuries related to suicidal behavior, and loss of productivity and earnings).
  • Build strong connections to family, community, and other forms of social support.
  • Provide effective clinical care for mental, physical, and substance abuse disorders.
  • Supply access to healthcare and social services.
  • Teach gatekeepers to recognize warning signs (see box for definition of gatekeepers).
  • Restrict access to lethal means.
  • Train in problem solving, conflict resolution, and nonviolent handling of disputes.
  • Encourage responsible media reporting to decrease sensationalism, imitation, and suicide contagion.
  • Identify families with one or more members who have completed suicide.
  • Decrease the stigma of mental health and/or substance abuse disorders, particularly among men (women seek help more than men).

Universal, Selective, Indicated Suicide Prevention

Suicide prevention can be conducted on a variety of levels. Strategies can be aimed at individuals, at-risk subgroups, or the entire population. Traditionally, prevention efforts have been classified as:

  • Universal - Designed for everyone in a defined population regardless of their risk for suicide, such as a healthcare system, a county, or a school district.
  • Selective - Designed for subgroups at increased risk, due to age, gender, ethnicity, or family history of suicide.
  • Indicated - Designed for individuals who have a risk factor that puts them at very high risk.

Suicide Prevention Strategies

A few effective suicide prevention interventions at the community level are described below and should be combined to maximize results.

Create Safer Environments

Suicide prevention also involves changing the environment affecting all individuals whether they are at risk or not. For example, by changing social mores to eliminate stigma regarding treatment for mental illness and substance abuse, society is also taking steps to prevent suicidal behaviors. Regulating dosages of drugs that can be used for non-medical purposes, including suicide, and teaching families with members at risk how to safe-proof their homes by restricting access to dangerous household chemicals helps deter impulsive suicides.

Incorporate Cultural Awareness

Suicide prevention is not just the job of mental health experts.

As with other issues of concern, suicide prevention must be culturally competent. Programs must respect and embrace the values, language, and mores of local communities and groups. For example, some communities, such as American Indians, may per to obtain health advice from the local spiritual leader rather than from a doctor. Effective prevention efforts affirm these ties and utilize these community leaders in promoting healthy messages.

Expand Prevention Efforts

Most importantly, to be most effective and long lasting, suicide prevention efforts must be on a scope that moves beyond the moment of crisis. One of the leading experts in suicide prevention has compared the field of suicide prevention to the early days when health experts were learning about the causes of heart disease.  

The public health is served not only by medical advancements such as heart bypass surgery but also by programs promoting healthy lifestyles. Similar inroads in preventative efforts to improve mental health, particularly severe conditions, have yet to be made.

Encourage Community Involvement

Society has yet to recognize that suicide prevention is not just the purview of mental health experts, but is a community-wide responsibility. Among a few of the community members and partners that hold potential roles in reducing suicide rates are employers, police and fire departments, ethnic communities, government agencies, universities, and military services worldwide.

Enlisting the help of these and other partners holds promise for the future.

Summary

  • Suicidal behaviors extend across a continuum of increasing risk, from suicidal ideation (having thoughts of suicide), to suicide planning (coming up with ideas about how to end one's life), to suicide attempt (implementing a suicide plan or impulsively acting to take one's own life), to death by suicide.
  • Both the risk and protective factors for suicide occur along biopsychosocial, environmental, and sociocultural dimensions, with some of the risk and protective factors being conversely linked to one another.
  • Prevention of suicide can occur at the universal, selected, and/or indicated level(s). Suicide prevention is a critical public health issue and there are numerous gatekeepers, or helping persons, who can be identified to help ease this problem.

Module 3: Substance Abuse as a Major Contributor to Suicide

Alcohol Abuse and Increased Suicidality

"Suicide and substance abuse, they were my only friends. Suicide was my friend because I had control over it compared to everything else in my life. I can't stop drinking, but I can hurt myself. I can shave my head. I can kill myself. That felt good.

I started drinking in third grade. I've had several suicide attempts. The last one was after my mother died and after I lost my son. I lost everything. My family hated me. They were tired of empty promises. I was homeless because my dad wouldn't let me back in the house. It was February and I was freezing and crying in the mail slot asking my father to let me back in the house.

I was either going to die or be a drunk the rest of my life.

So many people working in treatment don't see you as having an illness. They get jaded and frustrated from seeing people come in, relapse after relapse. Finally, a woman really treated me differently. She told me that I hadn't lost it all--there was still hope.

I couldn't stop drinking just like that. But my dad worked with me to go from drinking a 12-pack of beer a day, to nine, and then only two beers a day. I turned my bank account over to my father so I wouldn't be tempted to get drunk. I found a program that worked for me in dealing with my alcohol abuse and my mental illness.

I learned things like one size doesn't fit all people in treatment. I learned that I don't really have control over anything except for my Perception, my Attitude, and my Response to things--PAR. I also learned that it's not just substance abuse. You need good nutrition. You have to give the person some method of doing it their way. You can't just treat from the neck down.

Alcohol abuse and mental illnesses should be treated like any other illness. I am not ashamed to say to people, I am a recovering alcoholic. I am bi-polar. At the same time, it's very important to separate yourself from the mental illness or the substance abuse. My mother's illness didn't define her. We knew her for her loving personality. She was a survivor.

I am so happy that I get to have a relationship with my children again. I feel like I am starting over. All my life, I've been numb with alcohol. I'm actually feeling things. It's scary. I feel so rich right now. Every conversation I have I want it to mean something.

For so long all I wanted to do was die. I care about people now. I care about life."

--The words of a suicide attempt survivor.

For thousands of people, the dual conditions of substance abuse and suicidality create a living nightmare. Substance abuse (particularly alcohol) can make the suicidal feelings, thoughts, and/or behavior even worse. Substance abuse can also impair one's impression of a situation or experience, contributing to misjudgments about what reality is. Any substance that alters a person's consciousness and awareness in a distorted or exaggerated manner can increase suicide risk because the person is not operating at their full capacity and awareness, leading to impaired judgment, perception, reality-testing, and comprehension.

Example of Alcohol as a Risk Factor*

Frank's hand was shaking as he tipped the bottle into the glass and downed the shot. He joked to himself, "Is the glass half empty or half full?" and poured another drink. Frank had no illusions. His "glass" wasn't just half empty, it had bottomed out. Yet Frank drank anyway, seeking a break from his problems and from himself.

Over the past few months, Frank's depression had taken on a drastically new and frightening shape. His mind raced ahead to the future. A few weeks, a few months, even a few years. He saw himself. One of those crazies. Abandoned. Maybe even homeless. Another frightening image came to Frank: his father, slumped over the kitchen table, dead drunk. And then years later, his father in an institution. A hospital gown barely covering his bony knees and thin arms.

Frank began to think more about his past. His dear Aunt Paige came to mind. Frank remembered Aunt Paige's quiet assurances. "Frank, when you hit rock bottom, there is no where to go but up," she would say. But Aunt Paige was wrong. When you hit rock bottom, there was another option.

* Created for illustrative purposes only , not a real person.

As the example shows, Frank is under the false impression that the alcohol will make him feel better. Instead, using alcohol is merely driving him deeper into the depths of depression.

Alcohol Abuse

Alcohol can have an effect on the body in direct proportion to the amount consumed. It is a central nervous system depressant that is rapidly absorbed from the stomach and intestines and into the bloodstream. Negative effects of alcohol include impaired judgment, reduced reaction time, slurred speech, and difficulty walking.

When drunk quickly and in large quantities, alcohol can result in coma and death. Alcohol also interacts with a number of prescription and nonprescription medications in ways that can intensify the effects of the alcohol, the medications, or both. Alcohol use can be particularly potent if there are other suicide risk factors present, such as depression or other mental illnesses.

One need not be an alcoholic to be at risk for suicide. Anyone who abuses alcohol, depending on the other risk factors present in their lives, can be at risk for suicide. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), drinking becomes too much when it causes or increases the risk for "alcohol-related problems or complicates the management of other health problems."

Screening for heavy drinking is important because:

  • At-risk drinking and alcohol problems are common
  • Heavy drinking often goes undetected
  • Clinicians and other healthcare professionals are in a prime position to help make a difference  

Alcohol's Impact

Alcohol use is less associated with premeditated suicide. Premeditated suicide is typically thought through and planned out in advance. However, when a suicidal person is under the influence of alcohol, there is a greater likelihood of impulsivity and poor decision-making. This can contribute to the use of firearms, along with increased aggression, antisocial behavior, and risky behaviors that are associated with suicidality while under the influence of alcohol. As a result, suicide prevention initiatives frequently involve reducing access to weapons and other means for expressing violence.

The link between alcohol and suicide is strong enough that when an individual like Frank stops using alcohol, the risk of suicide substantially decreases, assuming the person gets help.

Researchers have found that people die by suicide for different reasons--depending on whether or not alcohol is present. Although the vast majority of people who are depressed or who are alcoholics do not kill themselves, research indicates those individuals who complete suicide from either group differ in the motivation for their action. Persons suffering from major depression, for instance, may take their lives for internal reasons: feelings of misery, guilt, and hopelessness. Alcoholics, by contrast, frequently kill themselves in reaction to events in their environment.

Of Alcoholics Who Die From Suicide...

  • One-third experienced the loss of a close relationship within the prior six weeks
  • Another third have expectations at the time of their suicide that they will sustain an equally severe interpersonal loss  

By extension, people who are both depressed and abuse alcohol may believe they have internal and external reasons for attempting suicide, a combination that compounds and expands the likelihood of a completed suicide.

Suicide and Non-Alcohol Substance Abuse

Drugs other than alcohol also contribute to suicidal behaviors. This is due to the mind-altering impact of abused drugs, which impairs judgment, reasoning, perception, and one's sense of reality. Just as alcohol loosens inhibitions, so do other drugs, especially when taken in higher doses.

However, it is difficult to completely separate out alcohol from other kinds of drug abuse. Alcohol is typically used in conjunction with other drugs. Alcohol is the easiest and least expensive drug to purchase and the fact that it is legal makes access to it common.

Factors Leading to Suicide in Substance Abusers:

A leading researcher on suicide risk among substance abusers identified the following factors that are frequently associated with the suicide deaths of substance abusers:

  • Substance abuse (alcohol included) is found in 25-55 percent of suicides
  • The rise of substance abuse other than alcohol is likely to have contributed substantially to the increase in suicide among young people in the past 30 years, particularly males
  • Two-thirds of substance-abusing individuals who die from suicide have a major depressive disorder
  • Major depression has been seen as a late complication of alcoholism more often than its antecedent
  • The loss of a close personal relationship is a frequent contributor to suicide in substance abusers (for both alcoholics only and those not primarily alcoholic)
  • Half of the suicide victims were unemployed
  • Half had serious medical problems
  • Nearly two-fifths lived alone
  • Of the suicides among people who were alcoholics, more than four-fifths of them had communicated suicidal thoughts verbally, behaviorally, or by both means
  • Thirty-eight percent had a previous suicide attempt  

Preventing Suicide in Substance Abusers

Given the manifestation of suicidal behavior among individuals with a drug problem, experts recommend treating co-occurring disorders simultaneously.

The connection between suicide and substance abuse is complex. Researchers have established the connection, but the precise causal relationship will vary from person to person. As with all human behavior, there are multiple factors for determining risk, and conversely, for fostering resiliency within individuals. For the most part, researchers and practitioners must limit discussion to the risk factors that are most frequently identified among a range of individuals.

In general, suicide attempters have a history of abusing far more substances than non-attempters. In addition to alcohol, sedative hypnotics were the substance most abused by suicide attempters. In one study, among suicide attempters the following ratios were found for substance abuse.

The number of substances used is more of a predictor of suicide attempts than the types of substances used, according to one study. A key finding from this study is that the major risk of suicidal behavior is linked to current use rather than to past use. This study found that "the effects of substance use disorders on suicide attempts are not entirely due to the effects of co-occurring mental disorders," suggesting that substance abuse in and of itself is a risk factor for suicidal behavior.

Steps to Preventing Suicide in Substance Abusers:

  • Recognize and treat depression
  • Recognize and treat active alcoholism and other drug abuse
  • Take interpersonal crises and financial difficulties in this population seriously
  • Do not dismiss suicide risk during intoxication  

Misuse of Legally Prescribed Medications and Suicide

The British Journal of Psychiatry conducted a meta-analysis (statistical overview) of the literature and published the information contained below about the increased risk for suicidal behavior among substance abusers. The article focused on the misuse of legally prescribed medications, the diversion of medications for inappropriate or illegal uses, (including illegal opioids such as heroin), or a combination. All combinations increased the risk of suicide.

Misuse of Legal Drugs and Suicide:

  • Opioid dependence/abuse has been linked to a 10 times higher risk of suicide
  • Misuse of legal drugs (prescription and over-the-counter) has been linked to a 30 times higher risk
  • Legal drugs plus alcohol, has been linked to a 39 times higher risk
  • Legal drugs plus illegal drugs, has been linked to a 86 times higher risk  

Opioid Abuse

Many of the legal drugs abused are opioids, which are narcotic analgesics, or pain killers. Many of these legal drugs are subject to abuse and are used in inappropriate and illegal ways, through diversion from prescribed use and availability, "on the street," in schools, the workplace, the home, and other places.

Frequently Abused Prescribed Pain Medications:

  • Morphine
  • Codeine
  • Oxycontin
  • Darvon
  • Vicodin
  • Dilaudid
  • Demerol

Suicide Risk and Mental Illness

Researchers have found that just as some mental illnesses put individuals at risk of suicide so do they put them at greater risk of substance abuse. This mutually reinforcing situation merely increases the likelihood of suicidal behaviors. The mental illnesses that are commonly associated with an increased risk for substance abuse are depression, bipolar disorder, schizophrenia and the other psychotic-spectrum disorders, and some personality disorders, particularly borderline personality disorder and anti-social personality disorder.

As research has demonstrated over the past few years, many of these mental illnesses are much more prevalent than recognized in the past. In fact, the President's New Freedom Commission on Mental Health has found that mental illnesses affect almost every American family.

Mood disorders, such as depression and bipolar disorder, rank as the fourth greatest cause of illness in the world, according to the World Health Organization (2001). The WHO predicts that mood disorders will move up to third place by the year 2020.

Risky Consequences for Substance Abusers With Mental Illness:

  • Impulsivity, dangerous behaviors (driving under the influence, riding in a car with someone under the influence)
  • Homicide
  • Sexual and/or physical abuse and trauma
  • Legal problems
  • Relationship problems
  • Financial problems
  • Inherited or generational risk factors (history of mental illness and/or substance abuse, history of suicides)

Co-Occurring Disorders

According to the meta-analysis of the literature on suicide and mental disorders, major depression increases one's suicide risk by 21 times, bipolar disorder increases suicide risk by 12 times, and schizophrenia increases suicide risk by 9 times.

When a person has a co-occurring disorder, he or she may begin to self-medicate using alcohol, prescription, and/or illegal drugs to alleviate internal and external sources of discomfort, distress, medical, and/or social problems. The tendency to self-medicate is rarely a conscious, intentional decision. Instead, it is typically passed on through learned behavior, genetics, lifestyle choices, or a combination of these factors.

Society has come a long way in its attitudes toward mental illnesses. However, the long-standing stigma associated with mental illnesses is still very present in society. Many individuals internalize feelings of fear, disrespect, and inferiority, having little regard for what goes into their bodies--no matter the harm.

For individuals with a co-occurring mental illness who are on mood stabilizing medications, self-medicating through alcohol or other non-prescribed drugs can be especially lethal. Alcohol when mixed with some prescriptions can cause serious side effects and make the prescribed drug either more potent or less effective.

Barriers to Seeking Care

Despite the prevalence of mental illness and suicidal behaviors, all too often people face barriers to seeking care. When it comes to seeking care for co-occurring conditions such as depression and substance abuse, the barriers are even greater.

The stigma associated with mental illnesses and substances abuses may be higher among some groups. For example:

  • Rural Americans who may have had little exposure or access to the mental health service system
  • Racial and ethnic minority groups who may hesitate to seek treatment in the current system
  • People whose primary language is not English  

Systemic Barriers

Up to two-thirds of people who die by suicide are not receiving mental health or substance abuse treatment at the time of their death.

Another major barrier for individuals is the fact that typically services for mental health disorders and those for substance abuse disorders have been kept in separate streams. For example, a mental health therapist would er an individual with a substance abuse problem to treatment at a substance abuse treatment facility or center, thus prematurely stopping the mental health treatment.

It has not been unusual for people seeking treatment for substance abuse issues to be told to get clean and sober before receiving mental health treatment. It has also been commonplace for 12-step abstinence programs to discourage the use of all medications, including anti-depressants, anti-anxiety medications, and other similar drugs.

Only recently have experts identified the need for a holistic approach toward treatment so that co-occurring conditions are addressed together. However, a significant shift in the mindset of both mental health and substance abuse treatment providers is still required to unify the treatment of both kinds of disorders together.

A common emergency room scenario, as described by Dr. Richard McKeon, who is heading the Substance Abuse and Mental Health Services Administration's efforts to incorporate a unified approach toward mental health and substance abuse treatment and prevention, features an intoxicated, suicidal patient who is held in the emergency room until his blood alcohol level drops. He may be discharged if the suicidal behavior is no longer presented once the alcohol wears off. Yet, although research shows that substance abuse may result in impulsive suicide attempts, there is rarely follow-up after discharge.

Obstacles to Care for Persons With Mental Illness:

  • Unfair treatment limitations and financial requirements placed on mental health benefits in private and public health insurance
  • The fragmented mental health service delivery system
  • The stigma that surrounds mental illness  

Integrated Care: "No Wrong Door" for Treatment

The Center for Substance Abuse Treatment (CSAT) has been a leader in supporting the principle of "no wrong door." This concept states that treatment providers across the healthcare delivery systems have a responsibility to address the range of client needs and supports a model of integrated care.

Only recently have experts identified the need for a holistic approach toward treatment so that co-occurring conditions are addressed together.

Treating people for underlying causes of suicide, including mental illnesses and substance abuse problems, serves to not only improve mental health but will help reduce suicide rates.

The National Treatment Improvement Evaluation Study surveyed more than 4,000 adults and adolescents being served by treatment units receiving government funds. The study found marked reductions in suicidality the year following substance abuse treatment compared to the year prior to treatment for adults, young adults, adolescents, and subgroups of abused and non-abused women.

The study found:

  • Suicide attempts for the group as a whole declined about four-fifths for male and female clients.
  • Of the adults aged 25 and over included in the study, only 4 percent reported suicide attempts during the year following treatment compared with 23 percent who reported suicide attempts the year prior to treatment.
  • Only 4 percent of the 18- to 24-year-old young adults reported suicide attempts during the 12 months following treatment compared with 23 percent who had a suicide attempt the year before treatment.
  • Adolescents 13 to 17 years of age showed declines from 23 to 7 percent in pre- and post-suicide attempts.
  • In two groups of women, those who had reported sexual abuse and those who reported no prior sexual abuse, suicide attempts declined by about half in both groups and had fewer inpatient and outpatient mental health visits and less reported depression.  

Suggested Practices

Reducing substance abuse has cumulative benefits, including that of reducing the risk of suicide--at any age and within any population.

Researchers, practitioners, and national organizations are recognizing the need to make sure patients with co-occurring disorders receive the treatment they need. Advances in the treatment of co-occurring disorders include improved assessments, psychological interventions, psychiatric medications, and new treatment models and methods. These improvements have increased the options for the counselor and the client.

To encourage best-practices and to provide guidelines for mental health and other professionals, the Center for Substance Abuse Treatment develops Treatment Improvement Protocols (TIPs) and draws on the experience and knowledge of clinical, research, and administrative experts to produce them.

"Substance Abuse Treatment for Persons With Co-Occurring Disorders" TIP (#42) provides information for professionals in related fields on successful programming, assessment, strategies for working with clients with co-occurring disorders, cross-cutting issues, and other topics related to the co-occurring disorders of mental health and substance abuse. TIP 42 includes special sections on suicide and substance abuse.

The Substance Abuse and Mental Health Services Administration (SAMHSA) has also established a Co-Occurring Center for Excellence (COCE). This initiative is led by CSAT and the Center for Mental Health Services (CMHS). It acts as a vital link between SAMHSA and the States, communities, and providers. COCE provides technical assistance, information, and training resources. It focuses on evidence-based treatment models and strategies, unified service systems, client/consumer focus and cultural competence, and quality improvement.

Impact on Prevention: The Psychological Autopsy

One method of research which holds promise for translation into prevention and early intervention is the psychological autopsy. Investigators conducting a psychological autopsy attempt to determine an individual's mental and emotional condition prior to the suicide by extensive interviews with family, friends, and others and by reviewing personal history. Psychological autopsies are most often conducted in suicide or homicide cases and serve as a means to reconstruct the person's life and character.

The results of psychological autopsies may help prevention efforts target identifiable risk factors to decrease or modify unhealthy behaviors among diverse populations. Researchers and practitioners are also examining the best ways to reinforce protective factors--within an individual, family, and society--to reduce suicide rates. At this stage in the process, there are still major gaps in our understanding about the best approaches to suicide prevention. What experts do know, however, is that reducing substance abuse has cumulative benefits, including that of reducing the risk of suicide-at any age and within any population.

Summary

  • Alcohol use, whether as a form of abuse and/or addiction, is potentially lethal as an impetus to suicide, when combined with other serious risk factors.
  • The persons who are most at risk are those with access to firearms; who have had the recent loss of a significant relationship; who are unemployed or living alone; who have a co-occurring mental illness; and/or who have noticeably impulsive, aggressive, or antisocial tendencies.
  • Persons using drugs other than alcohol, particularly in combination with a mental illness such as depression, are also at great risk of suicidal ideation, suicide attempt, and/or death by suicide.

Module 4: Suicide Across the Life Span

Stages of Development

"There's a history of suicide in my family. Two of my great aunts died from suicide in their 20s by jumping off a cliff. My grandfather was an alcoholic and committed suicide. He was at home, stinking drunk, and shot himself. My mom was bi-polar and had suicide episodes. My aunt fought feelings of despair her entire life. I remember phone calls as a child from my aunt in New York City to my mother when she kept threatening to jump to her death.

When I was 8 years old, I saw my mom in a straight jacket in the isolation unit. When I visited my mom in the hospital she looked wild, she did not look like the person I knew.

Once they had adjusted her medication, she would slowly return to the mom we knew."

-- The words of a suicide survivor

Human development expert Erick Erikson identified 8 stages of development from infancy to death. Erikson's model recognizes the fact that human beings face different growth challenges, depending on where they are in the stages of development. Whereas an infant's task in life is to develop a sense of trust, an adolescent's role is to find independence.

Each stage in development may result in different suicidal behaviors or risks: A teenager may want to commit suicide for reasons much different than an older person. Understanding suicide's impact across the life span can help uncover the causes of suicide among various populations and ages. In addition to age, suicide rates differ by gender and ethnic affiliation. Suicide rates by age shows how suicide risk varies across the life span.

Among the goals of the National Strategy for Suicide Prevention is eliminating healthcare disparities that are attributable to differences such as race or ethnicity, gender, education or income, disability, age, sexual orientation, and others.

Suicide in Youth

It is very rare for someone under the age of 10 to commit suicide. However, elementary age children may have suicidal ideation. Suicide rates increase with adolescence.

Due to extensive media coverage, the American public is well aware of the relatively rare cases of suicide/homicide shootings by troubled adolescents who eventually turn their weapons on themselves. These catastrophic events reinforce why reducing access to firearms and other lethal means is so important.

According to the Centers for Disease Control and Prevention (CDC), between 1994 and 1999, approximately 126 students "carried out a homicide or suicide that was associated with a private or public school in the United States." Of these students, 28, or 22 percent, died by suicide, including eight who intentionally injured other people before taking their own life. Two of the suicide victims had been reported for fighting and four had disobedient behavior in the year preceding their deaths; none were associated with gangs.

It was also reported that the following suicide risk factors were indicated:

  • Expression of suicidal thoughts
  • Recent social stressors
  • Substance abuse

Each of these three risk factors was common among the suicide victims. Statistics such as these bear out reasons why school staff need to learn to recognize and respond to risk factors for suicide.

Despite the press attention, most youth suicides don't involve school shootings. Most young people kill themselves without harming others. The methods may vary (firearms and suffocation being the most common), but one factor that does not vary is the frequent presence of substance abuse. Perhaps more than any other age group, substance abuse in older children and teens is more often associated with psychological distress.

Depressed Youth at Highest Risk

Perhaps more than any other age group, substance abuse in older children and teens is more often associated with psychological distress.

A study was performed between 1991 and 2000 at the Pittsburgh Adolescent Alcohol Research Center (PAARC) to test the effects of psychiatric disorders on attempted suicide among adolescents with substance use disorders. This study found that major depression and bipolar disorder placed both males and females at the highest risk for making a suicide attempt.  

Attention-deficit hyperactivity disorder (ADHD) was also associated with an increased risk for male-attempted suicide, and conduct disorder was significantly associated with female-attempted suicide. Males with hallucinogen use disorders, inhalant use disorder, and sedative-hypnotic use disorders had a higher risk for attempting suicide. Females with substance use disorders other than cannabis had a higher risk for attempting suicide.

Teenage Girls and Alcohol

Another study found girls aged 12 to 16 who were currently drinking alcohol, were four times more likely than their non-drinking peers to suffer from depression.

What Puts Teens at Risk?

Mood disorders, substance abuse, a family history of suicidal behavior, poor parent-child relationships, parental mental illness and substance abuse, and a sense of hopelessness and stressful life events all put teens at risk for suicide.

Life Stressors That Increase a Teen's Suicide Risk:

  • The ending of an important relationship
  • Legal or disciplinary problems
  • The combination of stressful life events with an underlying vulnerability to depression, or other mood disorders
  • Homosexual or bisexual orientation.  

Teen Suicide Risks

Of the teens at risk for suicide, an alarmingly high number say they have attempted suicide. The National Household Survey on Drug Abuse (NHSDA) asked adolescents aged 12 to 17 whether they had seriously thought about taking their own life or had tried to kill themselves 12 months prior to the survey. The results show that of the teens at risk for suicide, 37 percent had a suicide attempt. Females were about twice as likely as males to be at risk for suicide, and the highest suicide risks for youth were aged 14 to 17.

Those responding to the survey were also asked about their use of alcohol and other drugs. The major drugs used were alcohol, marijuana, cocaine (including crack), inhalants, hallucinogens, heroin, or prescription drugs used for non-medical purposes.

Research funded by the National Institute on Drug Abuse has shown that adolescents with co-occurring substance abuse and mood disorders are the most likely to try suicide.

Another study conducted at the Pittsburgh Adolescent Research Center between 1991 and 2000 revealed the following:

  • Males with hallucinogen use disorders, inhalant use disorders, sedative hypnotic use disorders, and attention-deficit hyperactivity disorder were more likely to have attempted suicide than males without these disorders.
  • Males who attempted suicide had more symptoms of mood, alcohol, and disruptive behaviors than non-attempters.
  • There was an earlier onset age for alcohol use and conduct disorders among male suicide attempters, compared with the onset age of males with these disorders who did not attempt suicide.
  • Females with conduct disorders and substance abuse were at higher risk for attempting suicide than females not diagnosed as such.
  • Female suicide attempters had more symptoms of substance abuse and mood disorders compared with female non-attempters.
  • Female suicide attempters with mood disorders had an earlier onset age of mood disorders compared with the age of onset for mood disorders of female non-attempters.
  • Suicide risk generally begins to increase at age 11 for females and 12.5 for males with substance abuse disorders.  
Example of Suicide and Early Adolescence*

Kallie, age 15, recently had a setback in the one bright spot in her life. Although alienated from school in general, she looked forward to her fourth-period English class. Kallie has feelings for a boy in her class, George, and was hopeful that he might take an interest in her. A couple of embarrassing moments with George have been blown out of proportion in Kallie's mind. "My friends know I like him. Once they tripped me right in front of him. They just broke up over it--it was so funny. I looked like a real jerk. I was so ashamed! Now I can't even look at him. The whole school found out. I feel like a complete dork."

This disappointment merely compounded Kallie's depression. "Sometimes, I wish I could just sleep forever. I hate waking up."

*Created for illustrative purpose only, not a real person.

Suicide in Adults

Much of the public discussion of suicide and suicide prevention has focused on teenage and early adulthood suicides, and rightly so. However, less attention has been focused on suicide among people in middle adulthood.

When measured in terms of numbers alone, adult men in this population, aged 25-65, commit more than half of all suicides in the United States.  

The largest number of deaths occurs in white males aged 24-55. These findings are particularly alarming because this population is least likely to seek mental health treatment prior to the suicide and prevention efforts and other services have been lacking for this age group.

As with other age groups, experts predict that the number of suicides among adults is underreported. Many times, the cause of death is misclassified as homicide, accidental, or undetermined, frequently because of the stigma associated with suicide.

In contrasting suicide risks among different age groups, middle age suicide risk centers on relationship problems, work problems, substance abuse, and mental illness.

Suicide Risk Factors in Middle Age:

  • Relationship problems
  • Work problems
  • Substance abuse
  • Mental illness

In addition to enormous personal losses to families and communities, the economic loss from potential losses of earnings is highest among the age group of men who commit suicide in mid-life.

The loss in earnings may cause a chain reaction increasing the number of people needing public assistance, childcare, housing, and job training, as well as other economic and social costs.

Risks Among Adults

Research shows that large numbers of middle-aged people at risk for suicide are not seeking out and are not getting the treatment they need. Men in the middle years have a particularly high rate of undiagnosed depression and are less likely to seek help for depression than women. The National Institute of Mental Health is working to decrease the social stigmatization of men asking for help. (http://menanddepression.nimh.nih.gov/.) Yet, researchers are still determining what treatments are effective: Fewer studies exist for this age group, particularly for males.

The use of a firearm is the most common method of suicide for both men and women in the second half of life. Increased suicide risk in the home was associated with the existence of a firearm, more for handguns than long guns, and was more prevalent in men than women. Because of the obvious lethality with the use of a firearm, the person is less likely to be discovered in time to save their life.

Men and women show different trends in suicidal behavior. Although women attempt suicide far more than men, the rates of completed suicide are higher for men than for women. This gender difference is true across all age groups. Men tend to choose more lethal means of ending their lives, such as firearms and hanging. Women are more likely to choose slower-acting methods, such as drug overdosing and taking poisons, which allows for more time to find them and intervene. Other causes for the gender gap are possibly a difference in aggression and impulsivity between men and women, with men generally being more aggressive and impulsive. One important protective factor that has implications for gender differences in suicidal risks is that men and women are socialized differently, with women typically forming and keeping closer social ties to others.

Suicide in Older Adults

People over age 65 account for only 13 percent of the population but represent 18 percent of all suicide deaths. This means that as a group, older adults have the highest overall suicide rate in the country.

Elderly males take their own lives far more than elderly females (NSSP). Firearms, overdosing, and suffocation were the most common ways that people age 65 and over took their own life.

Description of a Suicidal Older Adult

William, 79, shifts uncomfortably in the recliner in his living room. A walker is propped against the arms of the chair. The pain in his legs has gotten progressively worse in recent months. William says it's getting "harder and harder to get around." After his wife died last year, he moved in with his daughter for a few weeks. His wife's death devastated William who assumed he would be the first to go. He says things have not gone "according to plan."

William says he is a "burden" to the family. "They don't have to say anything," he says, "I can just see it.... Who wouldn't resent having to baby sit an old man who can hardly even get his own dinner?"

William is back in his own home again, but he's not sure for how long. And, after living with his wife for 50 years, he is lonely and finds himself unable to control his emotions. In a matter of weeks, William went through the couple's liquor supply and has taken to ordering home delivery of new supplies every couple of days.

William admits that he sometimes thinks killing himself would be the best thing. That way no one would have to "be bothered with me anymore." He considers taking enough sleeping pills to "put myself to sleep forever."

Risk Factors For Older Adults

The risk factors for the elderly differ from their younger and middle-aged counterparts. Many elderly people are socially isolated and have a host of medical problems that can chronically cause pain, distress, and discomfort. Our age-conscious society that glorifies youth may cause some older persons to consider themselves used-up or unwanted. Older adults may be subject to ageist attitudes that diminish their contributions and their capacity for active and fulfilled lives.

Although older adults are frequently less impulsive than youth and make fewer suicide attempts than younger people, they have a higher suicide completion rate. Some of the key risk factors for suicide among this population are loneliness, social isolation, physical health problems, depression, and substance abuse. Life losses and changes, poor coping skills and problem solving abilities, and lack of meaning and purpose in life can also play a role.

Older adults may already talk about death and dying, making it more difficult to determine their risk of suicide. Adults and older adults have the highest rates of depression. Healthy People 2010 notes that 12 percent of older persons hospitalized for medical problems, such as hip fractures and heart disease, are diagnosed with depression. For older adults in nursing homes, the rates range from 15 to 25 percent.

Depression does not have to be an inevitable part of aging:

Older persons should pay particular attention if they feel:

  • Nervous or empty
  • Guilty or worthless
  • Very tired and slowed down
  • Don't enjoy things the way they used to
  • Restless and irritable
  • Like no one loves them
  • Like life is not worth living

Or if they are:

  • Sleeping more or less than usual
  • Eating more or less than usual
  • Having persistent headaches, stomach aches, or chronic pain

These may be symptoms of depression; a treatable medical illness.

Substance Abuse and Older Adults

Although estimates of substance abuse problems among older adults who died by suicide have been lower than other age groups, Dr. Frederick Blow, a leading expert in older adults and substance abuse, notes that the role of alcohol may be underestimated in late-life suicide. He observes that it may be difficult to show the link between suicide and alcohol abuse because of:

  • The difficulty in assessing and detecting alcohol abuse in this population
  • Increased effect of even light to moderate alcohol use among older adults
  • Problems with using standard criteria for diagnosing alcohol abuse and dependence among the elderly.  

The National Strategy for Suicide Prevention (NSSP) establishes suicide prevention for the elderly as a top priority and has identified goals pertinent to this population:

  • Increase the proportion of evidence-based suicide prevention programs among state or local area agencies on aging to help coordinate services for older people and training for workers and volunteers working with older adults.  
  • Reduce access to lethal means, such as improving automobile design to deter carbon-monoxide-mediated suicides.  
  • Train nursing care workers in the assessment and management of suicide risk.  
  • Implement screening for depression, substance abuse, and suicide risk in primary care settings, hospices, and skilled nursing facilities.  

Unlike other age groups, particularly youth and adolescents, there appear to be fewer programs targeting older adults for suicide prevention. Suicide prevention efforts are already occurring at the grass roots level in physician's offices, among family members, and in elder-care facilities. The suicide prevention movement is a relatively new public health priority. As the NSSP's goals are implemented, and public awareness of suicidal behaviors as a public health problem grows, suicide prevention programs aimed at senior citizens should grow.

Future Prevention Needs

Changing demographics and behaviors do not bode well for the next wave of older Americans. The aging "baby boomers" are now making older adults the fastest growing segment of the population. It's not clear how aging will affect the suicide rates in this population. However, experts note that the baby boomers in general drink greater quantities of alcohol and do so more frequently than their predecessors.

A national longitudinal survey also indicates that the baby boom cohort has higher rates of alcohol and other drug abuse/dependence than previous generations. All of these factors point to the need for both substance abuse and suicide treatment and prevention targeted to older adults.

Suicide Across the Generations

Each person is an individual. However, we are inevitably influenced and shaped by our biological relatives and others who are in close contact with us over an extended period of time. How we behave, the choices we make, what our personalities are like, the values we possess, our culture, religion, socioeconomic status, what our physical and/or mental health is like, may be passed from one generation to the next.

Family history of suicide and mental or substance abuse disorder are among the most frequent risk factors for suicide in the United States.

Most Americans know that novelist Ernest Hemingway killed himself. Few may know that five people in Hemingway's family over four generations died from the same cause.

Inherited Risks

Suicide can cluster in families with a history of psychiatric problems, substance abuse disorders, and/or completed suicide. Studies of twins show that identical twins have a greater probability of both completed and attempted suicide than do fraternal twins (where other suicide risk factors also exist).

There is strong evidence of the intergenerational transmission of behavior from one generation to the next. Research shows that a child with a parent or parents with a mental health or substance abuse problem and/or a history of suicide is at more risk for the same behaviors.

Other characteristics, such as aggressiveness, impulsivity, tendency toward violence, lack of attention, may be genetically based. Other socialized behaviors are learned and are behaviorally modifiable. Identifying the areas that put a person at risk and fostering buffers for addressing them can help promote healthy development.

Despite the influence of family history, however, research also shows that family history does not predetermine outcomes. If that were the case, even more people would struggle with mental illness, substance abuse, and suicide. Nor is suicide a typical response to stress factors in life, such as divorce, job loss, or other difficulties. George Vaillant, M.D., author of a landmark research project, "The Study of Adult Development," tracked 824 individuals over a period of decades, from the teenage years until death. This study showed how people surmounted pitfalls and setbacks, including poverty, poor education, abusive parents, substance abuse, and poor health. The results of the study demonstrate how individuals have the ability to steer the course of their lives, in spite of factors that put them at risk for unhealthy behaviors, including suicide and substance abuse.

Summary

  • Suicide behaviors may differ across the life span.
  • As important as identifying the problems and needs for improvement is an understanding of the services, programs, and resources that already exist that can be accessed to reduce suicidal behaviors and outcomes. These entities may not have been created with suicide prevention in mind, but their role and function can be ramed to address suicide prevention, intervention, and treatment.
  • A public health model of suicide supports developing an effective network of prevention, early intervention, and treatment for those who are at risk for suicide. Continuity of care and integration of systems so that service delivery cracks are detected and fixed is a necessary goal.

Module 5: Special Populations and Suicide Risk

Cultural Understanding

Some ethnic and racial minorities and other special populations have higher risk of suicide. As with other populations, substance abuse increases the risk of suicidal behaviors.

Racial and ethnic minorities are increasing in the United States. U.S. Census Bureau data shows that the nonwhite population will exceed 50 percent of the overall U.S. population by the year 2050. This trend reinforces the need for public health interventions that are tailored to the needs of special populations.

Reducing people to their dominant ethnic or racial group (or other categories) alone can be limiting. For one thing, the process of acculturation may impact or even displace the norms, behaviors, and beliefs of an individual's cultural base. People assimilate by varying degrees into the dominant culture of the United States over generations. Being from a minority population also does not mean that a person is uncomfortable with the "majority culture" (which is already in a state of constant flux as cultural influences are felt among various sectors of society).

Prevention efforts must also take into account the role of poverty, language, and experiences that make it difficult to generalize within ethnic or religious categories.

Populations may be more at risk of suicide and substance abuse based on occupation (Veterans) or life situation (suicide survivor, people impacted by abuse and/or trauma, women with postpartum depression, and the severely and persistently mentally ill [SPMI]). These groups and population categories are not mutually exclusive. Many people are in more than one of these groups.

Cultural competence is an ongoing process that requires continuous learning, sensitivity, and awareness.

Each of these groups has its own set of complexities, which are beyond the scope of this course.

Culture Competence

Cultural competence is an ongoing process that requires continuous learning, sensitivity, and awareness. This module seeks to assist the reader in developing an understanding of culturally sensitive prevention and intervention strategies. This knowledge can then be applied to the reader's area(s) of work with suicide and substance abuse, with the goal of gaining additional knowledge, inement, and skills over time.

Culturally Competent Programs:

A culturally competent program is one that demonstrates sensitivity to and understanding of cultural differences in program design, implementation, and evaluation. Culturally competent programs:

  • Acknowledge culture as a predominant force in shaping behaviors, values, and institutions
  • Acknowledge and accept that cultural differences exist and have an impact on service delivery
  • Believe that diversity within cultures is as important as diversity between cultures
  • Respect the unique, culturally defined needs of various client populations
  • Recognize that concepts such as "family" and "community" are different for various cultures and even for subgroups within cultures
  • Understand that people from different racial and ethnic groups and other cultural subgroups are usually best served by persons who are a part of or in tune with their culture
  • Recognize that cultural diversity enhances us all  

People of Color

The National Organization for People of Color Against Suicide (NOPCAS) is part of the National Council for Suicide Prevention. NOPCAS supports research and community-based strategies to prevent suicide and associated problems; builds alliances through corporate partnerships; and assists local government, law enforcement, schools, and others in suicide prevention.

Research in the area of suicide prevention for people of color has been limited. With the exception of American Indian populations, historically, the suicide rates for minority populations have been much lower than for the Caucasian population. However, the gap is starting to shrink, making suicide prevention research and strategies for minority populations more and more essential.

African Americans

Although the rates of suicide for African Americans as a whole remain lower than other groups and has declined in recent years, suicide is still the third leading cause of death among African American youth.

The National Center for Injury Prevention and Control (NCIPC) data on violent deaths show that for 2002 suicide was:

  • The leading cause of violent death for Blacks ages 65-74 of both sexes
  • The second leading cause of violent death for Blacks ages 10-34 and ages 55-64 of both sexes  

The primary means of suicide were firearms and suffocation. Black males had a far higher rate of suicide than black females, primarily taking their lives with firearms, but also through suffocation, poisoning, drowning, and falls.

Black females died by homicide far more than by suicide and used suffocation and poisoning more than firearms, as is consistent with male-female differences in suicide methods.

Reducing the stigma and bringing the issue out into the open are key prevention goals. Prevention efforts must take into account the gap between the suicide rates of black males and females. (Black females have a low suicide rate.) Some of the protective factors identified for black females include lower rates of hopelessness, being able to tough it out, resiliency, spiritual attributes, good interpersonal skills, and positive support systems.

Prevention efforts for Black youth focus on improving secondary education, increased employment opportunities, delinquency prevention, drug abuse prevention and treatment, increased use of mental health clinics in inner cities, and other means to increase the life options and coping skills of black youth.

American Indians and Alaska Natives

American Indians and Alaska Natives (AI/AN) experience higher suicide rates than any other group in the United States. (Although suicide rates vary among tribes) Suicide is:

  1. The second leading cause of death for males aged 15-35
  2. The third leading cause of death for males aged 10-14  

When only violence-related deaths are considered, suicide was the leading cause of all violence-related deaths among AI/AN populations aged 15-64. Most of the violent deaths were firearm related, except for those in the 25-34 year old age group, who used suffocation methods.

The One Sky Center

The One Sky Center (www.oneskycenter.org) was created in 2003 as the first national resource center dedicated to improving the prevention and treatment of substance abuse and mental health among the AI/AN population. This center's mission focuses on assessing the needs and strengths of Native communities, and developing strategic plans.

Much of the research done by The One Sky Center identifies domestic violence and childhood sexual abuse as part of the systemic transmission that continues problems from one generation to the next. AI/AN females ages 25-34 have a homicide mortality rate about 1.5 times that of the general population of females in that age group.

Factors associated with high rates of abuse and neglect include:

  • Overcrowding in homes
  • Lack of employment
  • Other socioeconomic difficulties

More American Indian and Alaska Native families live below the poverty level than the general population. All of these factors contribute to high rates of physical and mental health problems and a high rate of alcoholism and substance abuse.

The One Sky Center has an American Indian Community Suicide Prevention Assessment Tool that can help those in Indian Country in internal program assessment and planning and in providing background material for grant applications.

Indian Health Initiatives

Beginning in 2002, the Indian Health Service (IHS) convened a tribal consultation on behavioral health. Over 200 tribes and tribal organizations were represented, providing recommendations for long-term goals to revitalize and improve behavioral health in Indian Country.

Federal collaboration among the IHS, the Office of Force Readiness and Deployment of the U.S. Public Health Service, SAMHSA, and the U.S. Department of the Interior was enhanced to develop better Federal response capability.

The Jicarilla Apache of Northern New Mexico developed a reservation-based suicide prevention program over a period of ten years. At one time, the suicide rate on this reservation was one of the highest in the United States. By bringing key players in their community together, the suicide rates were significantly decreased. Tribal leadership, community members, youth, clinicians, researchers from the University of New Mexico, and IHS personnel designed and implemented the program.

Another successful suicide prevention program involves the Phoenix Indian Medical Center, the second largest Indian Medical Center in the United States. This Center stopped scheduling mental health appointments, because there were patient waiting lists up to six months long. Instead, the Phoenix Center instituted an "Open Access Model of Care," where a patient can come as a walk-in between the hours of 8:00 a.m. and 2:00 p.m. and see a mental health professional the same day. The Phoenix Center reports that in the first five months that the open access program was in operation, there was not one suicide completion noted among active patients in the service. The Center sees an average of 18,000 patients per year.

The Behavioral Health Aid program in rural Alaska trains community members as paraprofessionals to screen and intervene in the smallest villages. Specific training is provided in screening, crisis intervention, erral, and consultation, with supervision and culturally-sensitive techniques available. This program has allowed first responders to exist in communities that are too small and too isolated to otherwise access behavioral health professionals. This program is still quite new, but it is considered a promising program with hopes of replicating it elsewhere.

Many American Indian and Alaska Native communities, however, are vastly underserved in terms of behavioral and physical health needs. As the above initiatives show, however, communities have found innovative and culturally appropriate ways to reduce the toll of suicide.

Hispanic/Latino Populations

It is estimated that by the year 2020, Hispanics will represent 17 percent of the U.S. population and will surpass all other racial/ethnic minority groups in size.

During 1997-2001, 8,744 Hispanics (or 5.95 per 100,000) died from suicide, with 85 percent of those suicides being male.

Half of the suicides were among people aged 10-34 and it was the third leading cause of death among 10-24 year olds. Firearms are the suicide method used most frequently. It is also important to note that young Hispanic females, particularly those in grades 9-12, reported more feelings of sadness, hopelessness, and suicidal ideation, compared with their White or Black non-Hispanic peers.

Hispanics have a far lower suicide rate than other minority populations. The suicide rate for the Hispanic population are much lower than those of Caucasians, African Americans, Native Americans, and Asian Americans.

Hispanics also appear to have some protective or mediating factors that help in reducing suicidal behavior. One study found less suicidal ideation and fewer lethal attempts among Latinos. They also scored higher on survival and coping skills, responsibility to family, and moral objections to suicide, possibly due to cultural norms associated with a strong identification to being Latino.

The Hispanic community is relatively new to operating behavioral health organizations within their community, particularly on a national, policy-setting level. One organization that is working to assist Latinos with mental health needs is the National Latino Behavioral Health Association, This organization provides links to resources, events, research, and policy issues.

Two other organizations that are of particular help to Hispanics/Latinos with mental health and/or suicidal problems are the Mental Health Association of New York City, which has a Spanish-speaking phone line: 1-877-298-3373 (http://www.mhaofnyc.org, and the National Alliance on Mental Illness (NAMI), http://www.nami.org formerly known as the National Alliance on the Mentally Ill). The main NAMI Web site has a link at the top of the page "En Espanol," where the information contained on their Web site is translated into Spanish.

Asian Americans and Pacific Islanders

In the United States, Asian Americans and Pacific Islanders are grouped together for Census purposes, although there are many differences in the groups in terms of ethnicity, language, culture, education, income level, English proficiency, and sociopolitical experience.

Accurate suicide data on Asian American communities overall may be underreported. Particular ethnicities, such as Japanese Americans or Chinese Americans, may have high suicide rates, possibly higher than the suicide rates for Whites, Blacks, and Hispanics.

The Asian American population has historically been an underserved population for mental health issues.

Data from the National Center for Injury Prevention and Control, for 2002, show that for violence-related deaths among the Asian/Pacific Islander populations, suicide was the leading cause of deaths for both sexes, aged 25 to 65 and over.

This shocking statistic serves to clarify just how serious the problem of suicide is in the Asian/Pacific Islander populations.

Slowly, there is a growing awareness both within and outside of the Asian American communities of the need for suicide prevention in particular and mental health services more generally. In May 2005, the Asian American Suicide Prevention Initiative (AASPI) sponsored a program called "Seeking the Light," which was held in the Chicago area to develop awareness and support for Asian American suicide attempters, survivors and the people close to them.

More and more Asian American organizations are working to reduce the stigma related to suicide through education and dialogue, along with presenting culturally competent models for suicide prevention, postvention, and intervention.

Asian American Health Needs

As secret issues that exist in all communities eventually come to light, the healing and learning can begin.

The first ever conference on Asian American Suicide was held in New York City October 21-22, 2005, dedicated to "breaking the silence" on not only suicide, but depression among Asian Americans and Pacific Islanders. This conference was sponsored by The New York Coalition for Asian American Mental Health (NYCAAMH), www.asianmentalhealth.org and The National Asian American Pacific Islander Mental Health Association (NAAPIMHA), www.NAAPIMHA.org.

Slowly, word is getting out about the mental health needs of Asian Americans and Pacific Islanders. Sadly, sometimes it takes a tragedy to bring help to others. The November 9, 2004 suicide of noted Chinese American writer Iris Chang, who died at age 36, has helped bring to light some of the hidden pressures and issues within this community. As a result of this suicide, and other factors, the Asian Community Mental Health Services has identified barriers to care for Asian Americans and Pacific Islanders. Stigma is the major barrier, stemming from lack of English proficiency, cultural shame about mental health problems, and cognitive and/or ethnic mismatches between therapist and clients.

The result of these barriers is that Asians and Pacific Islanders have the lowest utilization rates of mental health services among all ethnic populations, according to the U.S. Surgeon General's 2001 Report on Mental Health.

Gradually, there are a few more organizations committed to helping Asian Americans and Pacific Islanders with mental health problems and suicide in particular. As with other ethnic groups who have established their place in American society, as secret or hidden issues eventually come to light, the healing and learning can begin.

Veterans and Active Duty Military Personnel

Active duty military personnel serve in one of the most stressful occupations on the planet. They are frequently removed from their usual environment, sometimes for extended periods of time, and may be exposed to serious and prolonged violence.

Upon return to their homes, many veterans have changed in profound ways that may be difficult for them to share and hard for others to understand unless they have been in similar settings. Not surprisingly, a number of veterans who have seen active combat have experienced mental health and/or substance abuse problems, both while on active duty and once they return home.

The needs of active duty military and veterans are varied and complex. They may include post-traumatic stress disorder (PTSD), depression, substance abuse, and psychosocial adjustment upon returning home.

There are a number of studies on suicidal behaviors and veterans. Many regular or active duty military personnel come into daily contact with lethal means, such as firearms, which increases the opportunity for them to act on suicidal impulses.  

One study found that firearm suicides accounted for 53 percent of all the suicide cases. Even more significant, workplace suicides occurred when personnel were alone, usually at the start of a work day in the morning.

Post-traumatic stress disorder (PTSD), both accompanied by and separate from substance abuse, also posed a significant risk factor for veterans. One study found that over time there was evidence of a strong continuity among PTSD, drug dependence, and suicidality. This study found that the strongest causal link of drug dependence on PTSD and suicidality was in young adulthood. Self-medication was more evident in later adulthood.

Suicide Risk Factors for Veterans

Another study of veterans with PTSD identified high risk for negative behaviors (violence, suicide attempts, and substance abuse). Recent high-risk behaviors, rather than the patient's history, appeared to be more predictive of high-risk behaviors following discharge from a VA residential rehabilitation program. Following from this study, suicide prevention efforts could be best targeted at recent high-risk behaviors, in contrast to behaviors that occurred longer ago.

Suicide Risk Factors for Veterans:

  • Degree of caregiver attachment
  • History of sexual abuse and/or physical abuse, particularly when the abuse occurred early in life
  • Low resilience, self-efficacy, and self-esteem
  • Psychiatric comorbidity
  • Severity of substance abuse
  • Longevity of substance abuse  

As this course has shown, it is extremely challenging to predict suicidal behaviors. Even someone who has a number of risk factors for suicide will not necessarily die by suicide, or even attempt it.

However, a Department of Veterans Affairs study sought to determine just what factors differentiate a suicide attempter (SA) from a suicide completer (SC). Certain themes within psychiatric patients' suicide messages and the number of suicide messages, helped the VA to determine SAs from SCs.

SCs were more likely to have a fear of being killed and to show hopelessness and symptom distress. SAs were more likely to make a contract not to commit suicide while no SCs did so.  

Staff often overlooked or ignored indirect or unclear messages. This finding is particularly useful for community members who are in a position to hear or observe potentially suicidal messages. It points to the need for greater awareness and perception of distress among those who are at risk for suicide. In this study, all of the patients who died by suicide after hospital discharge did so in the first six weeks after discharge, pointing to the ongoing vulnerability that suicide attempters have to suicidal behaviors.

Gender differences among homeless veterans are also a factor in suicide risk. Childhood and current sexual and physical abuse, depression, fearfulness, relationship problems, limited social support, and low self-esteem were more strongly associated with suicidal thoughts and attempts for women than for men. Extent of alcohol and other drug use, aggression, resilience, self-efficacy, combat exposure, combat-related PTSD, and work problems were more strongly associated with suicidal thoughts and attempts for men than for women.

Violent Death Reporting

Early results of a National Violent Death Reporting System funded by the CDC provide critical information about the risk of suicide among veterans. Virginia is the first of 17 states to report on the results of its reporting system. The results are alarming for a number of reasons, including the fact that suicides outnumbered homicide as the leading cause of violent death in the Commonwealth in 2003.

The report found that one in four suicides involved a veteran.

The results underscore the need for suicide prevention and other services for special populations such as veterans. Module 6 of this course provides an overview of the Air Force Suicide Prevention Program, which is being implemented to specifically address suicide risks among active duty military personnel.

Within the military, there is a growing awareness that additional mental health and substance abuse resources need to be made available to active-duty military personnel and veterans. One pivotal organization is the Mental Illness Research, Education and Clinical Center (MIRECC), which through its mission seeks to "enhance the overall mental health and substance abuse care of veterans."

The Veterans Administration (VA) also has mental health and substance abuse treatment at each of its hospitals and at many outpatient clinics across the United States.

Severe and Persistently Mentally Ill (SPMI) and Homeless Populations

The Severe and Persistently Mentally Ill (SPMI), who are frequently impoverished, as well as the homeless population, are two of the populations most vulnerable to suicide. These are the people who have the fewest economic and financial resources. They frequently also have the weakest support systems, particularly among family and friends. These populations cut across all ethnic, racial, and religious populations. While there are more SPMI and homeless people in larger urban areas; they exist in all kinds of communities, and are of all ages.

Frequently, alcohol and other drug use fuels the suicide risks of these populations. There appears to be a reciprocal relationship between mental health problems and substance abuse, in many instances creating a vicious cycle of decline over a period of years.

The SPMI and homeless populations are among the most likely to feel hopeless; to express a desire to hurt and/or kill themselves; to feel trapped in their problems; to have withdrawn from society, family, and friends; to feel anxious, agitated, or have difficulty sleeping; to experience dramatic mood changes; to see no reason or purpose for living; and to seek ways to kill themselves or be killed. Each of these factors represents a major warning sign for suicide, as listed by the Suicide Prevention Lifeline.

The mental health system in the United States has become fragmented, making it even more difficult for those who are poor, homeless, and/or severely mentally ill, to get the help they need. The National Alliance on Mental Illness (formerly the National Alliance for the Mentally Ill) works with the SPMI population, their family members, and other concerned individuals on suicide prevention and/or substance abuse prevention.

Society has yet to come to grips with the extent of the fragmentation of mental health and/or substance abuse services. These are problems that exist within the larger framework of spotty and inconsistent healthcare delivery in general. Responses to the needs of special populations, as well as to the needs of individuals across the life span, require a concerted effort among government institutions, the private and nonprofit sectors, nongovernmental organizations, and others.

Summary

  • Suicidal behaviors may differ among special populations at risk. Each of the populations identified have unique characteristics and needs that require cultural competence and understanding.
  • An exploration of differences alone will not ensure the success rate of suicide prevention efforts; organizations and programs increase their viability through their linkages to the larger community.
  • As important as identifying the problem and the need for improving and expanding the suicide prevention, intervention, and treatment systems, is an understanding of the current systems that already exist to reduce suicidal behaviors and outcomes.

Module 6: Prevention and Early Intervention for Suicide and Substance Abuse Problems

Responding to Suicide

"Because of her history, my sister always had angels around her--family and loved ones who are watching out for her. And, in every instance, she was found before she killed herself.

There are potential "angels" all around us. They may be friends, doctors, pastors, school counselors, teachers, or coaches. Any of us.

After the birth of my son, I went through severe postpartum depression. At the pediatrician's office, I was having such a hard time filling out the forms for my son's visit that the doctor realized I was severely depressed. She counseled me, called my sister, wouldn't let me drive, and made sure I was safe.

Dr. D. saved my life. Another mother in similar distress with a less aware doctor might not have been so lucky."

- The words of a suicide attempt survivor

It's unacceptable for someone in danger of dying from a physical condition not to get the medical help they need. Doctors, nurses, emergency technicians, and others are trained to respond immediately when a life is in danger. Yet, when it comes to early intervention and treatment those at risk often fail to get the help they need to prevent them from harming themselves:

  • As many as two-thirds of people who died by suicide were not receiving mental health or substance abuse treatment at the time of their deaths.  
  • For every suicide death there are 5 hospitalizations and 22 emergency department visits for suicidal behaviors--over 670,000 visits per year.  
  • According to the 2000 National Household Survey of Drug Abuse (NHSDA), only 36 percent of youths at risk for suicide during the past year received mental health treatment of counseling.  

Crisis Response

The emergency department is the frontline of medicine and the doorway into the medical system for people in distress.

Physicians, school counselors, religious leaders, and others share a unique relationship with those at risk for suicide. They are often in a position to help, but the need and/or request for help may be beyond what a helping professional is able to recognize. The National Strategy for Suicide Prevention notes that in the month prior to their suicide, 75 percent of elderly persons had visited a physician. Yet, physicians and other key gatekeepers, such as school personnel, religious leaders, police, or others, frequently have no training or experience in identifying individuals at risk or know how to respond to self-destructive behaviors.

Sadly, people pay more attention to a crisis. By its very nature, a crisis attracts a lot of attention due to its magnitude. However, with children and adolescents, as well as with adults in their twenties, there is the opportunity to start small, before problems become huge and overwhelming. This can happen when a problem is prevented from getting out of hand, which also prevents or diminishes the stigma associated with bigger, more noticeable problems. It is much more likely to keep things contained and manageable when a problem is dealt with early. The younger a person is the more behaviorally modifiable their problems are, because the problems are caught early and because there is so much more time to work out effective solutions.

Screening, Assessment, and Treatment

Just because an individual may have risk factors, such as substance abuse or a mental illness, associated with suicidal behaviors it does not mean that he or she will commit suicide. As a result, healthcare and mental healthcare professionals and providers need to assess the risk of suicide and suicidal behaviors. Prevention professionals and others may not be conducting suicide assessments or providing treatment. Nonetheless, an understanding of screening and assessment guidelines for working with individuals in distress, and treatment options can benefit those working in suicide prevention.

Screening is a brief procedure to:

  • Determine the presence of a problem (mental health disorder, substance abuse)
  • Substantiate that there is a reason for concern
  • Identify the need for further evaluation

Assessment is a more comprehensive diagnostic and treatment planning process typically based on screening information. A detailed assessment may take hours to complete and should help to prepare a treatment plan. Some goals of assessment are to:

  • Examine the scope and/or severity of mental health or substance abuse problems
  • Identify other possible psychosocial problems that may need to be addressed further
  • Provide a foundation for treatment
  • Identify possible strengths that can become part of the treatment planning process

For more information about assessment, the American Psychiatric Association has developed guidelines for the assessment and treatment of patients with suicidal behaviors.

Communicating About Suicide

Experts stress that discussing suicidal ideation does not increase the likelihood of a suicide attempt.

In cases where a suicide attempt has been made, The National Alliance on Mental Illness (NAMI) has produced a guide for medical professionals in the emergency department to help patients and their families after a suicide attempt. (NAMI offers companion guides to help individuals recover from a suicide attempt and to help families after an attempt by a relative.)

NAMI notes that the emergency department is the "frontline of medicine and often serves as the doorway into the medical system for people in distress, including people who attempt suicide."

Emergency room workers are, theore, in a unique position to help set people on the road to recovery.

Key steps in treating an individual who has attempted suicide include:

  • Patient assessment
  • Creating a safety plan, which may include what to do when suicidal thoughts reoccur, when to seek additional treatment, and contact information

"Is Path Warm" Tool

The American Association of Suicidology has developed its own screening tool, focusing on red flags for suicide risk: "Is the Path Warm."

IS PATH WARM?

  • IDEATION/threatened or communicated
  • SUBSTANCE ABUSE/excessive or increased
  • PURPOSELESS/no reasons for living
  • ANXIETY, agitation/insomnia
  • TRAPPED/feeling there is no way out
  • HOPELESSNESS
  • WITHDRAWAL from friends, family, society
  • ANGER (uncontrolled)/rage/seeking revenge
  • RECKLESSNESS/risky acts - unthinking
  • MOOD changes (dramatic)

--American Association of Suicidology

Additional Screening

Physicians have also developed training specific to suicide assessment to allow general practitioners to detect this problem, although none of these tools are meant to be mutually exclusive.,  The SAD PERSONS scale (below) provides a mnemonic instrument to help physicians and other healthcare workers determine the presence of risk factors in order to assess for suicide risk.

The "SAD PERSONS" Scale for Determining Risk:

  • Sex (male versus female)
  • Age
  • Depression
  • Previous suicide attempts
  • Ethanol abuse
  • Rational thinking loss (psychosis)
  • Social supports lacking
  • Organized plan to commit suicide
  • No spouse (divorced, widowed, single)
  • Sickness (physical illness)

Mental health professionals may have more training than others in addressing suicidal behaviors. But not all counselors and other professionals may be aware of the link between substance abuse and suicide.

Advice to the Counselor suggests steps to take when counseling a client who is suicidal to make sure the client remains safe:

Advice to the Counselor: Counseling a Client Who is Suicidal

  • Screen for suicidal thoughts or plans with anyone who makes suicidal erences, appears seriously depressed, or who has a history of suicide attempts. Treat all suicide threats with seriousness.
  • Access the client's risk of self-harm by asking about what is wrong, why now, whether specific plans have been made to commit suicide, past attempts, current feelings, and protective factors.
  • Develop a safety and risk management process with the client that involves a commitment on the client's part to follow advice, remove the means to commit suicide (e.g., a gun), and agree to seek help and treatment. Avoid sole reliance on "no suicide contracts."
  • Assess the client's risk of harm to others.
  • Provide availability of contact 24 hours per day until psychiatric erral can be realized. er those clients with a serious plan, previous attempt, or serious mental illness for psychiatric intervention or obtain the assistance of a psychiatric consultant for the management of these clients.
  • Monitor and develop strategies to ensure medication adherence.
  • Develop long-term recovery plans to treat substance abuse.
  • Review all such situations with the supervisor and/or treatment team members.
  • Document thoroughly all client reports and counselor suggestions.

Reprinted from U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. (2005). Treatment Improvement Protocol Series No. 42: Substance abuse treatment for persons with co-occurring disorders (DHHS Publication No. [SMA] 05-3992). Rockville, MD: Author, p. 215.

Screening, Assessment, and Treatment (continued)

Example of Emerging Recovery From Suicide Risk in an Adult

Frank looked at the calendar. The red circle on today's date signified his weekly appointment with his counselor. He skimmed back through the past six months recalling the weeks of pain, abstinence from drinking, and--slowly--recovery.

A slip of paper fell out of his date book. Frank remembered the day it had saved his life. "By the third drink, I had bottomed out," he thought.

Frank realized now just how close he came to killing himself. He glanced at the numbers on the slip of paper and recalled dialing them in a drunken stupor.

Miraculously, the voice on the other end, his one remaining friend, knew what to do.

Five minutes later, the voice at the other end was already on his way. Two minutes later, Frank heard someone at the door, "Frank?"

In Frank's case, his cry for help to his one remaining friend saved his life. The phone call would be the beginning of months of therapy to explore and address the causes for Frank's suicidal behavior.

Treatment for Suicidal Behaviors

Screening and assessment should be done by trained professionals with experience in mental health or substance abuse issues who use specialized instruments.

Effective treatments for suicidal behaviors are available, even among high-risk groups, such as those individuals who have had a prior suicide attempt. Researchers supported by the National Institute of Mental Health and the CDC found that a targeted form of cognitive therapy reduced repeat suicide attempts by 50 percent.

The study recruited 120 patients admitted to the emergency room for suicide attempts. The participants were:

  • On average in their mid-thirties
  • 61 percent female
  • 60 percent Black
  • 35 percent White
  • 77 percent had major depression
  • 68 percent had a substance use disorder

Patients were randomly assigned to a cognitive therapy designed to prevent suicide or to the usual care available through services in the community. Compared to the usual care available in the community, the cognitive therapy designed to prevent suicide proved better at lifting depression and feelings of hopelessness.

The cognitive therapy intervention consisted of 10 outpatient weekly or biweekly sessions to help patients:

  • Find more effective ways of looking at their problems
  • Learn new ways to handle negative thoughts and feelings of hopelessness

Additional sessions were provided to those participants who failed to complete a relapse prevention task. The task required participants to focus on the events, thoughts, feelings, and behaviors that led to previous suicide attempts and explained how they could respond in a more adaptive way.

One of the promising aspects of the intervention is that the short-term nature of cognitive therapy makes it a good candidate for treatment of suicide attempters at community mental health centers.

Intervention Examples

Another evidence-based suicide prevention program, The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), is an intervention designed to help address depression among older adults. The intervention involves a case management approach by a depression care manager who works with the primary care physician and a supervising psychiatrist. The program targets the following risk and protective factors among older adults:

  • Increasing effective clinical care for mental, physical, and substance abuse disorders
  • Increasing easy access to a variety of clinical interventions
  • Support for help seeking
  • Decreasing barriers to accessing mental health and substance abuse treatment and healthcare for mental disorders.

An evaluation of the intervention at 4- and 8-month intervals found statistically significant reductions in suicidal ideation among older adults in the program compared to those receiving treatment-as-usual.

This course is not intended to provide an exhaustive list of suicide interventions. Nor does one intervention necessarily fit the needs of those at risk. As noted by the President's New Freedom Commission, no less than a transformation of the mental health system is needed to help get those with mental illnesses the help they need. This transformation will involve finding ways to create a good "fit" for treatment among individuals with a range of mental illnesses.

The Federal Government is in the pocess of creating an Action Alliance to coordinate implementation of the National Strategy for Suicide Prevention (NSSP).

Prevention Strategies

Transforming the mental health system and practices to improve treatment for individuals is only the first step. Prevention activities addressed to diverse audiences must be conducted in tangent in order to improve the ability to identify those at risk of suicide, enlighten the public about suicidal behaviors and risks, and enhance conditions for promoting resiliency and mental health.

Individuals, communities, organizations, and governments at all levels are taking steps to reduce suicides using a range of prevention techniques. Many involve multiple strategies. Research and evaluation are ongoing. To stay abreast, professionals should review SAMHSA, Suicide Prevention Resource Center (SPRC) www.sprc.org, and other Web sites for the new advancements and findings.

To become informed of the latest developments in SAMHSA regarding suicide prevention, as well as mental health and substance abuse prevention-related information, there is SAMHSA's Information Mailing System (SIMS) at http://sims.health.org. SAMHSA also has a Grant Opportunity Web Page at www.samhsa.gov/grants.

The National Mental Health Information Center provides links to publications, news releases, mental health FAQs, a mental health services locator, calendar of events, and other relevant information on mental health topics.

The National Institute of Mental Health (NIMH) focuses on mental health disorders overall in a research and clinically-based environment. The Web site includes specific articles and links pertaining to suicide prevention.

MedlinePlus is a National Library of Medicine health information research tool, which provides articles that are both consumer-oriented and scholarly.

Specific prevention strategies and programs are described below. This is just a sampling of the efforts and types of strategies undertaken by communities across the country.

Increasing Gatekeeper Awareness

Experts in the field of suicide prevention are increasingly aware of the need to sensitize gatekeepers to the need for effective responses to suicide and to incorporate plans for community-wide prevention.

The Suicide Prevention Resource Center (SPRC) has a database of Customized Information which allows users to select a role, such as social workers/counselors, first responders, clergy, college students, law enforcement, media, and others, and download tailored information on prevention, warning signs, responses to warning signs, case studies, and resources.

Educational settings, at all levels, are an important place for interventions. Many school systems across the United States allow counselors and substance abuse prevention professionals to come into the schools and offer educational or therapy groups to identify students who are at risk.

Some states have developed school-based gatekeeper programs to help identify students at risk of suicide and to er them for help.

Other states have programs for community gatekeepers, such as psychologists, nurses, primary care physicians, psychiatrists, and other traditional caregivers, teachers, emergency room staff, clergy, and police officers.

Gatekeeper training helps school personnel to:

  • Learn the warning signs of suicide
  • Know the sources for erral and how to contact them
  • Be aware of the school policy for handling crisis situations  

Developing Collaboration and Partnerships

Most communities already have partners working on various prevention efforts, such as child abuse, domestic violence, school violence, and elder abuse. Some of these prevention and early intervention partners include (but are not limited to) designated prevention specialists, hotline workers, police officers, family support agencies, school personnel, mental health and/or substance abuse treatment professionals, and adult protective staff.

The National Council for Suicide Prevention recognizes that collaboration between organizations helps to pool resources and strengthens each organization's ability to bring about positive change, according to the plan developed in the National Strategy for Suicide Prevention.

The National Organization for People of Color Against Suicide (NOPCAS), whose mission is to stop the epidemic of suicide in minority communities, supports several strategies to save lives in communities of color. NOPCAS creates corporate partnerships to expand opportunity and build alliances in inner cities.

The Suicide Prevention Action Network USA, Inc. (SPAN) is organized through national affiliates across the country to conduct prevention activities, including building links among agencies and conducting advocacy on policies related to suicide prevention.

Creating Crisis Centers and Suicide Hotlines

SAMHSA's National Suicide Prevention Initiatives includes the National Suicide Prevention Lifeline, a national 24-hour free suicide prevention service, which consists of a national network of more than 100 certified local crisis centers.

A toll-free number 1-800-273-TALK (8255) is provided, where calls are routed to the nearest available provider at http://www.suicidepreventionlifeline.org/.

Crisis center hotlines offer an immediate available source of support, do not require a trip to a clinic, and are anonymous. Suicide hotlines are based on the thinking that many suicide attempts are:

  • Triggered by a stressful event
  • Are often impulsive
  • May include substantial ambivalence  

Raising Public Awareness

Suicide Awareness Voices of Education (SAVE) is dedicated to preventing suicide through public awareness and education and to eliminating the stigma of suicide. It also serves as a resource to those who are touched by suicide. SAVE has a community action kit with tools such as public awareness materials, pre-printed and pre-recorded ads that can be tailored to a community, community education programs (how to build a speakers' bureau and start a school-based program, etc.), organizing tips, materials for the press and the public, reproducible products, suggested activities, as well as contact and resource information.

Every year, SPAN USA sponsors a National Awareness Event in Washington, DC to raise awareness about the toll of suicide and the need for suicide prevention initiatives. Suicide prevention advocates come to the nation's Capital to remember those lost to suicide and conduct advocacy with members of Congress. The event features a display of Lifekeeper State Memory Quilts to put a face on the thousands of lives lost to suicide.

Among the prevention activities organized by Yellow Ribbon International Suicide Prevention Program is an annual yellow ribbon suicide awareness and prevention week beginning on the third Sunday of each September. Yellow Ribbon participants at the local level:

  • Contact elected officers about declaring a suicide prevention week in their communities
  • Post yellow ribbons and prevention posters and flyers
  • Hold candle lighting or memory memorials and walks for life
  • Contact local newspapers and other media about the epidemic level of youth suicide in the United States

Changing public attitudes about suicide includes increasing the awareness of suicide's human and financial costs on society. The majority, about two-thirds, of suicides occur among the nation's workforce (age 25-65). One researcher estimated the impact of suicide on a corporate "family" that included 100,000 employees with an average of four blood relatives per employee. The cost of suicide included:

  • The loss of a corporate family member to suicide every seven days
  • Three suicide attempts every day  

Key Messages To Raise Public Awareness:

  • Suicidal feelings are temporary
  • Treatment can make people feel better
  • Asking for help is a sign of strength
  • Talk of suicide should be taken seriously
  • Help is available  

State Prevention Plans

State governments are also playing an important role in suicide prevention by providing resources, training, and strategic planning. The National Governors Association notes that more than half of the states have developed suicide prevention plans.

Among the actions governors and state policymakers may take, and have taken, include:

"Contrary to popular believe, talking about suicide or asking someone if they are feeling suicidal will NOT put the idea in their head or cause them to kill themselves."  

  • Increasing public awareness by declaring a state suicide awareness week, quantifying the state's suicide problem and developing policy responses to address it, and helping state agencies disseminate information.
  • Creating state prevention plans that include public education, mental health evaluation and treatment, gatekeeper training programs, specialized curricula for out-of-school youth and those at-risk of becoming dropouts, and reduced access to lethal means of self-harm.
  • Establishing school-based prevention programs to give schools a larger role in suicide prevention efforts.
  • Dedicating resources to invest in building institutional capacity and developing a knowledge base within government around suicide and prevention.
  • Stimulating multi-agency and multi-sector collaboration among key state agencies, such as education, health, human services, and public safety, and between government and community partners.  

Maine Suicide Prevention

The State of Maine has a comprehensive youth suicide prevention plan; The Maine Youth Suicide Prevention Program (MYSPP).

The MYSPP employs several strategies to reduce the incidence of suicide behavior among 10-24-year olds and to improve youth access to appropriate prevention and intervention services. Since it's development in 1997, the program has trained more than 10,000 gatekeepers, including school personnel, youth serving agency staff, substance abuse clinicians, mental health clinicians, and department of health services clinicians and many others; designed and distributed Web site and printed information, established a statewide crisis hotline, developed and disseminated videos, and implemented a comprehensive suicide prevention program in 12 school systems.

The program in Maine was designed to address the high rates of youth suicide in the predominately rural state:

  • Maine has a suicide rate for 15- to 24-year-olds that is higher than the national average
  • Suicide is the second leading cause of death for Maine youth in that age category

The Maine Youth Suicide Prevention Program developed Youth Suicide Prevention Intervention and Postvention Guidelines to help schools and school districts make sure they have protocols to address suicidal behavior and to respond appropriately to suicide threats and to those potentially at risk in the aftermath of a death by suicide. The guidelines call for schools to develop school-based suicide intervention plans. The goals of the intervention plans are to:

  • Outline actions for responding to suicidal behavior
  • Designate individuals for responding to a variety of crisis situations and communicate this information to school staff and students
  • Identify sources for erral and contact, such as crisis service personnel, police and emergency medical service providers
  • Create forms and procedures for documentation
  • Outline follow-up steps for school personnel to take after an intervention with students  

For more information contact the Maine Injury Prevention Program, Division of Community and Family Health (1-207-287-5362).

Effective Suicide Prevention Programs

The Suicide Prevention Resource Center has a Registry of Evidence-Based Practices in Suicide Prevention Programs. Evidence-based programs were evaluated to show a "strong causal link" between the program and outcomes, such as increased protective factors against suicide, decreased risk factors for suicide, or decreased rates of suicidal behaviors. Promising programs demonstrated a "moderate causal link" between the program and outcomes.

SAMHSA also has a National Registry of Evidence-based Programs and Practices (NREPP). NREPP features those programs that have been implemented and evaluated and may be replicated in other communities. They have demonstrated positive outcomes in preventing substance abuse and related behaviors.

The programs described below are listed either with SAMHSA's NREPP or with the SPRC's registry and have, theore, been evaluated for effectiveness.

Lifelines

Among the Programs listed on the Registry of Evidence-Based Practices in Suicide Prevention is the Lifelines Program [Adobe PDF] school-based suicide prevention program.

Lifelines was adapted by Maine to provide a Suicide Awareness Program in order to provide extensive training to key staff in the schools, increase the capacity of the schools to provide additional training to staff, and to help health educators teach children about suicide.

Signs of Suicide (SOS) Prevention Program

Physicians, school counselors, religious leaders, and others may be one of the last points of outside contact for an individual with a suicide plan.

Another suicide prevention program that has demonstrated effectiveness in reducing suicidal behavior is the Signs of Suicide (SOS) Prevention Program, a SAMHSA Promising Program. This is a program targeted at high school students and it has been successfully run in Columbus, GA and Hartford, CN. In both locations, use of this program in area high schools resulted in significantly lower rates of suicide attempts and greater knowledge and more open-mindedness and understanding of depression and suicide.

SOS is the first school-based suicide prevention program to show marked reductions in self-reported suicide attempts.

The SOS Program brings two important suicide prevention strategies into one program: (1) combining a curriculum that raises awareness of suicide and related issues, with (2) a brief screening for depression and other risk factors.

One unique aspect of SOS is that it seeks to develop an understanding that suicide is part of mental illness, and is a key diagnostic criterion for major depression. This is in contrast to many other suicide prevention programs which try to de-stigmatize and normalize suicide, by separating it from mental illness. The SOS Program is clear in its belief that suicide is not a normal reaction to stress or problems.

How the Program Works

SOS focuses on teaching high school students to respond to signs of suicide as a mental health emergency, similar to how one takes emergency action when signs of heart attack are indicated. Students are taught to recognize the signs of suicide and depression in themselves and others. Students learn to:

  1. Acknowledge the signs of suicide and take them seriously
  2. Let the person know that you Care about them and want to help
  3. Tell a responsible adult (ACT)

The teaching materials include a video of interviews with real people affected by suicide.

Students are also asked to take the Columbia Depression Scale, which is a brief screening instrument for depression, and score themselves. Students with scores indicating depression are encouraged to seek help immediately and are given a list of resources available for help.

In the schools participating in the outcome study, the average number of teens seeking counseling for depression/suicidality in the 30 days following the program was almost 150 percent higher when compared with the average number of teens seeking help in the year prior to the program. Results also showed that 3 months after the programs ended, there was still a substantial impact of the attitudes and behaviors on the teens involved in the program.

This study will need to be repeated in more high schools, insuring that the program is offered in geographically, ethnically, and socially diverse areas. A longer-term follow-up is also necessary.

The American Indian Life Skills Development Curriculum

The suicide rate among 15-24-year-old American Indians is three times as high as than the national average.

The American Indian Life Skills Development: Community-based Suicide Prevention, a SAMHSA Effective Program that is also on the SPRC registry, is a school-based, culturally tailored, suicide prevention curriculum for American Indian adolescents.

Tailored to American Indian norms, values, beliefs, and attitudes, the curriculum is designed to:

  • Build self-esteem
  • Identify emotions and stress
  • Increase communication and problem-solving, stress management, depression and anger management, and goal setting skills
  • Recognize and eliminate self-destructive behavior, including suicide attempts and substance abuse

The curriculum was developed in collaboration with students and community members from the Zuni Pueblo and Cherokee Nation of Oklahoma. The life-skills approach to the curriculum helps students learn specific methods to help a peer turn away from suicidal thinking and seek help.

The curriculum includes seven units designed for three times a week over a 30-week period. An evaluation of the curriculum in the Zuni community where it was developed found statistically significant improvements in the levels of hopelessness, self-efficacy to manage anger, and in students' abilities to role-play suicide intervention skills and problem-solving skills.

The program developer stresses the following factors as critical to the success of the curriculum:

  • Community involvement that allows for the adaptation of cultural norms within the curriculum and establishes community support
  • Training techniques that provide information about the effects of target behaviors and modeling of appropriate skills
  • Role playing of appropriate skills, and providing feedback
  • Adequate training for teachers before the curriculum is utilized  

The Air Force Suicide Prevention Program

From a suicide prevention standpoint, middle-aged adults have been an underserved population. According to the National Strategy for Suicide Prevention (NSSP), adult males ages 25-65 commit more than half of all suicides in the United States, with White males aged 24-55 having the largest number of deaths by suicide.

Unfortunately, men in this age group are more likely to keep their problems hidden and to not seek help. A major reason for this is the stigma associated with having mental health and/or substance abuse problems. Keeping a job, maintaining relationships with partners and/or children, elderly parents, employers, professional and civic organizations, and religious institutions can be overwhelming, making some people feel that it is simply impossible to disclose or own up to debilitating problems. It is also easy for the potential gatekeepers involved in the lives of middle-age adults to miss or overlook existing risks.

The stigma and fear associated with feelings of depression and suicide can cause many people to go to great lengths to push away feelings that "something is not right," to try to ignore them until a breaking point occurs. The same kind of stigma and fear applies to those people who have a substance abuse problem. Sometimes, people will exhibit some of the risk factors for suicide and substance abuse, (such as verbal and/or physical aggression, impulsivity, depression, risky behavior, poor judgment, abuse of alcohol, and other drugs) which can be seen by others, but not by the person experiencing them. This is particularly true for the many people who are leading busy, pressured lives. Symptoms and risks can become externalized, acted out onto people, places, and situations.

The main gatekeepers for people in the middle years are employers, family members, and significant others, physicians and nurses, as well as friends, and peers from religious, professional, civic and sports organizations. Frequently, these entities are the unintentional gatekeepers. They can play a helpful, observant role but may not know that they can and should do so. From a public health point of view, this orientation needs to change to one of an expanded awareness and connectedness to those in proximity to us.

One promising community based prevention program, particularly for those in the middle years, is the Air Force Suicide Prevention Program.

AFPP Background

Coupled with the decline in the suicide rate, Air Force leaders also saw statistically significant decreases in violent crime, family violence, and deaths due to unintentional injuries.

During the early to middle 1990s, suicide rates in the U.S. Air Force (USAF) rose to an all time record high, making suicide the second leading cause of death among 350,000 Air Force members.

The high suicide rate was true for both Caucasian and African American males. Stigma, cultural norms and beliefs together discouraged help-seeking behavior. These three factors were identified as the major hurdles to suicide prevention.

Beginning in 1996, the Air Force implemented a top-down approach to suicide prevention. It identified the following risk factors as contributing to the high suicide rate in the USAF:

  • Legal problems
  • Finances
  • Distressful intimate relationships
  • Depression
  • Job stress
  • Alcohol and other substance abuse
  • Social isolation
  • Poor coping skills

Three protective factors were also identified:

  • Social support
  • Effective coping skills
  • Policies and norms that encourage help-seeking behavior

The Air Force Chief of Staff, as the key leader, supports an environment that shows that the Air Force takes care of its own. In addition, regular, ongoing, and repeated Professional Military Education (PME), key parts of which are repeated year after year, at all ranks of service. Public Service Announcements (PSAs) tailored to life in the military were developed and are disseminated dealing with different aspects of suicide prevention. The leadership at all levels demonstrated their commitment to reducing suicide in the Air Force. Confidentiality laws were strengthened, prevention and mental health services were emphasized and expanded for individuals, families, and units.

The Air Force developed clear policies that indicated that job performance would not be harmed by those seeking help; in fact long term job performance and advancement were enhanced because of help seeking behaviors. The Air Force found that the people who did the worst were those who did not seek help, but instead waited until a crisis erupted, and were then ordered into treatment, or committed suicide.

The delivery of the range of military services available to help people was integrated, so that it was clear where to go for help, how to access help, and how to utilize help once it was obtained. Epidemiological data is collected to record demographic, risk factor, and protective factor information about people who attempted or completed suicide. This gives leaders the ability to detect changes in patterns of suicidal behavior. When a traumatizing event occurs, teams of trained personnel are sent on locations to provide extra resources and help. A thorough examination of the entire Air Force community was undertaken to coordinate the suicide prevention efforts.

The suicide rate in the Air Force declined from 1996 to 1999, falling to 3.5/100,000. There have been some fluctuations since 1999, with the suicide rate increasing in 2000 and 2001, but the rates declined after April 2001 and have remained much lower than the rates prior to 1995. Coupled with the decline in the suicide rate, a research study also found statistically significant decreases in violent crime, family violence, and deaths due to unintentional injuries.

A longer term study to evaluate the Air Force suicide prevention program is now underway (Knox, NIMH).

AFPP Application

The Air Force community, although different from civilian communities, also has many similarities. All communities have identified leaders who can influence and shape community norms and policies. Community leaders help to establish what the priorities of a community are and/or should be. Like all communities, there are the official leaders and then there are the many people who fill community needs and roles and who take on leadership responsibilities unofficially. Both types of leaders can work together to form and establish priorities, such as suicide prevention and suicide as a public health problem.

Human service organizations occupy a multi-faceted position in both the Air Force and civilian communities, which are often not well connected and organized in both systems. Thus, efforts to organize knowledge of what services exist and how to access and utilize them is knowledge that can be transferred from one domain to another.

All communities contain aspects of a common identity. At the same time all communities are comprised of diverse individuals. This is as true of the Air Force as it is of civilian communities.

All communities also have gatekeepers, who are the people who assist in opening doors to help, whether help is in the form of other people, money, programs, and/or organizations. The Air Force established a network of gatekeepers and worked to get those gatekeepers to recognize themselves as such and take on appropriate roles and responsibilities.

In all kinds of communities, the leaders are able to:

  • Shape and direct cultural norms
  • Contact and train established gatekeepers and service providers
  • Improve coordination of diverse and duplicative services
  • Provide educational programs to community members

Faith-Based Suicide Prevention Initiatives

Across the United States, there are a number of faith-based initiatives designed to aid in preventing suicide. These initiatives typically originate within a particular church or denomination, and operate both within a specific religious framework and/or ecumenically.

One of the organizations that is part of the National Council on Suicide Prevention is OASSIS: the Organization for Attempters and Survivors of Suicide in Interfaith Services. This organization has worked with a number of different faith traditions to offer support and help to those who are at risk for suicide, as well as to family members, suicide survivors, and others. OASSIS provides a forum for people to gather around this difficult topic. It acts as an umbrella organization for religious communities who care about suicide prevention.

The National Alliance on Mental Illness also addresses the connection between faith and mental illness. The resources listed by NAMI are provided in the spirit of offering support and compassion to persons with mental illnesses. There are a number of pastoral and religiously-based organizations that can offer mental health counseling, participation in community, education, linkages, and resources to those who seek to approach co-occurring disorders from a spiritual point of view.

Future Prospects

The average life expectancy in the United States has gone up by leaps and bounds with each generation. But medical advancements alone won't prolong lives. Unlike the diseases that plagued generations in the past before the advent of modern medicine, most suicidal behaviors are treatable. Yet left unchecked, suicidal behaviors will have a devastating impact on the future.

In its wake, suicide leaves billions of dollars in medical, economic, and social losses and incalculable costs to society as a whole for failing to address such a large-scale public health crisis.

Today's health crises, such as mental illness and suicide, require all of us, not just professionals, to take ownership of the problem and find solutions in prevention and treatment.

The good news is that the progress that is made--inroads in substance abuse prevention or changing the stigma attached to mental illness, for example--are cumulative and interrelated. The end result is something all members of the community can live with--healthy individuals and a healthy society.

Summary:

  • Effective, successful prevention, intervention, and treatment are available for the entire range of suicidal behaviors, but suicide prevention efforts are in the early stages, and there is much grassroots work to be done.
  • Opportunities for integrated care for co-occurring substance abuse and mental health disorders are rapidly increasing. Many more people, programs, organizations, and institutions are being identified as the gatekeepers who can assist in promoting the many protective factors available to those at risk.
  • There are well-developed and researched model prevention programs for community-based suicide and substance abuse prevention efforts. The Federal government plays a critically important role in providing funding, guidance, structure, and technical assistance to local-and State-based suicide and substance abuse prevention work.

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MODULE 1

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MODULE 2

 

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MODULE 3

 

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MODULE 4

 

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MODULE 5

 

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Walker, R. D. Written testimony of R. Dale Walker, M.D., Director. (April 13, 2003). One Sky Center: American Indian/Alaska Native National Resource Center for Substance Abuse and Mental Health Services. Oregon Health & Sciences University. Oversight Hearing on Indian Health. Testimony before the United States Senate Committee on Indian Affairs.

 

MODULE 6

 

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Assistant Secretary for Health, U.S. Department of Health and Human Services, Office of Public Health and Science, U.S. Air Force Medical Service, Office of the Surgeon General. (2002). Air Force suicide prevention program: A population-based, community approach. Retrieved June 28, 2005, from http://www.osophs.dhhs.gov/pphs/bestpractice/usaf.htm

 

Caine, E. D., Catalano Feig, J., Knox, K. L., Litts, D. A., & Talcott, G. W. (December 2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention program in the U.S. Air Force: Cohort study. British Medical Journal, 327, 1–5.

 

Frierson, R. L., Melikian, M., & Wadman, P. C. (September 2002). Principles of suicide risk assessment: How to interview depressed patients and tailor treatment. Postgraduate Medicine, 112(3), n. page. Retrieved http://www.postgradmed.com/issues/2002/09_02/frierson4.htm

 

Gliatto, M. F., & Rai, A. K. (March 1999). Evaluation and treatment of patients with suicidal ideation. American Family Physician, 59(6), n. page. Retrieved November 22, 2005, from http://www.aafp.org/afp/990315ap/1500.html

 

LaFromboise, T. D. (2004). American Indian life skills development curriculum. [Overview of the book American Indian life skills development curriculum]. University of Wisconsin. Retrieved December 8, 2005, from http://www.wisc.edu/wisconsinpress/books/0129.htm

 

Maine Youth Suicide Prevention Program, Maine Children’s Cabinet. (May 2002). Youth suicide prevention intervention and postvention guidelines: A resource for school personnel. Author.

 

National Governors Association Center for Best Practices. (2005). Youth suicide prevention: Strengthening state policies and school-based strategies [Issue brief]. Washington, DC: Author.

 

One Sky Center. (2005). Conference readies Indian youth to fight suicide [Press release].

Retrieved December 8, 2005, from http://www.oneskycenter.or/news/news/NewsView.cfm?newsID=49

 

Patterson, W. M., Dohn, H. H., Bird, J., & Patterson, G. (1983). Evaluation of suicidal patients: the SAD PERSONS scale. Psychosomatics, 24(4), 343–349.

 

Paul, R. (2004). Suicide prevention: A call to action for EAPs. Behavioral Health Management,24(5), n. page.

 

Steering Committee on Practice Guidelines, American Psychiatric Association. (November 2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. Author.

 

Suicide Prevention Resource Center. (2005). Registry of Evidence Based Suicide Prevention Programs. Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT).

 

Suicide Prevention Resource Center. (2005). Registry of Evidence Based Suicide Prevention Programs. Zuni Life Skills Development. Retrieved January 26, 2006, from

http://www.sprc.org/featured_resources/ebpp/ebpp_factsheets.asp#title

 

The Nation’s Voice in Mental Illness. (n.d.). Suicide: Helping patients and their families after an attempt. A guide for medical professionals in the emergency department. Arlington, VA: Author.

 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Mental Health Information Center, Center for Mental Health Services.(2001). National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC, p. 60.

 

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Injury Protection and Control. (1992). Youth suicide prevention programs: A resource guide. Atlanta, GA: Author.

 

U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health. (August 2, 2005). Cognitive therapy reduces repeat suicide attempts by 50 percent. [Press release]. Retrieved October 28, 2005, from

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U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (n d.). SOS: Signs of suicide. Model Programs: Info on Promising Programs. Retrieved December 12, 2005, from

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U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention. (2003). Silence hurts: Alcohol abuse and violence against women [Online Course].

 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Mental Health Information Center, Center for Mental Health Services. (2001). National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC, p. 80.

 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Mental Health Information Center, Center for Mental Health Services. (2001). National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC, p. 87.

 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Mental Health Information Center, Center for Mental Health Services. (2001). National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington, DC, p. 99.

 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Mental Health Information Center, Center for Mental Health Services. (2001). National Strategy for Suicide Prevention: Goals and Objectives for Action. Washington,

DC, p. 184.

 

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (July 12, 2002). National Household Survey on Drug Abuse Report. Substance abuse and the risk of suicide among youths.