SUICIDE PREVENTION STRATEGIES

Effective suicide prevention is a comprehensive undertaking requiring the combined efforts of every healthcare provider and addressing different aspects of the problem. A model of this comprehensive approach includes:

• Identifying and assisting persons at risk. This may include suicide screening, teaching the warning signs of suicide, and providing gatekeeper training (see below).
• Ensuring access to effective mental health and suicide care and treatment in a timely manner and coordinating systems of care by reducing financial, cultural, and logistical barriers to care.
• Supporting safe transitions of care by facilitating the exchange of information, establishing follow-up contacts, rapid referrals, and patient and family education.
• Responding effectively to persons in crisis by ensuring available crisis services are available that provide evaluation, stabilization, and referrals to ongoing care.
• Providing for immediate and long-term postvention to help respond effectively and compassionately to a suicide death, including intermediate and long-term supports for people bereaved by suicide (see “Postvention for Suicide Survivors” below).
• Reducing access to lethal means by educating families of those in crisis about safe storage of medications and firearms, distributing gun safety locks, changing medication packaging, and installing barriers on bridges.
• Enhancing life skills and resilience to prepare people to safely deal with challenges such as economic stress, divorce, physical illness, and aging. Skill training, mobile apps, and self-help materials can be considered.
• Promoting social connectedness and support to help protect people from suicide despite their risk factors. This can be accomplished through social programs and other activities that reduce isolation, promote a sense of belonging, and foster emotionally supportive relationships.
  (SPRC, 2019g)

Suicide Prevention in Healthcare Settings

Each individual provider in any setting can contribute to the prevention of suicide by:

• Thoroughly screening patients
• Collaborating with patients to write safety plans
• Responding immediately and effectively to a patient’s suicidal thoughts and behavior
• Counseling about removal of lethal means (see below)
• Supportively following up with patients
  (SPRC, 2019f)

The following strategies are recommended for providers that care for patients in primary care settings:

• Establish protocols for screening, assessment, intervention, and referrals.
• Train staff in suicide care practices and protocols, including safety planning and lethal means counseling.
• Create agreements with specific behavioral health practices that will take referrals.
• Ensure continuity of care by transmitting patient health information to emergency care and behavioral healthcare providers to create seamless care transitions.
• Follow up with at risk patients by phone between visits.
• Provide information on the National Suicide Prevention Lifeline crisis line and services.
  (SPRC, 2019f)

Emergency care and urgent care settings strategies should include the following:

• Conduct universal or selective screening for suicide risk.
• Provide at-risk patients with a full assessment by a mental health professional trained in effective suicide care.
• Provide brief interventions while patients are still in the ED (e.g., safety planning, lethal means counseling).
• Ensure careful discharge planning and safe transitions of care to outpatient services.
  (SPRC, 2019f)

Public Health Suicide Prevention Strategies

The Centers for Disease Control and Prevention along with the National Center for Injury Prevention and Control and the Division of Violence Prevention have put forth strategies to support the 13 goals and 60 objectives of the National Strategy for Suicide Prevention (see “Resources” at the end of this course). These strategies acknowledge that prevention is best achieved by focusing on the individual, relationships, family, community, and societal levels across all sectors, both public and private, and upon the best available evidence for preventing suicide (CDC, 2019c). These strategies include:

Strengthening economic supports based on evidence that suicide rates increase during economic recessions and decrease during economic expansions. Buffering the risks associated with the effects of high unemployment rates, job losses, and economic instability can potentially protect against suicides. Approaches may include:

• Strengthening household financial security through unemployment benefits and other forms of temporary assistance
• Establishment of living wages
• Provision of medical benefits
• Retirement and disability insurance
• Housing stabilization policies that provide affordable housing, such as:
  • Government subsidies
  • Loan modification programs to avoid foreclosure
  • Financial counseling services

Strengthening access and delivery of suicide care based on evidence indicating that suicide correlates with general mental health measures. Evidence also finds that relatively few people with mental health disorders receive treatment, and a contributing factor is lack of access to mental health care. Approaches may include:

• Providing health insurance policies that cover mental health conditions
• Reducing provider shortages in underserved areas
• Changing delivery systems so that care is provided that supports suicide prevention and patient safety

Creation of protective environments is based on evidence that they can reduce suicide and suicide attempts and increase an individual’s protective behaviors. Approaches may include:

• Reducing access to lethal means (see below). Evidence indicates the interval between decision and attempt can be as short as 5 or 10 minutes, and people tend not to substitute a different method when a highly lethal method is unavailable or difficult to access. These include intervening at suicide “hotspots” (places where suicide may take place easily) and safe storage practices.
• Community-based policies to reduce excessive alcohol use, which may include zoning limits or alcohol taxes

Promotion of connectedness based on evidence that lack of connectedness and weak social bonds are among the chief causes of suicidality. Approaches may involve:

• “Peer norm” programs that typically target youth and are delivered in school settings but can also be implemented in community settings
• Community engagement activities to provide opportunities for residents to become more involved in the community and to connect with other community members, organizations, and resources

Teaching coping and problem-solving skills based on evidence that the building of life skills prepares people to successfully tackle everyday challenges and adapt to stress and adversity. It has been deemed an important developmental component to suicide prevention. Approaches may include:

• Social-emotional learning programs that are typically delivered to all students in a particular grade or school and focus on developing and strengthening communication, emotional regulation, conflict resolution, help-seeking, and coping skills
• Parenting skill and family relationships programs to strengthen parenting skills, enhance positive parent-child interactions, and improve children’s behavioral and emotional skills and abilities

Identifying and supporting people at risk based on evidence that vulnerable populations tend to experience suicidal behavior at higher than average rates. These individuals may include those:

• With lower socio-economic status
• Living with a mental health problem
• Who previously attempted suicide
• Who are veterans and active duty military personnel
• Who are institutionalized
• Who were victims of violence
• Who are homeless
• Individuals of sexual minority status
• Members of certain racial and ethnic minority groups

Approaches may include:

• Gatekeeper training designed to train teachers, coaches, clergy, emergency responders, primary and urgent care providers, and others in the community to identify people who may be at risk of suicide and to respond effectively, including facilitating treatment-seeking and support services
• Crisis intervention intended to impact key risk factors, including feelings of depression and hopelessness, and to increase subsequent mental health care utilization
• Treatment for people at risk of suicide, which may include various forms of psychotherapy delivered by licensed providers
• Treatment to prevent re-attempts that include follow-up contact using diverse modalities

(CDC, 2019c)

Lessen harms and prevent future risk based on evidence that risk of suicide has been shown to increase among people who have lost a friend/peer, family member, co-worker, or other close contact to suicide, and that postvention and safe-reporting/messaging have the ability to impact risk and protective factors. Approaches may include:

• Postvention implementation after a suicide has taken place, which may include debriefing sessions, counseling, and/or bereavement support groups for surviving friends, family members, or other close contacts
• Safe-reporting and messaging about suicide to the public that avoids sensationalizing events or reducing suicide to one cause

Washington State Suicide Prevention Initiatives

Washington has been making great strides in the effort to prevent suicide. In 2018 there was a large increase in community and state efforts dedicated to suicide prevention, some of which include the following:

Washington State Suicide Prevention Plan is based on core principles identified by the State Suicide Prevention Plan Steering Committee as key values and attitudes. These principles state that:

• Suicide is preventable.
• Everyone has a role in suicide prevention.
• Silence and stigma are harmful.
• Known factors contributing to suicide must be changed.
• Prevention should be based on best available research and best practices.
• Persons deserve dignity, respect, and the right to make their own decisions.

The Bree Collaborative was established in 2011 to improve healthcare quality, outcomes, and affordability in Washington. In 2017 and 2018, recommendations were advanced to include prevention of suicide. The Bree Collaborative recommends integration of specified implementable standards into clinical pathways for the following focus areas:

• Identification of suicide risk
• Assessment of suicide risk
• Suicide risk management
• Suicide risk treatment
• Follow-up and support after a suicide attempt
• Follow-up and support after a suicide death

Project AWARE (Advancing Wellness and Resilience in Education), through the Office of Superintendent of Public Education, equips adults to detect and respond to youth mental health issues.

The Safer Homes, Suicide Aware campaign was developed by Forefront Suicide Prevention at the University of Washington School of Social Work in collaboration with the Second Amendment Foundation. It offers training for healthcare clinicians, pharmacists, gun dealers, and firearms instructors in recognizing and responding to the warning signs of suicide. The campaign encourages the safe storage of firearms and medications in a variety of settings, including hospitals, gun stores, and homes. In collaboration with local gun rights advocates, Safer Homes has also piloted the distribution of free firearm locks and safety cases (SPRC, 2017c; UW, 2019; Bree Collaborative, 2018).

Reducing Access to Lethal Means

There are many actions that can be taken by families, organizations, healthcare providers, and policymakers to reduce access to lethal means of self-harm. Examples include reducing access to medications and safe storage of firearms. When a person is at risk for suicide, other actions may be required that involve the entire removal of lethal means from the household. These may include:

• Storing firearms off the premises (perhaps with law enforcement), or locking up firearms and placing the key in a safe deposit box or giving the key to a friend until the crisis has passed.
• Asking a family member to store medications safely and dispense safe quantities only as necessary.

Collaborating with members of the community to increase safety can include:

• Instituting lethal means counseling policies in health and behavioral healthcare settings and training healthcare providers in these settings
• Passing policies that exempt at-risk patients from 90-day refill policies
• Working with gun retailers and gun owner groups on suicide prevention efforts
• Distributing free or low-cost gun locks or gun safes
• Ensuring that bridges and high buildings have protective barriers
  (SPRC, 2019h)

COUNSELING ON ACCESS TO LETHAL MEANS (CALM)

A protocol that is being used nationally is known as the CALM (Counseling on Access to Lethal Means) program, a 1.5- to 2-hour workshop that teaches providers ways to reduce access to lethal means by patients at risk for suicide. Goals of this program are to:

• Increase knowledge about the association between access to lethal means and suicide and the role of means safety in preventing suicide
• Increase skills and confidence to work with patients and families to assess and reduce their access to lethal means

This approach involves the following:

• Speak with both the person and family or friends.
• Discuss the risk of suicide and the rapid escalation of risk that may lead to an attempt.
• Ask if there are firearms in the home. If possible, speak with all adults in the home. It is important to ask about all firearms, as there is often more than one. If the person is a minor involved in a joint custody situation, ask about each parent’s home.
• Advise that all firearms be removed from the home until the situation improves.
• If handling a firearm is too risky for the person, enlist a support person to make the transfer. Store firearms with a trusted relative or friend. Law enforcement may temporarily hold guns, and most will dispose of them if requested. Also, some storage facilities, gun stores, or shooting clubs may hold guns.
• If family is unwilling to remove guns from the home and storing them in the home is desired, a member of the household should unload the gun(s) and lock them up in a place with no glass fronts or hinges (such as a lock box or a safe) with trigger locks or cable locks. Ammunition should be stored separately in a locked container.
• Prescriptions of lethal medicines should be removed from the home, and alcohol should be present only in small quantities, if at all. Clinicians should contact Washington State’s Prescription Monitoring Program (PMP) for objective evidence of the patient’s use of prescription medications and multiple prescribers.
  (SPRC, 2018b; WADOH, 2019)

Legal issues to be considered when counseling on access to lethal means include:

• Challenges to the professional autonomy of doctors involving powers of state to limit the topics that physicians can discuss with patients. In Florida, for example, an act that prohibited physicians from asking patients about firearm ownership and storage was ruled invalid by the courts. There is the possibility of additional attempts to gag medical professions, but this ruling supports the rights of physicians (APHA, 2018).

Many states have laws that enable family members and police to petition a court to issue an emergency order to remove guns from an at-risk person who will not voluntarily give up their guns for safekeeping. Other barriers include universal background check laws that limit the persons to whom a firearm can be legally transferred for temporary safe storage (SPRC, 2019i).

Postvention for Suicide Survivors

All settings should incorporate postvention as a component of a comprehensive approach to suicide prevention. Postvention is a term often used in the suicide prevention field. It is an organized response in the aftermath of a suicide to accomplish any one or more of the following:

• To facilitate the healing of individuals from grief and stress of suicide loss
• To alleviate negative effects of exposure to suicide
• To prevent another suicide among people who are at high risk after exposure to suicide

Postvention involves:

• Working with the news media to encourage safe reporting immediately following a suicide
• Working with those affected by suicide death to aid mourning in ways that avoid increasing the risk of contagion
• Building capacity for ongoing support and treatment, including professional and peer-support options for those who require it
• Providing support and guidance for friends and family members of the bereaved to help them obtain effective ongoing support

Postvention interventions that may be beneficial in providing support for families following a suicide include:

• Information about the manner, timing, and circumstances of the death
• An opportunity to view the body with emotional support
• Support and assistance with official procedures and investigations
• Assistance with interpreting the postmortem report
• If appropriate, seeing a copy of a suicide note or message
• Assistance with notifying family and others of the death and its circumstances
• Written information regarding grief and coping strategies for grief
• Contact information for local bereavement and suicide bereavement support groups
• Written information on supporting children following a suicide
• Access to professional individual or group counseling, therapy, or psychotherapy if needed
• Guidance in responding to media inquiries
• Advice on how to respond in social environments to questions about the suicide death
• Referral for financial evaluation and assistance
• Information about how suicide impacts family functioning and how other families have learned to cope
• Guidance in how to tell children about a suicide death of a family member
• Information on how to protect children from the risk of suicidal behavior
• Follow-up contact to offer support and assistance several times during the first year to reiterate offers of support and assistance and to provide information
  (RNAO, n.d.)

Many people have life insurance policies. However, the date the policy was issued is an important factor. If there is a suicide clause in the policy, it will state how much time must elapse between the date of issue and the date of the suicide. In most states the benefits will not be paid if the date of suicide is within one or two years from the date of issuance. In that event, premiums paid over the life of the policy may be returned to beneficiaries. For policies that have been in effect for longer than the one- or two-year time frame, the insurance company will typically pay the proceeds (AFSP, 2016).

POSTVENTION SERVICES AVAILABLE IN WASHINGTON STATE

Washington State offers many support groups for people who have lost a loved one to suicide, such as Crisis Connections (CC) Cares, a program for those newly bereaved by suicide from those who have experienced it themselves. CC Cares was originally a program started and nurtured by Forefront Suicide Prevention: A Center of Excellence at the University of Washington.

Other services offered through the University of Washington Forefront Suicide Prevention program include:

• Bridges: A Center for Grieving Children
• Suicide Survivors Supports group
• S.O.S.L (Survivors of Suicide Loss) support group
• Survivors of Suicide
  (AFSP, 2019c)

POSTVENTION SUPPORT TO MILITARY FAMILIES

Military-sponsored programs for families and next of kin have been established to assist military dependents. Most commonly, a casualty assistance office works with them. Mental health and counseling services are available to all dependents, as are religious, financial, and legal services. A military family life consultant is available to work with the families.

• Military OneSource offers 24/7 in-person, telephone, and online services to assist with emotional, bereavement, financial, and benefit issues.
• Veterans Affairs Bereavement Counseling offers bereavement support to parents, spouses, and children of active-duty and Guard or Reserve members who died while on military duty (Military One Source, 2019).
• Tragedy Assistant Program for Survivors (TAPS) is a national nonprofit veterans service organization that provides services to help stabilize family members in the immediate aftermath of a suicide. TAPS resources, programming, and events are offered throughout the year that support all types of military loss. Suicide loss survivors are welcome to join any programming that includes a focus on suicide loss specifically. These may include:
  • National Military Suicide Survivors Seminars, held each fall, offering an opportunity to connect with others. Includes peer-to-peer grief support, access to resources and experts, participation in intensive grief workshops, art therapy, relaxation, and family entertainment.
  • Survivor Care Team members who are trained survivors, available around the clock to help.
  • Peer Mentor Program trains survivors 18 months or more after their own loss to serve as mentors to new survivors seeking support.
  • Suicide Loss Online Community, an invitation-only, moderated Facebook peer group where members share stories and learn from others’ experiences. TAPS also monthly hosts a live online chat moderated by suicide survivor staff members.
  (TAPS, 2019)