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 formal referral protocols, interagency agreements, cross-training, follow-up contacts, rapid referrals, and patient and family education.
  • Responding effectively to persons in crisis by ensuring 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, 2020b)

Public Health Suicide Prevention Strategies

The Centers for Disease Control and Prevention “Suicide Prevention Resource for Action” details the strategies based on the best available evidence to help states and communities prevent suicide.

  • Strengthen economic supports
    • Strengthen household financial security
    • Stabilize housing
  • Create protective environments
    • Reduce access to lethal means among persons at risk of suicide (see below)
    • Reduce substance use through community-based policies and practices
  • Improve access and delivery of suicide care
    • Cover mental health conditions in health insurance policies
    • Increase provider availability in underserved areas
    • Provide rapid and remote access to help
    • Create safer suicide care through systems change
  • Promote healthy connections
    • Promote healthy peer norms
    • Engage community members in shared activities
  • Teach coping and problem-solving skills
    • Support social emotional learning programs
    • Teach parenting skills to improve family relationships
    • Support resilience through education programs
  • Identify and support people at risk
    • Train gatekeepers (see below)
    • Responses to crises
    • Plan for safety and follow up after an attempt
    • Provide therapeutic approaches
  • Lessen harms and prevent future risk
    • Intervene after suicide (postvention) (see below)
    • Report and message about suicide safely
    (CDC, 2022g)

GATEKEEPER TRAINING PROGRAMS

Gatekeeper training (GKT) is one of the most widely used suicide prevention strategies. It involves training people who are not necessarily clinicians to be able to identify individuals experiencing suicidality and refer them to appropriate services. GTK improves people’s knowledge, skills, and confidence in helping those who experience suicidal ideation and enhances positive beliefs about the efficacy of suicide prevention (Hawgood et al., 2023).

One example of gatekeeper training, QPR, involves three steps—Questions, Persuade, and Refer—that can be learned in as little as two hours (Purdue University, 2022).

VETERANS HEALTH ADMINISTRATION PREVENTION FRAMEWORK

Within the Department of Veterans Affairs (VA), the Veterans Health Administration’s approach to suicide prevention is based on a public health framework that focuses on intervention within populations rather than a clinical approach that intervenes with individuals.

This public health perspective considers questions such as:

  • Where does the problem begin?
  • How can we prevent it from occurring in the first place?

The VA follows this systematic approach:

  1. Define the problem by collecting data to determine the who, what, where, when, and how of suicide deaths.
  2. Identify and explore risk and protective factors using scientific research methods. Develop and test prevention strategies.
  3. Assure widespread adoption of strategies shown to be successful.
    (VA, 2018)

Under the Veterans Comprehensive Prevention, Access to Care, and Treatment (COMPACT) Act of 2020, veterans in suicidal crisis can receive free emergency healthcare at any VA or non-VA healthcare facility (VA, 2023).

Resources available for veterans and their families include:

  • Suicide Prevention Coordinator, available at each VA medical center, who provides veterans with counseling and other services; as appropriate, callers to the Veterans Crisis Line are referred to their local coordinator
  • Coaching Into Care, a national telephone service to educate, support, and empower family members and friends seeking care or services for a veteran (call 888-823-7458)
  • Veterans Crisis Line (call 988 or text 838255)
  • Suicide Safety Plan template
  • inTransition, a free, confidential program offering coaching and specialized assistance over the phone for active-duty service members, Guard and Reserve members, and veterans who need access to mental health care
  • Make the Connection, an online resource that connects veterans, family members, friends, and other supports with information and solutions to issues affecting their lives
  • Vet Centers’ readjustment counseling services
    (VA, 2018)

Reducing Access to Lethal Means

When a person is at risk for suicide, actions are required to removal 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.

Responsible firearm storage involves keeping them locked and preferably unloaded, and separating firearms and ammunition when not in use. Secure storage options include either storing firearms away from home or locked at home in a secure gun safe, gun cabinet, or lockbox. In addition, unloaded firearms can be secured with a gun-locking device or can be disassembled with parts securely locked in separate locations.

When considering temporary gun storage with friends or relatives, under federal law, a person should not ask someone to store their firearm if that person is prohibited from possessing a firearm.

Reducing means of suffocation includes taking measures to reduce suicide by hanging. About 10% of suicides by hanging occur in the controlled environments of hospitals, prisons, and police custody. The remainder occur in the community, where ligatures and ligature points are all widely available. Healthcare systems can reduce suicide by hanging by installing collapsible shower heads, light fixtures, door knobs, and providing bedding that is resistant to tearing.

Safety measures available for individual storage and disposal of prescription and nonprescription drugs include drug lockboxes, drug buyback programs, and confidential drug return programs. Many states also have similar online tools to identify local collection sites and resources (NAASP, 2020). (See also “Resources” at the end of this course.)

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

  • Instituting lethal means counseling policies in health and behavioral healthcare settings and training healthcare providers in those 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, 2020d)
COUNSELING ON ACCESS TO LETHAL MEANS (CALM)

CALM is a free, self-paced online course for healthcare and social services providers that focuses on how to reduce access to the methods used by people at risk for suicide. It covers who needs lethal means counseling and how to work with people at risk for suicide—and their families—to reduce access (Zero Suicide, 2022).

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 suicide among people who are at high risk after exposure to another’s suicide

Postvention ensures that individuals and families who have experienced a suicide and/or suicide attempt are offered support. Postvention activities are intended to normalize anger, minimize self-blame, help survivors find meaning in the victim’s life, and be sensitive to cultural differences regarding suicide.

Key principles for creating a comprehensive postvention effort include:

  • Planning ahead to address individual and community needs
  • Providing immediate and long-term support
  • Tailoring responses and services to the unique needs of suicide-loss survivors
  • Involving survivors of suicide loss in planning and implementing postvention efforts

All suicide prevention efforts should include a comprehensive postvention component that reduces risk and promotes healing for the immediate family and reaches out into the community to support the broader group of loss survivors, including friends, coworkers, first responders, treatment providers, and others exposed to the death (SPRC, 2020e).

INSURANCE COVERAGE FOLLOWING SUICIDE OR ATTEMPTED SUICIDE

There are federal protections to ensure that most health insurance plans will pay for medical care resulting from a suicide attempt. There are, however, many forms of health insurance, and some plans may expose people to substantial uncovered costs after an attempted suicide (NAMI, 2021).

Many people have life insurance policies. However, a suicide clause is a standard clause in life insurance policies that limits payments made to survivors of a policyholder who dies by suicide within a certain period after purchasing the policy. Insurance companies typically do not pay a death benefit if the covered person dies by suicide within the first two years of coverage, commonly known as the exclusion period.

When the exclusion period ends, the policy’s beneficiaries can receive a death benefit if the covered person dies by suicide (Cornell Law School, 2021).

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.

  • Casualty Assistance Program provides support for understanding all benefits and other forms of assistance.
  • 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.
  • 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.
  • TRICARE provides mental health care services during bereavement; outpatient psychotherapy is covered for up to two sessions per week in a combination of individual, family, group, or collateral sessions.
  • Bereavement camps and other groups for children include:
    • Comfort Zone Camp
    • The Dougy Center
    • Eluna
    • Good Grief Camps
    • SnowballExpress
    (TAPS, 2023; Military One Source, 2022)
CASE

ALICIA AND PHILLIP

Alicia and Phillip, ages 15 and 17, were aware that their father had lost his job several months ago due to his company’s downsizing. He has been unsuccessful finding new employment, and they have been living on credit cards and handouts from family. They could see that their father was becoming more and more withdrawn, isolating himself, and avoiding activities he usually enjoyed. He no longer played golf with his buddies and had taken to drinking more alcohol. Their mother was concerned that he was becoming depressed and urged him to see a counselor. He told the family he was fine and would be okay once he found another job.

On Friday, as they arrived home from school, Alicia and Phillip saw an ambulance leaving their home. A police car stood in front of the house, and their mother met them at the door. She said something awful had happened. Their father had taken the handgun from his bedside table and shot himself in the head while she was out running errands.

Suddenly, their lives were turned upside down. Everything became surreal. Alicia and Phillip could not believe their father was dead. Only vaguely did they remember the people who came and went or the memorial service their mother arranged. Everything was a blur. They were in profound shock and denial.

The local newspaper headlined the news. The school nurse recognized the surname of Alicia and Phillip and consulted the school psychologist and principal. She called the teens’ mother, offering support and care. She referred the family to local resources, including an ongoing support group for suicide survivors offered by the local mental health agency. The nurse also arranged a suicide prevention workshop at the high school.

Alicia and Phillip joined the survivor group and did well. Their mother sought individual counseling for assistance with her grieving process and the aftermath of her loss.

Discussion

This case study outlines the efforts made to provide postvention care for a family that has experienced the loss of a loved one. The focus is on providing referrals to resources and support services, as well as efforts to teach the teen’s schoolmates about suicide prevention.