By Cele Fichter-DeSando, MPM

"In the depths of winter, I finally learned that within me there lay an invincible summer."
-  Albert Camus 

Suicide is a highly complex, preventable public health problem. Globally, more than 700,000 people die each year due to suicide. Suicide is the 4th leading cause of death throughout the world among 15-19-year-olds.

In the United States, suicide is the 10th leading cause of death, with prevalence estimates of suicidal thoughts and behaviors varying by sociodemographic factors, region, and state requiring targeted evidenced-based strategies and interventions.

The Role of Prevention

Suicide is a serious public health problem with tragically painful consequences for individuals, families, communities, the nation, and the world as a whole. When facing a health crisis of such magnitude, it is difficult to know where to begin and how to proceed. Prevention practitioners with their knowledge and experience of protective and risk factor theory can bring hope and strategic action to develop effective suicide prevention programs. As with other evidence-based prevention programs, there is not a single approach or strategy to address suicide prevention. A comprehensive, multifaceted, data-driven plan is essential.
The World Health Organization (WHO) developed LIVE LIFE: An implementation guide for suicide prevention in countries. The guide recommends that effective prevention programs are not built on a single approach but utilize a foundation of six pillars:

• situational analysis,
• multisectoral collaboration,
• awareness-raising,
• financing,
• surveillance, and
• monitoring and evaluation.

The six pillars are the infrastructure that supports four interventions and should be part of a comprehensive suicide prevention strategy.

• limit access to the means of suicide (e.g. pesticides, firearms, certain medications);
• interact with the media for responsible reporting of suicide;
• foster socio-emotional life skills in adolescents;
• early identify, assess, manage and follow up anyone who is affected by suicidal behaviors.

Prevalence Data to Guide Prevention Programs and Reduce Disparities

To accurately assess, identify, plan, and evaluate suicide prevention programs, there needs to be an understanding of the risk factors and patterns of suicide and suicidal behavior. The Centers for Disease Control (CDC) recently released a surveillance summary report summarizing 2015–2019 National Survey on Drug Use and Health (NSDUH) data collected from 254,767 respondents regarding national-, regional-, and state-level prevalence of suicidal thoughts, planning, and attempts by age group, sex, race and ethnicity, region, state, education, marital status, poverty level, and health insurance status. This surveillance data and accompanying tables can be used to design local, regional, and state programs that increase protective factors and decrease risk factors.
Risk Factors

Surveillance and prevalence data along with an understanding of specific risk and protective factors can serve as a roadmap for designing comprehensive suicide prevention programs. The National Suicide Prevention Lifeline outlines risk factors that make it more likely that someone will consider, attempt, or die by suicide. Programs and strategies that are designed to reduce risk factors are an important component of suicide prevention. Specific Risk factors for Suicide include:

• Mental disorders, particularly mood disorders, schizophrenia, anxiety disorders, and certain personality disorders
• Alcohol and other substance use disorders
• Hopelessness
• Impulsive and/or aggressive tendencies
• History of trauma or abuse
• Major physical illnesses
• Previous suicide attempt(s)
• Family history of suicide
• Job or financial loss
• Loss of relationship(s)
• Easy access to lethal means
• Local clusters of suicide
• Lack of social support and sense of isolation
• Stigma associated with asking for help
• Lack of healthcare, especially mental health and substance abuse treatment
• Cultural and religious beliefs, such as the belief that suicide is a noble resolution of a personal dilemma
• Exposure to others who have died by suicide (in real life or via the media and Internet)

Protective Factors

CDC promotes increasing connectedness as a key protective factor strategy for suicide prevention. Connectedness is defined as the degree to which a person or group is socially close, interrelated, or shares resources with other groups or persons.

Substance use prevention programs are provided in multiple settings across multiple timeframes and can increase opportunities for connectedness. Connectedness and social support strategies can be tailored to provide outreach to particular groups identified by The Substance Abuse and Mental Health Services Administration (SAMHSA) as groups who may be at risk for suicide. These groups include: youth and young adults, LGBTQ+, American Indians, Alaskan Natives, middle-aged men, veterans, older adults, attempt survivors, disaster survivors, loss survivors and other groups who may be at risk. CDC outlines protective factors that individuals and communities can promote to increase protection from suicidal thoughts and behaviors:

• Coping and problem-solving skills
• Cultural and religious beliefs that discourage suicide
• Connections to friends, family, and community support
• Supportive relationships with care providers
• Availability of physical and mental health care
• Limited access to lethal means among people at risk

Science into Practice: Call to Action

Prevention practitioners are adept at creating collaborations and utilizing and disseminating resources to put science into practice. Each year as prevention programs conduct needs assessment, set goals and design action plans for their communities, suicide prevention should be included as an integral part of the overall prevention plan. Science and data driven resources are available for prevention practitioners to utilize in developing and participating in effective suicide prevention programs.

1. Access: Beginning in July 2022 a three-digit dialing code 988  will be operated through the existing National Suicide Prevention Lifeline. Until the formal launch of 988 in July 2022, anyone in a mental health crisis or emotional distress should call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). People not in crisis who are seeking treatment options for mental health conditions should visit findtreatment.samhsa.gov or call 1-800-662-HELP (4357). Prevention programs can disseminate access information with other prevention materials and help to spread the word when access becomes easier with the 988 dialing code.
2. Action Alliance: SAMHSA is a partner of the National Action Alliance for Suicide Prevention, (Action Alliance)  a public-private partnership advancing the national strategy for suicide prevention. The National Action Alliance for Suicide Prevention is a public-private partnership of more than 250 national partners to advance the National Strategy for Suicide Prevention and provides research, plans, messaging, and other resources. Current Action Alliance priority areas include: transforming health systems, transforming communities, and changing the conversation. Learn about the existing campaigns and utilize their materials in your organization's messaging. Help is available and hope is a reality.
3. CDC Strategic Direction:  CDC developed a Suicide Prevention Strategic Plan  to promote the use of data, science, and partnerships to identify and implement effective suicide prevention strategies to foster healthy and resilient communities across the United States. Prevention programs can access surveillance summary data and other information to tailor suciide prevention programs for a specific region, population and/or community.
4. Opioid and Alcohol Misuse and Risk of Suicide: A Literature Review:  the Central East PTTC developed a literature review product to in identify and summare research on how and to what extent substance use increases the risk of suicide. It also provides information on evidence-based prevention strategies that address both the risk of substance use and the risk of suicide.
5. Screener for youth: Researchers have developed a computerized adaptive screener to identify youth at risk for attempting suicide. The screener, called the computerized adaptive screen for suicidal youth (CASSY), consists of 11 questions on average and correctly identified 82.4% of youth who went on to attempt suicide in the three months following the screening. The results suggest this screener could serve as an easy-to-use way for providers to detect youth suicide risk in emergency department settings.
6. The Suicide Prevention Resource Center (SPRC) https://www.sprc.org/  is the nation’s only federally funded resource center dedicated to advancing the National Strategy for Suicide Prevention. SPRC works with states, tribes, health systems, colleges and universities, and other public and private groups, bringing the latest science and interactive resources to support suicide prevention efforts across the country, and has compiled a selection of web pages and information sheets on mental health and coping with the effects of COVID-19.

Action Alliance tells us that we all play a role in developing and delivering effective suicide prevention. Substance misuse prevention practitioners plan, implement and evaluate effective, data-driven programs and practices that reduce behavioral health disparities and improve wellness. They are critical to suicide prevention efforts. Prevention practitioners bring invincible summer to the depths of winter.

Author's Note

Cele Fichter-DeSando, MPM (She, Her) is a consultant and trainer in substance use and gambling prevention and tobacco prevention and control. Cele has a Master’s degree in Public Management from Carnegie Mellon University and more than 35 years of experience in the management, training, and implementation of research-based prevention programs in Pittsburgh Pennsylvania. In 2020, Cele started a certified woman-owned business, CFD Consulting LLC, and has provided consulting for numerous organizations including Tobacco-Free Allegheny, the PTTC Network, and the Danya Institute Central East ATTC. She is passionate about providing resources, materials, and practical applications for evidenced-based prevention programs and prevention science to prevention practitioners.

Cele Fichter-DeSando, MPM
CFD Consulting, LLC
[email protected]
412-580-3089

References

Costanza, A., Amerio, A., Odone, A., Baertschi, M., Richard-Lepouriel, H., Weber, K., Di Marco, S., Prelati, M., Aguglia, A., Escelsior, A., Serafini, G., Amore, M., Pompili, M., & Canuto, A. (2020). Suicide prevention from a public health perspective. What makes life meaningful? The opinion of some suicidal patients. Acta bio-medica : Atenei Parmensis, 91(3-S), 128–134. https://doi.org/10.23750/abm.v91i3-S.9417

Ivey-Stephenson AZ, Crosby AE, Hoenig JM, Gyawali S, Park-Lee E, Hedden SL. Suicidal Thoughts and Behaviors Among Adults Aged ≥18 Years — United States, 2015–2019. MMWR Surveill Summ 2022;71(No. SS-1):1–19. DOI: http://dx.doi.org/10.15585/mmwr.ss7101a1

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Live life: an implementation guide for suicide prevention in countries. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO.item/9789240026629

King CA, Brent D, Grupp-Phelan J, et al. Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth. JAMA Psychiatry. 2021;78(5):540–549. doi:10.1001/jamapsychiatry.2020.4576

https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2775993

Scarth, B., Bering, J. M., Marsh, I., Santiago-Irizarry, V., & Andriessen, K. (2021). Strategies to Stay Alive: Adaptive Toolboxes for Living Well with Suicidal Behavior. International Journal of Environmental Research and Public Health, 18(15), 8013. MDPI AG. Retrieved from http://dx.doi.org/10.3390/ijerph18158013

Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, S., and Wilkins, N. (2017). Preventing Suicide: A Technical Package of Policies, Programs, and Practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

Substance Abuse Mental Health Services Administration (SAMHSA) 2022.

https://www.samhsa.gov/newsroom/press-announcements/202112201100?utm_source=SAMHSA&utm_campaign=a278103bbe-SAMHSA_Announcement_2021_12_20_1600585&utm_medium=email&utm_term=0_ee1c4b138c-a278103bbe-169226202

https://www.samhsa.gov/find-help/suicide-prevention

World Health Organization (WHO). 2022 https://www.who.int/news-room/fact-sheets/detail/suicide

https://www.cdc.gov/mmwr/volumes/71/ss/ss7101a1.htm?s_cid=ss7101a1_w

National Institute of Mental Health (NIMH) 2022.

https://www.nimh.nih.gov/health/topics/suicide-prevention

https://www.nimh.nih.gov/news/science-news/2021/adaptive-screener-may-help-identify-youth-at-risk-of-suicide