A Public Health Approach to Suicide Prevention

 

Joseph Galanek, M.A.

 

 

 

           

Introduction to Suicide

The past ten years have seen a shift in thinking about suicide.  No longer confined to the domains of mental health professionals suicide has been declared a public health problem by the Surgeon General1.  A review of the most recent statistics from the Centers for Disease Control and Prevention indicate the magnitude of the problem.  Suicide took the lives of 29, 350 Americans in 2000, 1.7 times as many homicides in the nation. Globally, the picture is equally as bleak.  It is a leading cause of death in the world, with 1.4 million deaths attributed to suicide in 1990 2.

Suicide is the 11th leading cause of death for all Americans, and the third leading cause of death for young people aged 15-24.  In terms of differences between sexes, men are four times more likely to die from suicide than are females, accounting for 72% of all suicides.  Females, however, are more likely to attempt suicide than are males. White males and females accounted for 90% of all suicides.

There are also significant differences in between age groups in rates of suicide.  First, there have been alarming trends in youth suicide, with the rates of suicide doubling in 15-19 year olds from 1970-1990, and stabilizing at a rate of 11 suicides per 100,0003.  Elderly men are of particular risk for suicide4.  In 1990 the suicide rate for men aged 75-84 was 24.9 per 100,000; in 1998 the rate had risen to 42 per 100,000.

In addition to these key differences found between age and gender, there are significant variations between ethnic groups within the United States5, suggesting that social and cultural factors play a significant role in rates of suicide6.  For example, from 1979-1992 suicide rates for American Indians and Alaska Natives were about 1.5 times the national rates, approximately 11-14 per 100,000.  Suicide among males aged 15-24 accounted for 64% of all suicides by American Indians.  Although the suicide rates in African American populations has been historically lower than of European-American populations (6.14-6.53 per 100,000), recent data indicate that among young African-American males (age 10-19) there has been a 114% increase in the suicide rate.  For Asian-Pacific-Islanders and Hispanics, these rates have also been historically lower than of European-Americans and American Indians with rates of 6.14-6.53 per 100,000.     

Geographically, suicide rates are higher in western states and lower in Midwestern and eastern states, with the highest rates being found in Alaska with 21 per 100,000 7.  Finally, 57% of all suicides were committed with a firearm.  This particular statistic has been given special attention in regards to suicide prevention, particularly in youth populations in the United States where guns are the most common means for suicide.

  Data on suicide attempts are unavailable, but it is estimated that that there are 10-25 non-fatal suicide attempts for every suicide completion, and these numbers rise to 100-200 for adolescents8. The AAS estimated that there are then 765,000 annual attempts in the United States with a ratio of 100-200:1 for the young and 4:1 for elderly9.  An estimated 5 million Americans have attempted to kill themselves with 3 female attempts for each male attempt.  

When reviewing this data there are significant factors to take into account in the reporting of rates of suicide.  “Medical examiners sometimes erroneously rule a suicidal death as a homicide or accident for a number of reasons including pressures from surviving relatives who want to avoid the social stigma associated with suicide; conscious on unconscious attempts by others to obscure information necessary to make determination of suicide; and the examiners’ own biases.”10   From this, we may assume that the statistics available are actually underestimating the true number of suicidal deaths. 

The emotional cost of suicide for families is severe and inestimable.  However, an economic framework can be helpful for the reader in understanding the costs to society in comparison with other public health issues.  Four factors are included in this analysis11.  First, there are medical expenses of emergency intervention and non-emergency treatment for suicidality.  Second, there is the lost and/or reduced productivity of people, suffering from suicidality. Third, there is the lost productivity of families and friends who are grieving for the completed suicide.  Fourth, there are lost wages of those completing suicide, with the greatest number of suicides occurring before retirement.  The IOM report estimated that in 1998 the value of lost productivity was calculated to be $11.8 billion (in 1998 dollars)12 

 

 

 

 

Definition of Suicide and Suicidal Behaviors

 

When addressing the complex issue of suicide prevention, researchers are faced with the daunting task of the definition of suicide itself.  It has been recognized that the greatest difficulties that face suicide researchers is the diversity and inconsistency of terms and nomenclature in the suicide literature13 14 15.  This issue has created difficulties in assessment, treatment, and prevention of suicide and is compounded by the lack of elementary terms that are universally valid, interfering with reliable measurements16 

            Recognizing this issue, as well as the complexities of suicide as a behavior, it is essential to begin with a simple, operational definition.  “By suicide we understand that: first, there was a death; second, that the death was achieved by the individual who died; third, the death was intentional; fourth, there was an active or passive agent (e.g. it was commission or omission of an act that resulted in death)17.  In 2002, the Institute of Medicine, further recognizing the difficulties in terminology, provided the following definitions for the reading of their report on suicide. Although not meant as recommendations to the field of suicidolgy, they are appropriate to provide a framework for the discussion of suicide prevention 18 

            Suicide: Fatal self-inflicted destructive act with explicit or inferred intent to die.  Multiaxial description includes: Method, Location, Intent, Diagnosis, and Demographics

            Suicide Attempt: A non-fatal, self-inflicted destructive act with explicit or inferred intent to die.  (Note: important aspects include the frequency and recency of attempt(s), and the person’s perception of the likelihood of death from the method used, or intended for use, medical lethality, and/or damage resulting from method used, diagnoses, and demographics.)

            Suicidal Ideation: Thoughts of harming or killing oneself (Frequency, intensity, and duration of these thoughts are all posited as important to determining the severity of ideation)

            Suicidal communications: Direct or indirect expressions of suicidal ideation or of intent to harm or kill self, expressed verbally or through writing, artwork, or other means.  The more concrete and explicit the plan is and the more lethal the intended method, the greater the seriousness of suicidal communications.  Suicidal threats are a special case of suicidal communications, used with the intent to change behavior of other people.

High Risk Groups: Those that are known to have a higher than average suicide rate.

            Suicidality: All suicide related behaviors and thoughts including completing or attempting suicide, suicidal ideation, or communications.

           

 

 

 

Etiology; Risk and Protective Factors

 

The etiology of suicide is complex. “Suicide is a consequence of complex interactions among biological, psychological, cultural, and sociological factors.  Mental disorders and substance abuse, childhood and adult trauma, social isolation, economic hardship, relationship loss, and individual psychological traits such as hopelessness and impulsiveness all increase the risk.  The presence of multiple risk factors further increases the risk”.19 Within the United States, over 90% of all suicides are associated with the presence of at least one DSM-IV psychiatric illness20.  Major depression, in particular, is highly associated with suicide21.

Additionally, substance abuse plays a major role in suicide, as 50% of all people who commit suicide are intoxicated23. The presence of both a depressive disorder and a substance abuse disorder increases the risk of suicide by 70-80%24.   

  Although understood to be the result of these complex interactions, risk factors have been identified that allow clinicians and researchers to identify certain groups that are at higher risk of suicide.  Risk factors may be defined as factors that are associated with a greater suicide potential and greater potential for the likelihood of suicidal behavior25.  An understanding of risk factors illuminates the fact that suicide is not a random occurrence, but that there are a host of factors that either singly or in conjunction with one another, place an individual at risk for suicide.  In regards to prevention, an understanding of risk factors can also be utilized for prevention programs in that some of these risk factors can be changed.  For example, providing appropriate and effective psychiatric treatment for individuals with psychiatric disorders such as major depression can minimize the risks of suicide26.      

            Within The Surgeon General’s Call to Action to Prevent Suicide27, 15 risk factors are listed.

 

Risk Factors

§         Previous Suicide Attempt

§         Mental disorders-particularly mood disorders such as depression and bipolar disorder

§         Co-occurring mental and alcohol and substance abuse disorders

§         Family History of Suicide

§         Hopelessness

§         Impulsive and/or aggressive tendencies

§         Barriers to accessing mental health treatment

§         Relational, social, work, or financial loss

§         Physical Illness

§         Easy access to lethal methods

§         Unwillingness to seek help because of stigma attached to mental and substance abuse disorders

§         Influence of significant people, such as family

§         Cultural and religious beliefs

§         Local epidemics of suicide that have a contagious influence

§         Isolation, a feeling of being cut off from other people

Protective factors are those that decrease the risk of suicide in an individual.  Programs that augment protective factors or increase resilience are essential for the prevention of suicide28.

Protective Factors Include:

§         Effective and appropriate 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 methods of suicide

§         Family and Community support

§         Support from ongoing medical and mental health care relationships

§         Learned skills in problem solving, conflict resolution, and nonviolent handling of disputes

§         Cultural and religious beliefs that discourage suicide and support self-preservation instincts

Within the Surgeon General’s 1999 report, the understanding of risk and protective factors are utilized as the paradigm for the prevention recommendations within the National Strategy for Suicide Prevention.  

 

 

 

 

Approaches to Suicide Prevention

 

            Within the past 20 years suicide prevention programs have been of value for

providing data on risk and protective factors, empirical methods for suicide prevention, as well as enhanced research methods29.  A review of two prevention models will illustrate approaches that are utilized and frame a discussion of the public health approach, a model adopted by the Surgeon General.

            The Operational Model30 focuses on intervention rather than causality or etiology.  Three categories of intervention are applied to suicidal behavior: universal procedures, selective procedures, and indicated procedures. In terms of resources, the cost of these interventions increases as the focus of the interventions moves from the general population to specific groups.

Universal interventions are aimed at an entire population such as the nation, county, or school, rather than specific groups within that population.  Universal strategies are created to facilitate mental health care, improve knowledge for interactions with suicidal individuals in order to provide help, and bolster and reinforce protective factors of social support and coping skills31.  These interventions include public education programs, “suicide awareness” programs in schools, restriction to lethal means of suicide, education of media on reporting of suicides, and crisis response teams and procedures within schools32.

            Selective interventions are designed to target sub-groups of the greater population who demonstrate greater risks of suicidal behaviors.  These interventions aim to prevent the onset of suicidal behavior by utilizing screening methods, providing training for caregivers and peers, group treatment that provides skill training and support, as well as making accessible crisis services.

            Indicated prevention strategies target specific high risk groups, defined as those displaying signs of suicidal potential.  These interventions attempt to bolster protective factors and reduce the impact of risk factors.  Within this level of intervention is included case management of high risk youth, support and skills training groups in schools, and appropriate referral sources for treatment and crisis intervention. 

            The Antecedent Conditions Model is reflective of a shift in thinking about suicide prevention.  This model assumes that there is not one specific etiological factor that is identifiable33. The mechanisms and the processes that generate the behaviors are the focus, rather than on the individual34.  The implication here is that the behaviors may be appropriate adaptations to dysfunctional, unhealthy environments.  This model states that there are two sets of conditions that are precursors to suicidal behavior, predisposing and precipitating conditions.  These conditions generate increased risk for the individual, creating a vulnerability to suicidal behavior. Predisposing conditions are somewhat removed from proximity to the individual, but are necessary to create increased risk for the individual.  Precipitating conditions are proximate to the individual and are correlated with the temporal expression of the suicidal behavior and the interaction of these two conditions will lead to the expression of suicidal behavior.  Two focuses of intervention are implied by this model.  The first is on the macro level that reduces the predisposing conditions for an entire population, and the second is a focus on identified individuals who have experienced these predisposing characteristics. 

            The Injury Control Model, first proposed by William Haddon, Jr. within the context of public health, frames suicide as an injury that was not prevented.  It provides identification of methods of suicide and proposes various testable methods that have the ability to break the causal chain in suicidal behavior.  For example, restricted access to firearms follows from an injury prevention model, as the availability of guns in the household generate the greatest risks for youth suicide.  This model assumes that suicide, however, is the result of an unintentional injury, but the prevalent viewpoint within suicide research is that suicide is an intentional act35.  There also has been little research on environmental restrictions impacting non-fatal suicide attempts.  Further, this approach does not address biological, sociological, psychological, or other factors that are recognized at contributing to suicidal behavior.  However, environmental controls such as manufacturing non-lethal oven gas have been demonstrated to break the causation chain of suicidal behaviors in many countries36.

            The Public Health Approach to suicide prevention follows from a public health model of disease prevention that emphasizes health promotion which combines health education and environmental support with an emphasis on the community’s influence on health.  This integrative approach includes not only targeting high risk populations but also involves a population approach that takes into account environmental and social factors that impact rates of suicide37. Within this approach there is a shift in focus away from the health and history of the individual within a clinical setting and an emphasis on larger patterns of suicide within a group or population38                         

            This approach contains four interactive elements40.  The first component is surveillance which identifies epidemics, patterns, and differential rates of suicide within a community.  The second component is epidemiologic studies for identification of causal chains that lead to suicidal behavior.  The third is design and evaluation of interventions to disrupt the causal chain of suicide.  The fourth is program implementation which consists of initiating interventions that have proven results.  A significant aspect of this approach is the transfer of prevention skills and knowledge to community public health practitioners.

            What has given this approach particular priority in recent years is the advocacy of public health officials4142, its systematic approach, and the success of public health models in disease prevention such as cardiovascular disease43.  Additionally, calls for integrative approaches to the problem of suicide and recognition that evaluation must be on-going and incorporated with epidemiological studies fit within the public health framework44.  Frequently preventive programs in the past have not adhered to this model, in that they were not evaluated.  Further, there has been an inadequacy in quantitative data in order to make decisions or implement changes in programming45.  These issues are related directly to the inherent problems of suicide research and include difficulties in terminology, low base rate of suicide, inadequacies in surveillance, ethical issues related to research with suicidal patients, and issues of research design and analysis46. 

Although this may be interpreted as severe barriers to initiating the public health approach, particularly in epidemiological studies and program evaluation, an understanding of the interactive nature of this process provides a more optimistic outlook.

“Surveillance often provides epidemiologic information; epidemiologic hypotheses are often generated and tested during evaluations and interventions; and programs frequently provide a source of data for surveillance”48.  The impact of suicide as a public health issue has further lessened the challenges of this daunting task, and when viewed from the standpoint of a crisis within our society, the public health approach, due to its integrative and systematic approach provides an adequate framework to approach this health problem.

 

A Public Health Approach to Suicide Prevention

 

            The following discussion of the public health approach to suicide prevention is taken from The Surgeon General’s Call to Action to Prevent Suicide49.

The first step in the public health approach is Defining the Problem through surveillance.  Surveillance is defined at the ongoing, systematic collection, analysis, and interpretation of health data with timely dissemination of findings.  Information is to be gathered on individuals’ characteristics, the circumstances of suicide, precipitating events, health services received and sufficiency of support, and costs and severity of injuries.  This step details the what, when, where, how, and how many of the problem50.  The inconsistencies in suicide reporting can create inaccuracies in measurements of prevalence and confounds analysis of protective and risk factors51.  Therefore, it is an essential component of the public health approach to suicide prevention to gather accurate data on the prevalence and incidence rates of suicide in order to set realistic priorities, design prevention measures that are effective, and evaluate the effectiveness of such programs52. 

Suicidal behavior is measured on a continuum of severity from suicidal ideations to completed suicidal acts.  Although suicide attempts resulting in minor or no injuries are difficult to monitor, data on deaths from suicide are collected.   It has been suggested that surveillance of mortality and morbidity should be done separately, due to the differences in reporting of suicide attempts and completions53. 

In the United States, the United States Vital Statistics system which is operated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention collects all mortality data on suicide54.  Although this data provides no information on etiology of suicidal behaviors, the monitoring of this data can indicate trends of suicide within populations that warrant attention55.

            In terms of morbidity, the data collection is less formal.  Within the US, agencies that compile data on suicide morbidity are the National Hospital Ambulatory Medical Care Survey (NHAMCS), the National Electronic Injury Surveillance System (NEISS), the National Hospital Discharge Survey (NHDS), the Youth Risk Behavior Surveillance System (YRBSS), and the Injury Control and Risk Factor Identification Survey (ICARIS)57.  

            The second step is Identifying Causes and Protective Factors.  Risk factors are addressed such as presence of psychiatric disorders.  Frequently this step is utilized to identify groups of people considered high risks for suicide.  As stated previously, the casual chain in suicidal behavior is complex and not entirely understood.  Particularly, the interactions between risk and protective factors have not been illuminated, creating difficulties in creating preventive measures. 

Conwell et al 58, in their discussion of the methodological difficulties in assessing risk factors for the elderly state, “Until very recently, very few studies suicidal behavior at any point in the life course met the methodological requirements for evaluating the risks associated with particular characteristics; almost none that focused on later life.  Because investigators rarely included control groups with which to establish base rates in the population, risk factors for suicide could not be identified and the relative risk associated with them could not be quantified.”   However, it must be reiterated that identification of risk factors alone is not the key issue in suicide prevention59. 

A recent review of empirically identified risk factors for youth suicide concluded that suicide prediction was not feasible60.  However, a risk management approach has been suggested to reduce the presence of risk factors.  This approach includes appropriate treatment of psychiatric disorders, addressing familial psychopathology, effecting environmental changes to reduce access to lethal means of suicide, provision of social support to manage environmental stressors, provision of counseling to suicide survivors, and a decrease of media exposure to suicidal behavior61.    

            The third step is Developing and Testing Interventions.  This step includes the development of strategies to address identified risk factors.  A significant aspect of this step is that the strategies implemented are feasible, safe, and ethical.  Included also within this step is pilot testing of programs that may reveal what particular age, gender, or ethnic group may best benefit from an intervention.  The traditional method for establishment of causation, random assignment to exposures, is not ethical or feasible for suicide studies62.  Case control studies have been especially useful for study of suicide, especially in events of suicidal ideations and behaviors within population-based cross-sectional survey designs62.  As mentioned previously, variances in terminology have impacted the reliability and validity of studies.  Finally, ethical considerations within the testing of interventions cannot be emphasized enough given the sensitive nature of the subject matter and the population under study.

            The fourth step is Implementing Interventions.  Once effectiveness of interventions has been established, implementation of these prevention programs must follow.  Data collection is an essential component of this step to facilitate the ongoing evaluation of a particular prevention.  An intervention found to be effective within a clinical trial could potentially have significantly different outcomes when applied to a community setting.  Continual monitoring of the intervention is essential to determine effectiveness.  An evidence base is created through this evaluation process and is used to enhance successful programs.  Finally, cost-effectiveness is also measured to ensure that resources are utilized effectively.

            Prevention programs have traditionally been focused on individual interventions63.  However, involvement of the community and networking among community agencies is viewed as vital for implementation of suicide prevention programs64 65, which includes organization of resources prior to any episodes of suicide clusters.  “This requires community leaders to build effective coalitions across traditionally separate sectors, such as the health care delivery system, the mental health system, faith communities, schools, social services, civic groups, and the public health system.  Interventions must be adapted to support and reflect the experience of survivors and specific community values, cultures, and standards.  They must also be designed to benefit from multi-ethnic and culturally diverse participation from all segments of the community.”66

            The fifth and final step, and perhaps the most important, is Program Evaluation.

The absence of precise evaluation is currently viewed as the most considerable obstacle to the identification and implementation of suicide prevention programming67.  Program evaluation includes identifying benefits and deficiencies in the interventions, including which aspects of the program need modification.  Evaluation also provides unanticipated information that may be of benefit to program improvement.  It also communicates facets of the program to key stakeholders, who must be part of the ongoing evaluation process.  Dissemination of findings in scientific journals is also a key issue, as the sharing on information on which prevention measures work is essential to modification of existing strategies68.

            Evaluation components include setting achievable goals and objectives and must be integrated into the program from its onset.  The objectives must be specific, measurable, attainable, relevant, and time based.  Evidence based interventions must be evaluated to be found safe, ethical, feasible, and effective69. 

           

A National Strategy for Suicide Prevention

 

Recognizing the public health approach to suicide prevention, and following from guidelines of the World Health Organization, the United States has created a partnership between public and private agencies to address this issue.  The formulation of this partnership included the US Department of Health and Human services, the Centers for Disease Control and Prevention, the Health Resources and Service Administration, the Indian Health Service, the National Institute of Mental Health, the Office of the Surgeon General, and the Substance Abuse and Mental Health Services Administration, and the Suicide Prevention Advocacy Network, as well a public advocacy organization that includes suicide survivors, community activists, and health and mental health clinicians.

            The Surgeon General’s Call to Action70 has created a framework for addressing this public health concern, AIM: Awareness, Intervention, and Methodology.  Assessing that mental and substance abuse disorders generate the greatest risk for suicide, there has been a focus for better methods of detecting and treating these disorders.  In addition to these key elements, other areas of focus will be constructive public health policy, measurable objectives, implementation of monitoring and evaluation procedures for the objectives, and providing appropriate resources to agencies designated to carry out the Surgeon General’s recommendations. 

            The National Strategy For Suicide Prevention (NSSP), created from the Surgeon General’s Call to Action can be characterized as “a catalyst for social change with the power to transform attitudes, policies, and services…It strives to promote and provide direction to efforts to modify the social infrastructure in ways that will affect the most basic attitudes about suicide and its prevention, and that will also change judicial, educational, and health care systems”71.  The following are the goals of the National Strategy for Suicide Prevention:

1. Promote Awareness that suicide is a public health problem that is preventable

2. Develop Broad Based Support for Suicide Prevention

3. Develop and implement strategies to reduce the stigma associated with being a         consumer of mental health, substance abuse, and suicide prevention strategies

4. Develop and implement suicide prevention programs

5. Promote efforts to reduce access to lethal means and methods of self harm

6. Implement training for recognition of at-risk behavior and delivery of effective treatment

7. Develop and promote effective clinical and professional practices

8. Improve access to community linkages with mental health and substance abuse disorders

9. Improve reporting and portrayals of suicidal behavior, mental illness, and substance abuse services

10. Promote and support research on suicide and suicide prevention

11. Improve and expand surveillance system

            Finland was the first nation to implement the National Strategy for Suicide Prevention, beginning in 1986.  A 20 percent reduction in suicide rates between 1991-1996 were credited to the implementation of the plan, and the United Nations and World Health Organization has used Finland’s program as a model for suicide prevention72.  In 1999 the suicide rate was recorded as 9% below the nation’s rates prior to program implementation.  The Suicide Prevention Project in Finland not only sought to reduce suicide, but also to promote mental health within the country.  Strategies included improving collaboration between health agencies as well as enhancement of protective factors such as improvement of living conditions and enrichment of individuals’ personal resources.  Following from the public health model of improved coordination and communication between community agencies, the Finnish program built a national network of professional contact persons that included health professionals, social service personnel, clergy, police, and rescue departments. Mental health research was also a strong component of the program.  A more concerted national depression treatment program was also initiated, targeted to all age groups, that included not only basic services but also specialized care. Additionally, the ways in which media depicted suicide were also affected through education programs focusing on mental illness and suicide. For a more detailed examination of Finland’s program, see Beskow et al 199973.

The United States Air Force, in response to suicide being the second leading cause of death among its members, implemented a comprehensive suicide prevention program modeled on a public health approach to suicide prevention from 1996-199774.  This approach, called LINK, not only focused on individual psychiatric issues, but also emphasized the community and social elements of suicide, and sought to affect suicide risk factors, but also promote positive mental health.  This strategy follows from the United Nations and World Health organization recommendations75.  Key components of the Air Force’s program included promotion of early mental health interventions, coordination of services among various agencies in the organization, decreasing stigma associated with help-seeking, and the promotion of protective factors such as social support and teaching effective coping skills.  Staff were trained in suicide awareness, policy changes were made following from epidemiological data collection, and a database was created that effectively monitored suicide attempts and completions among personnel and their families. 

            There was also a strong move to change the culture of the Air Force, which placed the responsibility of the well-being of staff on all members of the organization, and not on the individual or select social services.  Additionally policy changes were made that encourage help-seeking behavior; new confidentiality policies were established which protected individuals within the confines of doctor patient relationships.  Collaborative efforts within the organization’s existing services were also viewed as a significant element within the program.  Six agencies within the Air Force were seen as critical for the prevention of suicide and the promotion of mental health, given that risk factors have no clear demarcation and there is overlap within the areas of risk.  These agencies included the chaplains, family advocacy, family support, health promotion and health wellness centers, child and youth programs, and mental health services.  This coordination is managed under the Integrated Delivery System and delivers services among broad aspects of military life such as work sites, community sites, and schools.

The results of this program implementation, utilizing an integrated, public health approach were successful.  Between 1994-1998, suicide rates decreased from 16.4 per 100,000 to 9.4 per 100,000 (p<0.002).  Within the first 8 months of 1999, the estimated rate of suicide is 2.2 per 100,000. This rate is approximately 80% lower than the lowest annual rate since 198076.   The significance of the Air Force’s prevention program is that it incorporated the entire community, and did not just focus on the health services system to detect and treat those at risk of suicide.  This community focus bolstered pre-existing protective factors and attempted to change the culture of the community to be more responsive, as well as diminish the impact of risk factors for suicide77. Following from the public health model, the Air Force continues to assess its data for program modification, and has also created an epidemiological data base and surveillance system.  This system collects social, psychological, economic, behavioral, and relationship factors surrounding suicide attempts and completions among non-active and active duty members78.

            In reviewing the Air Force’s program, it must be taken into account that these changes occurred within a controlled environment, where individuals have access to basic services, have housing provided for them, there is a higher level of education among the personnel, there is less use of illegal drugs, there is less prevalence of mental illness, and there are personnel who take personal responsibility for the well-being of the members of the Air Force. Additionally, a casual relationship between program implementation and decreased suicide rates was not conclusively established. Finally, key components of the program have not been identified that may have contributed to the decline in suicide rates79.  Given this, however, “This study highlights that suicide is a preventable health problem and demonstrates the importance of using multiple agencies to address the issue.  It also indicates that a community-wide, multiple strategy program can be planned an implemented and can contribute to reducing self-directed violence.”80

 

Conclusions

            Suicide, now defined as a public health issue by the United States, must be approached as such.  An approach that relies on clinicians to manage and reduce risk in suicidal patients has limited applications, as the prediction of suicidal behavior, has been characterized as “dismal” by some researchers81.  Additionally, Knox et al82 state, “[Clinicians] have promoted, however unwittingly, the social isolation of the community problems of suicidal behaviors….exploring the nature of protective factors requires engaging the public health community, and opportunity not yet exploited.” 

            The program of the US Air Force and Finland’s National Strategy for Suicide Prevention offers promising approaches to suicide prevention utilizing a public health approach.  Regardless of some of the methodological issues inherent in these programs, the broad coalition of resources that were coordinated for both programs appeared to have had an impact.  As suicide is a multifaceted event, a multifaceted approach is warranted that incorporates not only professional services, but also a change in the attitudes and awareness within a community or organization.  “Suicide and suicidal behaviors can be reduced as the general public gains more understanding about the extent to which suicide is a problem, about the ways in which it can be prevented, and about the roles individuals and groups can play in prevention efforts.”83

            Within areas of research, the stages of the public health approach to suicide must be refined.  Especially important is the issue of surveillance, particularly for suicide attempts.  As previous history of suicide attempts is a risk factor for future attempts, a data base to monitor community rates of suicide attempts is essential.  The relationship between risk factors and protective factors is largely unknown.  Adding variables of ethnicity, age, and gender further complicate the areas of risk and protective factors.  Research is needed that addresses these issues.  Interdisciplinary research is essential in areas of risk and protective factors.  The social, cognitive, cultural, and biological must all be addressed within the areas of research.  Programs that are initiated must be done so with built-in mechanisms for measuring outcomes.  Without the ability to monitor program effectiveness, modifications can not be made in prevention strategies.  Also at issue in evaluation and monitoring of prevention strategies are costs.  Are the programs utilizing resources effectively?       

            Although the challenges are enormous, considering the magnitude of suicide within the nation and the world, the methodological challenges to research and appropriate preventive measures, as well as the difficulties in coordination of resources, suicide is a public health issues that must be addressed.  It is a preventable occurrence, and innovative programming has demonstrated that when done appropriately, it can make an impact on rates of suicide.  Perhaps the most encouraging sign that this problem can be addressed, given the challenges, is that suicide is becoming a health problem that is increasingly in the government’s and public’s awareness.  An awareness and understanding of the significance of the problem is the first step in creating strategies to reduce rates of suicide. 

 

 

References

 

 

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