Responding to Tough Questions for Suicide Prevention
We are excited to announce the release of the American Foundation for Suicide Prevention Call to Action to Implement the National Strategy to Prevent Suicide in collaboration with the U.S. Department of Health and Human Services and the Office of the Surgeon General. The Action Alliance + it's partners helped to develop The Surgeon General's Call to Action to Implement the National Strategy for Suicide Prevention (Call to Action), identifying six key actions that must be prioritized and implemented now in order to reverse the upward trend of suicide deaths in the U.S. AFSP, the leading non profit for suicide prevention, will continue to play a major role in the implementation of strategies, programs and activities that address the six action areas.
Read the Call to Action Report here.
The Call to Action identifies six key actions that must be prioritized and implemented now in order to reverse the upward trend of suicide deaths in the U.S. These actions, and corresponding strategies, include:
Action 1. Activate a Broad-Based Public Health Response to Suicide
- 1.1 Broaden perceptions of suicide, who is affected, and the many factors that can affect suicide risk.
- 1.2 Empower every individual and organization to play a role in suicide prevention.
- 1.3 Engage people with lived experience in all aspects of suicide prevention.
- 1.4 Use effective communications to engage diverse sectors in suicide prevention.
Action 2. Address Upstream Factors that Impact Suicide
- 2.1 Promote and enhance social connectedness and opportunities to contribute.
- 2.2 Strengthen economic supports.
- 2.3 Engage and support high-risk and underserved groups.
- 2.4 Dedicate resources to the development, implementation, and evaluation of interventions aimed at preventing suicidal behaviors.
Action 3. Ensure Lethal Means Safety
- 3.1 Empower communities to implement proven approaches.
- 3.2 Increase the use of lethal means safety counseling.
- 3.3 Dedicate resources to the development, implementation, and evaluation of interventions aimed at addressing the role of lethal means safety in suicide and suicide prevention.
Action 4. Support Adoption of Evidence-Based Care for Suicide Risk
- 4.1 Increase clinical training in evidence-based care for suicide risk.
- 4.2 Improve suicide risk identification in health care settings.
- 4.3 Conduct safety planning with all patients who screen positive for suicide risk.
- 4.4 Increase the use of suicide safe care pathways in health care systems for individuals at risk.
- 4.5 Increase the use of caring contacts in diverse settings.
Action 5. Enhance Crisis Care and Care Transitions
- 5.1 Increase development and use of statewide or regional crisis service hubs.
- 5.2 Increase the use of mobile crisis teams.
- 5.3 Increase the use of crisis receiving and stabilization facilities.
- 5.4 Ensure safe care transitions for patients at risk.
- 5.5 Ensure adequate crisis infrastructure to support implementation of the national 988 number.
Action 6. Improve the Quality, Timeliness, and Use of Suicide-Related Data
- 6.1 Increase access to near real-time data related to suicide.
- 6.2 Improve the quality of data on causes of death.
- 6.3 Expand the accessibility and use of existing federal data systems that include data on suicide attempts and ideation.
- 6.4 Improve coordination and sharing of suicide-related data across federal, state, and local levels.
- 6.5 Use multiple data sources to identify groups at risk and to inform action.
Action 1. Activate a Broad-Based Public Health Response to Suicide Inspire and empower everyone to play a role in suicide prevention.
The National Strategy calls for the implementation of a broad-based public health response to suicide that engages all societal sectors—including government, health care systems and providers, businesses, educational institutions, community based organizations, family members, and friends— in suicide prevention.
Suicide prevention should be infused into schools, workplaces, faith-based organizations, corrections, senior living communities, and other diverse settings and systems. Integrating suicide prevention into the work of all sectors will help create a network of community-wide supports to reduce risk, enhance protection, and support the implementation of culturally appropriate prevention efforts that are tailored to each group’s unique needs and strengths.
Communication efforts can help activate a broad based response to suicide by changing knowledge, attitudes, and behaviors related to mental illness and suicide. As a society, we need to be comfortable talking about suicide openly and without judgment. Research suggests that we have made tremendous headway in reducing the silence around mental illness and suicide that prevents so many from seeking help. In a recent nationally representative survey, the vast majority of Americans (93 percent) believed that suicide was preventable, at least sometimes, and three in four were comfortable being there for a loved one who might be struggling or having thoughts of suicide.
We must build on this progress and continue to change the conversation around suicide to engage all Americans in suicide prevention. I was an inaugural appointee of the Workplace Task Force when the Action Alliance was started in 2010. At that time, we suspected that the culture, jobs, and lifestyles of our workers in the construction industry might place them at an increased risk for suicide. One particular concern was substance misuse, including the use of prescribed opioid pain relievers to cope with chronic pain from years of hard work. At that time, we didn’t know the extent of the problem because national data on suicide among different occupations was not readily available. When CDC analyzed occupational data from 17 states in NVDRS several years later, they found that the construction and extraction industries had the highest suicide rates and the highest number of suicides among all industries.
This finding persists in the most recent occupational data collected among 32 states in 2016. In response, our industry mobilized to actively embed suicide prevention into its safety culture. Our Construction Industry Alliance for Suicide Prevention provides access to information, resources, and training on how to make mental health and suicide prevention part of a company’s culture. Construction culture has shifted from getting workers home safely at the end of the shift to getting our people back to work safely from home.
Cal Beyer, MPA Vice President Workforce Risk & Mental Wellbeing CSDZ, A Holmes Murphy Company Action Alliance Executive Committee Member Action 1. Activate a Broad-Based Public Health Response to Suicide Inspire and empower everyone to play a role in suicide prevention. The Surgeon General’s Call to Action TO IMPLEMENT THE NATIONAL STRATEGY FOR SUICIDE PREVENTION PAGE 22
We also need to do better at translating what diverse systems, sectors, professionals, and individuals can do to reduce risk and build strengths. Every individual and organization must understand how they can support those who may be at risk for suicide and help everyone achieve a healthier and more connected, productive, and satisfying life. People with lived experience have an important role to play in guiding and informing the implementation of a broad-based, inclusive, and effective response to suicide.55 These individuals, who include program planners, health care providers, business leaders, teachers, and family members, have long contributed to improving supports for persons at risk for suicide by taking a lead role in the delivery of effective and compassionate care to prevent suicide. Their involvement has been key to emphasizing safety, dignity, and respect for individuals who may be experiencing a suicidal crisis. Stories and insights from those with lived experience can illustrate how we all can play a part in supporting others during a time of crisis.
Finally, we need to track our outreach efforts against established metrics and industry standard benchmarks to measure outcomes and inform continuous process improvement as messages are developed and tested, including segmented messaging to key subpopulations and the populations and communities at high suicide risk
1.1 Broaden perceptions of suicide, who is affected, and the many factors that can affect suicide risk.
Although mental health conditions are often seen as the causes of suicide, suicide is rarely caused by any single factor. Many influences at the individual, relationship, community, and societal levels can increase suicide risk or precipitate a crisis, including social isolation, relationship problems, the loss of a loved one, and legal or financial issues.
Other factors, such as a sense of purpose, social connectedness and support, opportunities to contribute, and access to effective care, can play protective roles. The National Strategy identifies several groups as being at a higher risk for suicidal behaviors than the general population:
Certain demographic groups, for example:
○ Working-age men
○ Military service members and Veterans
○ American Indians and Alaska Natives
○ Sexual and gender minority populations
○ Older adults
○ Individuals in child welfare and justice settings
Individuals experiencing risk factors linked with suicide, for example:
○ A history of suicidal behaviors
○ A loss of someone to suicide
○ Mental illness, substance misuse, and/or certain medical conditions
Suicidal behaviors—as well as risk and protective factors for suicide—can vary among subgroups and change over time. For example, although suicide rates have been historically lower among Black people than among white people, recent studies have identified an alarming increase in suicidal behaviors and deaths among Black children and adolescents. In some cases, the prevalence of suicidal behaviors and risk factors among some groups may not be known because data collection tools and systems do not yet collect this information or make it easily accessible. Access to timely and accurate data on deaths by suicide, suicide attempts, and related circumstances is critical in order to ensure that prevention efforts are reaching those most at risk. (For more on needed improvements to the quality and timeliness of suicide-related data, see Action 6.)
1.2 Empower every individual and organization to play a role in suicide prevention.
Every individual and organization in the community has a role to play in promoting health and well-being, reducing risk factors, and increasing protective factors for suicide.
For this to happen, we all must understand how we can help prevent suicide by supporting the implementation of effective suicide prevention strategies. For example:
• Help other people build life skills (e.g., coping, problem solving) and resilience
• Increase social connectedness and support
• Identify and support people at risk
• Support lethal means safety
• Support access to effective care
• Seek help, support, and care when experiencing suicidal thoughts
• Support individuals who have been affected by a suicide attempt or death
All community members should be equipped to build protective factors and to recognize the warning signs of suicide and respond appropriately to individuals in crisis by connecting them to sources of help. Two good resources are the National Suicide Prevention Lifeline (1-800-273-8255) and the new 988 number that will become operational by July 16, 2022 and will connect callers to the Lifeline. (For more on crisis care and related resources, see Action 5.)
1.3 Engage people with lived experience in all aspects of suicide prevention.
People with lived experience can play an important role in increasing understanding of how to respond effectively to suicide risk, identifying and driving needed improvements in policies and systems, and enhancing interventions for providing short- and long-term support to individuals who have experienced thoughts of suicide, made a suicide plan or attempt, or lost a loved one to suicide.
Guidance from people with lived experience can be particularly useful in implementing evidence-based prevention strategies in real-life settings. Engaging people with lived experience in the planning, design, implementation, and evaluation of suicide prevention efforts can also help reach diverse groups and meet their unique needs, thereby improving the quality and impact of suicide prevention efforts.
Sharing stories of lived experience can be a powerful way to increase understanding of what it is like to experience suicidal thoughts and behaviors. These stories may help reduce stigma by providing a personal connection to another human being’s journey and promoting respect and compassion for those who may be experiencing suicidal thoughts or behaviors. In collaborating with people with lived experience to share their stories with others, it is important to ensure that the information is conveyed in a way that supports the safety of the audience and the well-being of the narrator.
1.4 Use effective communications to engage diverse sectors in suicide prevention.
Communication efforts can help activate a broad-based response to suicide by changing knowledge, attitudes, and behaviors to support prevention. For example, these efforts can increase help-seeking by publicizing available care and supports for those at suicide risk; teach families, friends, co-workers, and others how best to support people in their lives who are struggling; and strengthen suicide prevention efforts by educating decision-makers about effective policy and systems change for prevention.
Goal 2 of the National Strategy calls for the implementation of communication efforts that are researchbased and reflect safe messaging recommendations specific to suicide.8 Decades of research indicate that public communications efforts are most effective when they have defined goals, are designed to reach specific populations, and feature a specific “call to action.”63 Communications should be tied to an overall prevention strategy and connect to other programmatic efforts, such as education programs, available supports and services, and other resources that can help the audience take action. Credible and culturally appropriate messages should be developed and conveyed through the channels (e.g., billboards, social media, events) most likely to reach and be trusted by the intended audience. Communication planners should engage their intended audiences to co-design suicide prevention efforts from the beginning, thereby informing choice of language, channels, and platforms—and helping to ensure that the call to action is accessible and realistic for them.
All individuals and organizations communicating about suicide—including suicide prevention leaders, advocates, and programs—must also ensure that their messages reflect existing recommendations regarding safety. The Action Alliance’s Framework for Successful Messaging is an online resource for developing safe and effective messages about suicide.64 How news stories and entertainment depictions of suicide are framed can support prevention or lead to harmful outcomes, such as imitation of suicidal behaviors. The Recommendations for Reporting on Suicide65 and National Recommendations for Depicting Suicide66 (in entertainment) provide guidance on how to depict and cover suicide safely and in ways that will be helpful to someone who may be struggling. (More information on these resources is available in Appendix 2.)
Action 1: Priorities for Action
• State government and public health entities should implement the Suicide Prevention Resource Center’s Recommendations for State Suicide Prevention Infrastructure to support comprehensive (i.e., multicomponent) suicide prevention in communities.
• Prevention leaders from the public and private sectors, at all levels (national, state, tribal, and local), should align and evaluate their efforts consistent with the Centers for Disease Control and Prevention (CDC) resource Preventing Suicide: A Technical Package of Policy, Programs, and Practices, to expand the adoption of suicide prevention strategies that are based on the best available evidence.
• Federal agencies and state, tribal, local, and county governments and coalitions should strengthen their prevention efforts by developing strategic suicide prevention plans based on available public health data. Mechanisms for the prompt sharing of innovations and best practices should be developed and supported.
State and local suicide prevention coalitions and health systems should actively reach out to organizations serving populations at high risk for suicide; these systems should also reach out to individuals with lived experience in order to learn from them and engage them in designing prevention efforts.
• The public and private sectors should invest in patient-centered research and include people with lived experience in research design and implementation.
• Federal agencies, mental health and suicide prevention non-governmental organizations, and others conducting communication efforts should ensure that suicide prevention communications campaigns (1) are strategic, (2) include clear aims for behavior changes that support broader suicide prevention efforts, and (3) measure their impact.
• The federal government (Congress) should expand and sustain support for states, territories, communities, and tribes to implement comprehensive suicide prevention initiatives similar to the Comprehensive Suicide Prevention Program, funded by CDC, and the Garrett Lee Smith youth suicide prevention grants, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), which have been shown to reduce suicide in participating counties, particularly in rural areas.12 Funding targeting substance use disorder should be broad enough in scope to allow for interventions that address suicide prevention and related workforce and infrastructure needs.
Action 2. Address Upstream Factors that Impact Suicide
Focus on ways to prevent everyone from suicide.
Strategic Direction 1 of the National Strategy calls attention to the need to “create supportive environments that will promote the general health of the population and reduce the risk for suicidal behaviors and related problems” (p. 29).8 Toward this end, suicide prevention efforts should include strategies aimed at reducing risk and increasing protection among all Americans. In particular, suicide prevention efforts must consider factors that influence the health of the population, including economic stability, education, social and community context, health care, and neighborhood and built environments.67 For example, to prevent suicide among Black children and adolescents, we must address key upstream factors, such as disparities in health care and exposure to racism.68
As previously noted, suicide prevention theory and research suggest that two upstream strategies may be particularly effective in protecting individuals from suicide risk: increasing social connectedness, and providing opportunities for individuals to make a meaningful contribution.32 Research also suggests that buffering the impact of economic stressors, such as unemployment and the threat of eviction, can play a protective role.32 Diverse sectors and groups can contribute to the implementation of these strategies, including organizations that may not think of their work as contributing to suicide prevention. Addressing these types of societal-level factors that can affect suicide risk provides a critical opportunity to partner with diverse sectors, communities, and groups to impact suicide and other health issues as part of a broad-based collective effort.
2.1 Promote and enhance social connectedness and opportunities to contribute.
Research has consistently identified social isolation as a strong risk factor for suicide and other negative health outcomes69–71 and has identified social connectedness to family,72 school,73 and community as a protective factor.74 In fact, connectedness has been a key component of theories about suicide since French sociologist Émile Durkheim first identified a link between suicide and low social integration in the late 1800s.49, 75 Positive, meaningful, and supportive social connections can make individuals feel valued, cared for, trusted, and respected.50 Opportunities to make a meaningful contribution to society can support the development of these positive connections and also enhance one’s sense of purpose, thereby increasing reasons for living.52
Based on a recent review of the evidence, CDC’s Preventing Suicide: A Technical Package of Policy, Programs, and Practices recommends two specific approaches to increasing connectedness that have been linked to such benefits as reduced stress and improved attitudes toward help-seeking:32
• Peer norm programs that support the development of positive connections with peers and encourage help-seeking and the development of connections to trusted helpers
• Community engagement activities that bring together members of the community, such as a walking program or a community garden All individuals and organizations in the community, including workplaces, schools, faith-based organizations, and youth, senior, and Veteran centers, can play a role in enhancing connectedness and fostering opportunities to contribute. Examples include providing peer support to others, participating in service-learning activities, or serving as a volunteer.
Efforts to increase positive social connections and opportunities to contribute should be inclusive and tailored to the needs of specific groups (e.g., ethnic, racial, and sexual and gender minorities; adolescents; older adults). Through activities such as support groups and peer-delivered services, people with lived experience can play an important role in fostering these connections and opportunities and providing hope to individuals who may be struggling. Online and social media-based approaches, by presenting both challenges and opportunities for suicide prevention, can also be safely and effectively used to enhance feelings of connectedness among young people.76
2.2 Strengthen economic supports.
Economic factors are linked to suicide risk in different ways. Research has long identified financial problems as a factor that can precipitate a suicidal crisis in a person at risk.77 Studies have also found that suicide rates increase during times of economic recession.78, 79 For example, an analysis of suicide deaths in 16 states during the U.S. housing crisis that started in 2006 found that deaths by suicide related to evictions and foreclosures doubled from 2005 to 2010.77 The study concluded that housing loss can precipitate a suicidal crisis and that prevention efforts should provide support to prevent home loss, particularly during times of economic crisis.
Experts note that the relationship between an economic crisis and suicidal behaviors can vary, depending on such factors as the unemployment rate, unemployment protection, the minimum wage, and access to welfare benefits.80–82 Emotional factors, such as the fear of losing one’s job or being evicted—either now or in the near future—may also increase psychological distress that could contribute to suicide risk.83, 84
Buffering the impact of these risk and precipitating factors by strengthening economic support systems may reduce suicide risk and also contribute to improved mental and physical health. An evidence review conducted by CDC identified two approaches that have been found to reduce suicide risk:32
• Strengthening household financial security through efforts such as unemployment benefits programs, transfer payments related to retirement and disability, medical benefits, and other forms of family assistance
• Housing stabilization policies, such as programs that protect homeowners from foreclosures and evictions.
Although local suicide prevention programs may not be able to directly address these economic factors, they can monitor trends (e.g., increases in unemployment, evictions, or homelessness) and partner with others in the community to recognize and reduce associated distress. For example, suicide prevention coordinators and coalitions could partner with organizations in the community, such as unemployment offices, to provide training to employees on suicide prevention and to educate them about crisis lines and other resources. Similarly, suicide prevention programs could partner with workplaces that may be downsizing to ensure that their workers are aware of options, benefits, and community services and supports. These programs should also consider ways to provide support to affected individuals and their families.
Employers have a significant opportunity to influence the mental health and well-being of their employees through workplace culture, policies, practices, and programs. By educating and engaging employers, we can ensure that they become part of the overall effort to prevent suicide.
2.3 Engage and support high-risk and underserved groups.
As discussed in Action 1, the prevalence of suicidal behaviors—and of risk and protective factors for suicide—varies across groups and subgroups and changes over time. Suicide prevention efforts should focus on populations disproportionately impacted by suicide in different ways. Some groups may have high or increasing rates of suicidal thoughts and behaviors. Others may experience factors that can increase the risk for suicidal behaviors, such as social isolation and unemployment, or have fewer protective factors in their lives, such as access to effective mental health care. To develop and implement suicide prevention efforts tailored to each group’s unique needs and strengths, program planners must review the data available from existing sources and conduct their own data-gathering efforts, as needed.
To be effective, efforts aimed at preventing suicide must include members of the affected group— particularly persons with lived experience—and organizations already working with this population, not only as key informants but also as leaders, experts, and partners. This will help ensure that suicide prevention efforts are grounded in a thorough understanding of the relevant risk and protective factors, consider local strengths and assets, and are tailored to address the unique factors that may contribute to suicide prevention in the most effective and sustainable ways.
2.4 Dedicate resources to the development, implementation, and evaluation of interventions aimed at preventing suicidal behaviors.
Research is key to guiding action by helping us understand what works to reduce suicide risk and strengthen protective factors in different systems and with diverse populations. Goal 12 of the National Strategy called for the implementation of new research on suicide prevention and for the dissemination and application of findings. However, funding for suicide prevention research and for the evaluation of comprehensive suicide prevention programs continues to be very limited.85 More resources should be dedicated to developing, implementing, and evaluating programs aimed at preventing suicide. The research must be conducted in collaboration with the affected communities, including individuals with lived experience.
As noted, much of the existing research has focused on identifying individuals at risk and assessing the effectiveness of clinical supports and care. Suicide prevention interventions and research must also focus on upstream risk and protective factors for suicide—such as social connectedness, coping skills, opportunities to contribute, and economic supports—and identify ways to best address them in partnership with other organizations in the community. In addition, suicide-related outcomes must be incorporated into existing programs and research in related fields (e.g., violence prevention, prevention of substance misuse, positive youth development, response to adverse childhood experiences and trauma) that focus on upstream factors relevant to suicide prevention.86, 87
Action 2: Priorities for Action
• Private companies and workplaces should leverage their health care benefits purchasing power to enhance employee mental health (e.g., invest in benefits and programs to prevent and treat behavioral health problems) and work to shape worksite values and culture to promote mental health by providing access to crisis support, support to employees following a suicide, and ongoing mental health wellness programming.
• Suicide prevention leads in federal, state, tribal, and local public health and behavioral health agencies should partner with their counterparts in labor and workforce, housing, health care, and other public assistance agencies to collaborate on strengthening economic supports for families and communities.
• Foundations and other philanthropic organizations that support early intervention programs— particularly those targeting (1) social determinants of health (e.g., reducing poverty and exposure to trauma, improving access to good education and health care, improving health equity) and/or (2) enhanced social interactions (e.g., improved parenting skills) and problem-solving and coping skills— should ensure that these programs include outcomes related to suicide (e.g., ideation, plans, attempts) and evaluation of those programs for suicide-related outcomes.
• Federal government and private sector research funders should support the analysis of existing data sets of longitudinal studies to determine the impact of various interventions (e.g., home visitation, preschool programs, substance misuse, child trauma) on suicidal ideation, plans, and attempts, and on deaths by suicide. This could include such projects as the CDC’s efforts to assess and prevent adverse childhood experiences and examine their effect on suicide-related problems, and National Institutes of Health (NIH) initiatives that focus on aggregating prevention trial data sets to better understand the long-term and cross-over effects of prevention interventions on mental health outcomes, including suicide risk,88 and to address suicide research gaps.89, 90
Action 3. Ensure Lethal Means Safety
Keep people safe while they are in crisis.
Although different paths can lead a person from suicidal intent to an attempt, research suggests that many suicidal crises are short-lived, with the time period between the decision to act on suicidal thoughts and a suicide attempt averaging less than 10 minutes.91 Moreover, individuals who are thinking about suicide, even when they experience strong intent, are often ambivalent about their wish to die. Although it is commonly believed that reducing access to a lethal means of suicide will lead to substitution with another lethal means, in many cases this does not occur.92 As a result, putting time and distance between a person at risk and lethal means of self-harm can save lives.
Firearms, which are highly lethal,93 are the most common means of suicide in the United States, accounting for more than half (51 percent) of all suicides.94 Among military service members, about 60 percent of suicides involve firearms,95 and among Veterans this number reaches 70 percent.96 Approximately 90 percent of suicide attempts involving a firearm injury result in death.97 After firearms, the most common methods of suicide are suffocation, poisoning, and falls.94 Although most suicide deaths are firearms related, most suicide attempts involve poisoning.97
When someone is at risk for suicide, removing ready access to means that may be used in a suicide attempt (e.g., firearms, medications, illicit drugs, poisonous household chemicals, and materials that can be used for hanging or suffocation) can mean the difference between life and death when a suicidal crisis occurs. Reducing access to lethal means of suicide when individuals are in crisis is an effective strategy for preventing suicide.43, 98 Goal 6 of the National Strategy promotes the implementation of diverse approaches to lethal means safety in clinical and community settings.
3.1 Empower communities to implement proven approaches.
Research has identified several proven community-based approaches to lethal means safety, each of which needs to be adopted more widely.99 These approaches, described below, vary by type of method.
Firearms. Recommended approaches to firearms-related lethal means safety include the following:99, 100
• Storing firearms unloaded, with ammunition stored separately, in a gun safe or tamper-proof storage box or with external locking devices, such as cable locks
• During periods of crisis or acute suicide risk, temporarily storing firearms away from the home—for example, with a relative or friend; in a self-storage unit; at a gun shop, shooting range, or pawn shop; or with law enforcement
Partnering with gun retailers, ranges, and clubs to promote firearms safety by recognizing the signs that a purchaser may be in distress, educating purchasers on safety, facilitating safe storage, and distributing safety devices101
• Considering implementation of extreme risk laws—also known as extreme risk protection orders (ERPOs) or gun violence restraining orders— enacted in some states, which set in place a legal process for temporarily removing firearms from people who may pose an extreme risk to themselves or others, as per the recommendations of the Federal Commission on School Safety102, 103
Partnering with people with lived experience can be critical to engaging firearm owners and building support to implement these approaches.
Poisoning. Suicides by poisoning can include the use of medicines, illegal drugs, and poisonous chemicals. Recommended approaches to reducing access to these substances among individuals at risk for suicide include the following:99
• Partnering with pharmacies and drug companies to modify medicine packaging (e.g., blister packaging) and to reduce package sizes
• Partnering with health care systems and providers to ensure the safe prescribing of opioids (including naloxone kits)
• Educating consumers on the safe storage and disposal of medicines, including drug lockboxes, and about medication disposal sites and drug take-back events
• Partnering with drug companies and law enforcement to implement drug buy-back programs and confidential drug return programs • Reducing access to poisonous chemicals, such as pesticides
Other lethal methods. Other lethal methods of suicide include suffocation, falling from high places, and inhaling carbon monoxide from motor vehicle exhaust. Effective approaches to preventing suicide by suffocation include reducing access to ligatures (e.g., ropes, belts) and ligature points (e.g., beams, door knobs, trees). These approaches are primarily relevant to settings such as health systems, college dormitories, military barracks, prisons, detention facilities, and jails. Effective strategies to prevent suicide by falling include restricting access to sites such as bridges and rail lines, and installing physical barriers, fencing, or safety nets.104 To prevent carbon monoxide poisoning, one strategy is to install a device that detects unsafe cabin levels of the gas, warns the driver, and—if levels rise above a determined threshold in a stationary car—turns off the engine.
3.2 Increase the use of lethal means safety counseling
Research suggests that providing counseling on lethal means safety to patients at risk for suicide is effective in increasing the adoption of safety practices.105, 106 Although several national organizations and professional associations have endorsed the use of lethal means safety counseling with patients at risk for suicide, health care providers often receive only minimal training in this area, and few provide this type of counseling to patients.102, 107
Counseling on lethal means should be routinely conducted as part of safety planning with individuals at risk. Recommended approaches include training diverse health care providers—including nurses, social workers, case managers, and certified peer workers—on lethal means safety counseling, and incorporating safety planning with lethal means counseling into suicide prevention protocols and care pathways (see also Action 5).
Asking about firearms or other lethal means should not be viewed as an abrupt shift in a clinical conversation, but rather as a type of safety assessment—similar to questions about the use of seat belts, bike helmets, and carbon monoxide alarms—that providers can routinely ask patients and their families.102 However, several barriers prevent providers from providing this type of counseling, including discomfort in talking with patients about firearms, the misperception that suicide is inevitable, and a lack of awareness that lethal means safety works.107 Resources and tools, such as a recently piloted Web-based decision aid,108 are needed to help providers overcome these barriers. (Information on free online training for health care professionals is included in Appendix 2.)
3.3 Dedicate resources to the development, implementation, and evaluation of interventions aimed at addressing the role of lethal means safety in suicide and suicide prevention.
Although research on reducing access to lethal means among persons at risk has increased since the National Strategy was last updated, more research is needed,91 for example:
• Foundational research to increase our understanding of factors related to lethal means use and safety, including method choice, firearm ownership and/or access to firearms in the home,109 the role of social networks and contacts, and differences across sociodemographic groups
• Effectiveness evaluations to test the impact of different lethal means safety strategies and interventions
• Translation and dissemination research to identify effective components of each intervention and to extend and adapt these interventions to various populations and settings
• Communications research with various audiences (e.g., individuals at risk, family members and friends, health care providers, other industry and community partners) to identify and test messages regarding lethal means safety and to assess the acceptability of various approaches
• Research to determine whether lethal means safety counseling is effective in promoting firearms-related lethal means safety behaviors among adults, and whether these practices are associated with reduced suicide risk Additional funding from private and public sources will be needed to support this research.
Although federal funding of research involving firearms has been limited, with Congressional funding in FY2020, NIH110 and CDC111 have awarded research grants to understand and prevent firearm-related injuries, deaths, and crime, including those related to suicide. More funding is needed to support the development, implementation, and evaluation of other prevention efforts addressing the needs of diverse populations in various settings.
Action 3: Priorities for Action
• The federal government and private sector entities can support efforts to ensure that updated information on lethal means safety policies, programs, and practices (e.g., ERPOs, firearm owner and retailer education, bridge barriers, medication packaging, carbon monoxide shut-off sensors in vehicles) is incorporated into existing national clearinghouses and resource centers so that local municipalities, states, and tribes can adopt and evaluate them for their prevention benefits.
• States, communities, and tribes should collaborate with the private sector to increase awareness of and take action to reduce access to firearms and other lethal means of suicide, including opioids and other medications, alcohol and other substances or poisons, and community locations (e.g., railways, bridges, parking garages) where suicidal behaviors have occurred. This urgent multi-sector effort is key to saving lives by reducing access to lethal means for individuals in crisis.
• Health systems and payers should leverage their existing training and resources and collaborate on a national initiative to train general and specialty health care providers and care teams on safety planning and lethal means counseling.
• SAMHSA and the VA should coordinate to ensure that lethal means safety assessment and counseling are incorporated into the assessment and intervention procedures of the National Suicide Prevention Lifeline and Veterans Crisis Line call centers, particularly in preparation for the national launch of 988.
• The federal government can prioritize and fund research and program evaluation analyzing community and clinical lethal means safety interventions (e.g., ERPOs, firearm owner and retailer education, bridge barriers, medication packaging, carbon monoxide shut-off sensors in vehicles) at the population level.
• State and federal governments should collaborate with the private sector on a synchronized public health communication campaign addressing lethal means safety in the context of suicide prevention, which should then be evaluated to determine prevention benefits and inform future communication efforts.
Action 4. Support Adoption of Evidence-Based Care for Suicide Risk
Ensure safe and effective care for all.
Goals 8 and 9 of the National Strategy call attention to the need to include suicide prevention as a core component of all health care services, rather than limit it to services provided by mental health specialists, and to improve professional and clinical training and practice.8 To support the adoption of safe and effective care for suicide risk, an Action Alliance work group drew on findings from successful suicide prevention efforts, such the U.S. Air Force Suicide Prevention Program112 and the Perfect Depression Care program conducted by the Henry Ford Health System,113 to develop recommendations for a gold standard of care for people with suicide risk.114
These practices have been incorporated into the comprehensive Zero Suicide framework for providing effective care for suicide risk in health systems.115, 116 Zero Suicide provides a model of integrated practices and transformative culture and systems change. Now implemented in numerous health care organizations, including behavioral health programs, general and psychiatric hospitals, primary care settings, and health plans, Zero Suicide is showing effectiveness in decreasing suicidal thoughts and behaviors among patients in care and in lowering the number of hospitalizations and the related costs.115 To encourage bringing Zero Suicide to scale across the nation, SAMHSA provides grants to implement Zero Suicide in health care systems, and a Zero Suicide toolkit can be accessed on the SAMHSA website.
While Zero Suicide is the gold standard for evidence-based care for suicide risk, comprehensive systems change for safer suicide care is a lengthy and challenging endeavor. In response to the need for a minimum standard of care for individuals at risk for suicide, in 2018 the Action Alliance developed Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe. This report identifies individual recommended practices—such as screening and assessment for suicide risk, collaborative safety planning, treatment of suicidality, and the use of caring contacts—that can be adopted in outpatient mental health and substance misuse settings, emergency departments (EDs), and primary care.
Safe and effective practices for suicide care should be embedded into diverse clinical care settings, including primary care offices and clinics, EDs, inpatient and outpatient mental health practices and facilities, and other health systems. Like other established practices for addressing the risk for health problems such as heart disease or diabetes, best practices for preventing, identifying, and treating suicide risk should be incorporated into providers’ everyday practice. There is also a need to increase the use of the Collaborative Care Model (CoCM), a team-based approach that allows a primary care provider to treat symptoms of mental illness in coordination with a care manager and a mental health specialist. This model of primary care integration has been shown to improve a range of patient outcomes, including suicide risk and health disparities. The CoCM approach is now covered by Medicare, many commercial health plans, and a growing number of state Medicaid programs.117
Access to treatment has long been a challenge for those in rural or remote settings, who often must drive for hours to access medical and behavioral health services. During the COVID-19 pandemic, federal restrictions on practicing across state lines have been eased and reimbursement has expanded, with a resulting rise in telehealth visits.29 These expansions should be retained even after the pandemic has passed in order to improve access for those with distance, transportation, childcare, or other barriers to physically accessing services. Although more research on the use and efficacy of telehealth for suicide prevention is needed, existing evidence suggests that virtually delivered psychiatric services can have benefits similar to in person therapy.118 Remaining barriers that need to be addressed include the fear of adverse events and lawsuits, and disparities in access to computers and high-speed Internet.18 Strengthening suicide prevention resources in critical access hospitals and rural health clinics can provide rural communities with the flexibility needed to determine the best approach to addressing suicide care challenges.119
Some of the evidence-based practices presented under Action 4 may also be appropriate for other settings that provide services to individuals at risk for suicide, including the justice system, university health services, school health clinics, and organizations that provide social services. Public and private stakeholders—including policymakers, payers, and accreditors—must take the steps needed to make these practices the standard of care for individuals at risk for suicide.
4.1 Increase clinical training in evidence-based care for suicide risk.
Objective 7.2 of the National Strategy recognizes the need to “provide training to mental health and substance abuse providers on the recognition, assessment, and management of at-risk behavior, and the delivery of effective clinical care for people with suicide risk” (p. 77).8 In a study conducted in England and Wales, training clinical staff in the management of suicide prevention at least every three years was among the key elements associated with lower rates of suicide among mental health patients.120 Although several states have enacted legislation requiring training in the assessment and treatment of suicidality,121 many behavioral health providers still receive only minimal training on how to care for patients at risk for suicide.122–124
Providing regular training to health care providers on how to recognize and address suicide risk is increasingly being recognized as an essential element of effective care.115 Education in this area should be started early in clinical training and then updated on a regular basis. Different levels of providers and staff in diverse health systems, including primary care providers, should all receive at least basic training on how to identify suicide risk and provide appropriate support to diverse groups, including sexual and gender minorities.
Behavioral health providers are assumed to be equipped with skills to address patient suicide risk and therefore should have adequate training in evidence-based suicide prevention. Although suicide risk is often associated with mental illness, such as depression or an anxiety disorder, it also includes a distinct combination of symptoms that must be treated independently. If someone is suicidal and has a serious mental illness, it is not enough to treat the illness and hope that the suicidality will resolve.125 To be effective, care for the mental illness should be combined with specific treatment for suicidality.
126 Evidence-based psychotherapies for addressing suicide risk include the following:127
• Cognitive-Behavioral Therapy for Suicide Prevention (CBT-SP)128, 129
• Dialectical behavior therapy (DBT)130
• Collaborative Assessment and Management of Suicidality (CAMS)131, 132
• Brief cognitive-behavioral therapy (BCBT)133
• Suicide-specific brief interventions, such as the Attempted Suicide Short Intervention Program (ASSIP)134
More work is needed to ensure that all behavioral health providers are prepared to assess suicide risk and to intervene, using evidence-based practices. Training on evidence-based suicide care practices should be incorporated into medical education programs and behavioral health graduate programs and should be included as criteria for professional licensure and license renewal. Professional associations and accrediting bodies should be encouraged to work together to advance training in suicide prevention. For example, for clinicians to maintain licensure or certification, state behavioral health licensing boards should add a continuing education requirement for suicide prevention. There is also a need to identify and address barriers to training, such as time, financing, and turnover of clinical staff.
4.2 Improve suicide risk identification in health care settings.
Studies have found that many individuals who die by suicide are seen by a health care provider in the weeks or months before their death.135 These visits are opportunities to detect suicide risk, address safety, and connect persons at risk to appropriate sources for care and support.
Research suggests that asking patients about thoughts of suicide or self-harm is a simple and effective way to uncover most suicide risk136 and does not increase a person’s risk of suicidal behavior.137, 138 This brief intervention can be done safely in many settings, including behavioral health care, primary care, and the ED. Universal screening in EDs has been found to nearly double the identification of suicidal patients.139 Research on youth has also found that children age 10 or older can be safely and effectively screened for suicide risk in the pediatric ED.140 More research is needed regarding younger children’s understanding of and ability to report suicidal thoughts.141
The United States Preventive Services Task Force (USPSTF) has endorsed depression screening for adults and adolescents ages 12–18. The USPSTF notes that “screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” The USPSTF is in the process of updating its recommendations for suicide screening in primary care for youth142 and adults.143
Identifying suicide risk through screening is a key component of recommended standard care.114 For individuals screening positive for suicide risk, the next step is a more thorough assessment that collects detailed information about the person’s risk, evaluates their immediate danger, and informs treatment decisions. Although the comprehensive suicide risk assessment is typically done by a behavioral health professional using a standardized suicide risk assessment tool, tools that do not require specialized mental health training are also available.144
The goal of suicide screening and assessment is not to predict suicide but rather to identify and address suicide risk, much as health care providers do in regard to other medical problems, such as heart disease or diabetes. For example, health care providers routinely assess patients for heart disease in order to identify and address relevant risk factors (e.g., unhealthy diet, lack of physical activity, smoking, high blood pressure) that can be addressed to prevent a heart attack or related problems, rather than to predict when a heart attack might take place. Similarly, identifying suicide risk and providing targeted, effective interventions is a key strategy for preventing suicide.
Screening and assessment for suicide risk should be conducted using workflows and electronic health record (EHR) fields that clearly indicate the need for suicide care. Training should also be provided to ensure that the interventions are done accurately and consistently and include appropriate follow-up and referrals.
4.3 Conduct safety planning with all patients who screen positive for suicide risk.
Safety planning is a brief intervention, conducted after a comprehensive suicide risk assessment, that has been shown to be effective in supporting safety among persons at risk for suicide.145, 146 In this brief intervention, the health care provider works collaboratively with the person at risk to develop a plan for recognizing suicidal thoughts and managing them safely. The patient safety plan—also referred to as a crisis response plan147—identifies prioritized coping strategies that the person will use when such thoughts arise, including both actions that the person can take alone and actions to obtain social support from family members and friends and by contacting a health care provider or crisis call center. Safety planning should not be confused with no-suicide contracts, which have not been shown to be effective and can provide a false sense of security.145
As discussed in Action 3, lethal means safety—identifying possible means of self-harm that are available to the person at risk, and taking specific steps to reduce access to those means during a time of crisis— is a critical component of safety planning. This approach has repeatedly been shown to be effective in community-wide suicide prevention and was also identified as an important factor in the success of suicide prevention efforts conducted at the Henry Ford Health System.148
As a brief intervention tied to a specific risk, safety planning is similar to other types of health interventions conducted by health care providers, such as counseling on smoking cessation or weight control, which can be done in many settings. Safety planning with lethal means safety should be embedded in the suicide care protocols and electronic medical record systems used in all health care settings.
4.4 Increase the use of suicide safe care pathways in health care systems for individuals at risk.
The use of suicide safe care pathways can help health care systems continually monitor and enhance the quality of care provided to individuals at risk for suicide, thereby improving processes and outcomes. A key component of the Zero Suicide model, the suicide safe care pathway ensures that patients at risk for suicide are identified and provided with continuing care tailored to their needs. All patients are screened on past and present suicidal behavior, and positive screens are followed by a full assessment. Individuals identified as being at increased risk are entered into a suicide safe care pathway, thus ensuring that they are provided with the attention and support they need to stay safe and recover. Components include periodic assessments of suicidality and ongoing follow-up, including contacting patients who fail to show up for an appointment or withdraw from care. The inclusion of family members and other identified support persons in pathway implementation may help support patient engagement.
Implementation of a suicide safe care pathway requires that protocols and systems be in place to collect and analyze data to track services, ensure patient safety, and assess treatment outcomes.149 The system should collect data on process measures, such as screening rates, safety planning, and services provided; care outcomes; suicide attempts and deaths; and any other relevant factors, such as sociodemographic characteristics, clinical history, and referrals to other sources of care.
EHRs can be programmed to support pathway implementation, for example, by prompting providers to conduct suicide risk screening and further risk assessment, and by facilitating connections to outpatient treatment.150 These systems can also be designed to “pre-screen” new patients for strong risk factors for suicide, such as a history of suicidal ideation, plans, or attempts, and to alert the provider to needed next steps. Suicide safe care pathways need to be incorporated into existing EHRs and built into new systems. A quality measure should be developed that requires systems to track the number of patients who screen positive for suicide risk, are on a suicide safe care pathway, or receive a collaborative safety plan. Health care systems must also consider ways to collaborate to ensure that patients in the suicide safe care pathway continue to be followed as they move across different settings and systems.
4.5 Increase the use of caring contacts in diverse settings.
Caring contacts are brief interventions that use encouraging notes and messages (which do not require a response from the patient) to ensure that individuals at risk receive ongoing follow-up and support, with the goal of preventing suicidal behaviors.151, 152 First tested more than four decades ago,153 caring contacts have been found to decrease subsequent suicide attempts by helping prevent gaps in care that can occur for different reasons. Examples include the transition from inpatient to outpatient care, the time period between a crisis line call or ED visit and seeking follow-up treatment, the interval between scheduled care sessions, and gaps in care caused by missed appointments.154
The contacts can be provided in many ways, including through postcards or letters with brief expressions of caring, telephone follow-up calls with patients after discharge or a missed appointment, and text messages and e-mails generated by automated systems.154 Although the messages can be designed to support diverse goals (e.g., provide information about resources or crisis lines, remind the person of upcoming appointments), they should always communicate that the sender cares about the person’s well-being. The intervention can also be used in diverse settings, including EDs, hospitals, outpatient behavioral health programs, crisis centers, community mental health, and integrated primary care. Contacts can be made by clinical or non-clinical staff, including peers who have lived experience of a suicidal crisis. The contents, media used, and delivery options should be adapted to the needs and preferences of the recipients.
Caring contacts should be routinely provided to individuals at risk for suicide, similar to other standard protocols for following up with patients after other types of medical treatment, such as a surgical procedure.
Barriers to the use of this brief intervention include a lack of familiarity with the billing codes that may be used and (in some settings) a lack of reimbursement. Bundled payment options with International Classification of Disease (ICD) codes that provide payments for follow-up phone calls to patients discharged from a health care provider, such as an ED or inpatient hospital, could help address these financial barriers.
Action 4: Priorities for Action
• The federal government, professional associations, and accrediting bodies should collaborate to address barriers to adopting the Action Alliance’s Suicide Prevention and the Clinical Workforce: Guidelines for Training to ensure increased clinical training in evidence-based care for suicide risk during graduate education and post-graduate training.
• State behavioral health licensing boards should add continuing education requirements for suicide prevention in order for clinicians to maintain licensure or certification.
• Payers from the public and private sectors should incentivize the delivery of evidence-based care via existing levers in contracting and reimbursement.
• Federal and state policymakers and commercial payers and health systems should take specific steps to improve outcomes for individuals with mental health and substance misuse conditions in primary care by using effective methods (e.g., CoCM) to integrate mental health and substance misuse treatment into primary care.
• To enhance workflows for suicide safe care, health systems should collaborate with EHR vendors to develop options for integrating screening, suicide safe care pathways, and safety planning into their EHR systems.
• Public and private health systems should adopt and/or implement the recommendations in Recommended Standard Care for People with Suicide Risk in all health care settings.
Action 5. Enhance Crisis Care and Care Transitions
Ensure that crisis services are available to anyone, anywhere, at any time.
In many states, the only options available to an individual in suicidal crisis are a call to 911 or a crisis call line or a visit to the ED—and after this call or visit, the person loses contact with the health care system, only to resurface during the next crisis. As a result, individuals in crisis may be readmitted to a hospital multiple times and receive expensive and restrictive care that may not match their needs. This approach to crisis care is not only insufficient, it is also dangerous, as it does not ensure safety or treat suicidality. The long-term consequences of inadequate crisis care can include homelessness, involvement with the criminal justice system, and premature death.155
Although the police are frequently called on to respond to individuals who engage in self-harm or who exhibit suicidal ideation or suicidal behaviors, SAMHSA’s recently released National Guidelines for Behavioral Health Crisis Care indicate that police officers and emergency medical services personnel should be involved in crisis response only if the nature of the crisis indicates that their involvement is needed (e.g., the person has a serious medical condition or poses an imminent threat of self-harm that cannot be de-escalated by phone-delivered crisis intervention). While local law enforcement has a role to play in mental health crisis response, crisis care should be provided by mental health specialists and others trained in mental health crisis response, who could include peers. This approach may contribute to more compassionate care and improved outcomes for individuals in crisis, and also reduce the burden that mental health crisis response places on law enforcement. As discussed in Action 5, strategy 5.5, the establishment of 988 as the national number for mental health crises14 (effective by July 2022) will help address this problem by connecting callers who are experiencing a mental health crisis with appropriate responders.
Individuals in crisis need immediate access to tailored services aligned with their needs, provided in the most comfortable and least restrictive setting, that will ensure their safety and connect them to continuing, effective care.155 The Air Traffic Control (ATC) system that monitors commercial aircraft provides a useful. analogy. From takeoff to landing, each aircraft is continuously monitored by air traffic controllers, who are ready to step in when needed. Much like the ATC system never loses track of an airplane, a crisis care system should never lose track of a person at risk. Rather, the system must combine multiple approaches to stay connected, verify when a safe hand-off has occurred, and secure a “safe landing.”
Ensuring that individuals at risk receive follow-up and are connected to sources of evidence-based ongoing care is best achieved through the use of a comprehensive and integrated crisis network that accepts all calls, welcomes all individuals who seek help at a health care setting, and provides real-time access to services that align with the needs of the person when and where the person needs it most. Individuals in crisis must be provided with appropriate and ongoing services regardless of their ability to pay, as intended by the Mental Health Parity and Addiction Equity Act,156 which requires health insurers and group health plans to provide the same level of mental health and substance misuse treatment services and medical and surgical services to all individuals in need.
The experience of states that have developed effective crisis care systems, and of the individuals and families with lived experience who have relied on these supports, suggests that crisis care systems must include three key components: regional or statewide crisis service hubs that work in coordination with national crisis lines; centrally deployed 24/7 non-law enforcement mobile crisis teams; and crisis receiving and stabilization facilities with 24/7 availability.155 All components should reflect the essential principles of crisis care, including partnering with law enforcement and emergency medical services, making significant use of peer support and peer-delivered services, and ensuring the safety and security of staff, peers, and individuals in crisis. Ongoing research and evaluation efforts addressing these services are needed to optimize individual outcomes as crisis care systems are further developed and implemented.
5.1 Increase the development and use of statewide or regional crisis service hubs.
Crisis call centers are clinically staffed statewide or regional centers that provide individuals in crisis with real-time access to a live person on a 24/7 basis—by telephone, text, chat, or other means. SAMHSA-issued guidelines indicate that, at a minimum, crisis call centers should do the following:155
• Operate every moment of every day
• Be staffed with clinicians overseeing clinical triage, and other trained team members to respond to all calls received
• Answer every call, or coordinate overflow coverage with a resource that also meets all minimum crisis call center expectations
• Assess the risk of suicide within each call in a manner that meets National Suicide Prevention Lifeline Risk Assessment Standards
• Coordinate connections to mobile crisis team services in the region
• Connect individuals to facility-based care through warm hand-offs and coordination of transportation as needed
To be most effective, the crisis center should function as a hub for the effective deployment of a range of crisis services (e.g., crisis stabilization, crisis respite, psychiatric hospitalization). A crisis service hub (e.g., NYC Well, Georgia Crisis & Access Line) uses connections to service providers and technological solutions (e.g., online databases, GPS-enabled mobile crisis dispatch) to ensure that individuals at risk are provided with the least invasive and most appropriate level of care. Sample capabilities include the ability to (1) track all persons who are waiting for care, how long they’ve been waiting, and where they are waiting, (2) access appointment slots for outpatient scheduling, and (3) identify and deploy the closest mobile crisis team. These ATC-like capabilities also help ensure follow-up and safety for individuals in crisis as they move across services and systems.
5.2 Increase the use of mobile crisis teams.
Mobile crisis teams are crews that can be dispatched to help the person in crisis at their home, workplace, or any other location in the community where the person is experiencing a crisis. These teams provide professional intervention and peer support in real time to the person in crisis in a comfortable environment. This approach has been found to be appropriate and effective at diverting individuals in crisis from psychiatric hospitalization and connecting them to outpatient services, while also reducing unnecessary involvement with law enforcement and lowering related costs.155
SAMHSA-issued guidelines indicate that, at a minimum, mobile crisis team services must:155
• Include a licensed and/or credentialed clinician capable of assessing the needs of individuals within the region of operation
• Respond where the person is (e.g., home, work, park) and not restrict services to particular locations, days, or times
• Connect individuals to facility-based care as needed through warm hand-offs, and coordinate transportation only if or when circumstances warrant transitions to other locations
These services should incorporate best practices, such as continuity of care. Ways to support continuity of care include scheduling outpatient follow-up appointments, providing a warm hand-off that actively engages and links the person at risk to treatment and other needed services, and offering caring contacts (see Action 4, strategy 4.5) that support continued follow-up.
5.3 Increase the use of crisis receiving and stabilization facilities.
Crisis stabilization facilities are home-like environments that offer a step-down option for persons who do not need inpatient care after their crisis episode. These settings provide individuals in crisis with “a place to go,” where they can stay for short-term observation (less than 24 hours) and receive crisis stabilization services.155 The facilities should accept not only referrals, but also walk-ins and drop-offs from first responders, including ambulance services, firefighters, and the police.
The following models are most often used to provide crisis stabilization services:155
• Short-term residential facilities. Also called crisis residential facilities, these sites should include licensed and/or credential clinicians onsite on a part-time basis and on-call.
• Peer-operated respite. In this model, the facility is typically staffed by peers who have personal experience with mental health challenges or suicide. Although these programs usually do not have licensed staff onsite, some facilities call on licensed providers to support suicide risk assessments. Non-peer-run facilities that offer crisis receiving and stabilization services should meet several requirements:155
Be staffed at all times (24/7), with access to a multidisciplinary team (e.g., psychiatrists, psychologists, social workers, nurses, licensed or credentialed clinicians, peers) capable of meeting the needs of individuals experiencing all levels of crisis
• Screen for suicide risk and complete comprehensive suicide risk assessments and planning when clinically indicated
• Address crisis issues related to both mental health and substance use
• Be able to assess physical health needs and deliver care for most major physical health problems and to connect individuals to other providers when needed
Facility-based programs should be adequately funded to deliver on the commitment of never rejecting a first responder referral or a walk-in referral, thereby ensuring diversion from the ED and the justice system.
5.4 Ensure safe care transitions for patients at risk.
Transitions in care—such as the transition from inpatient hospitalization to outpatient care in the community—are a time of increased suicide risk. Other care transitions include the time period following discharge from an ED or from other providers of crisis care services, including crisis stabilization facilities and mobile crisis teams. Studies have found that in the month after patients leave inpatient psychiatric care, the suicide death rate for these patients is 300 times higher (in the first week) and 200 times higher (in the first month) than the general population’s.157 Suicide risk is highest in the first few days after discharge from inpatient mental health care158 and can stay elevated for months,159, 160 yet many patients never attend their first outpatient appointment.161, 162 Ensuring a timely transition in care has been shown to reduce risk of subsequent suicide. In a recent study, suicide risk in the six months following psychiatric hospitalization was reduced among youth ages 10-18 who had an outpatient mental visit within 7 days of discharge.163
Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care issued by the Action Alliance notes that inpatient and outpatient providers need to accept shared responsibility for the patient’s care and work together to ensure a seamless transition with no interruption in services.164 This approach includes the following components:
• Developing relationships, protocols, and procedures that allow for rapid referrals.
• Making a follow-up phone call within 24 hours of discharge from psychiatric hospitalization, a crisis stabilization unit, or an ED to check in with the patient, and maintaining contact until the person attends the first outpatient appointment. It is also important to consider ways to support the transition in care, such as holding a videoconference with the patient and the outpatient provider.
Involving individuals with lived experience to inform practices.
• Involving family members and natural supports, including trained peer specialists, to increase social and emotional support, solve practical problems, and promote hope and ongoing recovery.
• Providing education to family members and natural supports.
• Providing brief interventions, such as safety planning and caring contacts, to reduce suicide risk during care transitions.
All health care providers who care for individuals at risk for suicide—in both clinical and community settings—should have policies, protocols, and pathways for ensuring continuity of care during transitions. For this to happen, financing related to care transitions needs to be improved. In particular, the case rate reimbursement structures need to be modified to support delivery of these services.
5.5 Ensure adequate crisis infrastructure to support implementation of the national 988 number.
The FCC has authorized the creation of a new three-digit number, 988, that will be used to connect callers to mental health crisis assistance. The new number will direct callers to the National Suicide Prevention Lifeline, as will the current 10-digit number 800-273-8255 (TALK).165 Similar to 911, which connects people in need to first responders for other emergencies, 988 will connect callers to Lifeline crisis centers that will deliver intervention services by phone, triage the call to assess for additional needs, and coordinate connections to additional support, based on the team’s assessment and the caller’s preferences. All carriers are required to implement the new number nationwide by July 16, 2022.165
As noted in SAMHSA’s report to the FCC as part of the National Suicide Hotline Improvement Act, the establishment of 911 gradually transformed the U.S. emergency medical system.166 The 988 number has the potential to play a similar role in behavioral health emergency and crisis services, with 988 being used to access a coordinated crisis system with call centers at the hub, connecting to mobile outreach, crisis stabilization units, and emergency rooms, with ATC-type monitoring to prevent persons at acute risk from falling through gaps in care.
However, this national mental health crisis line will only work if there are sufficient personnel and infrastructure to keep up with the calls and provide an effective response. Crisis centers that respond to calls from state-run helplines and the National Suicide Prevention Lifeline will see an increased volume of calls and will need to increase their capacity to respond, which will require additional personnel and funding. The system will also need to include contingency plans for meeting periods of increased demand, such as following the death by suicide of a celebrity.167 Legislation for building a framework to run 988, called the National Suicide Hotline Designation Act of 2020,14 was signed into law in October 2020 to allow states to add a fee to phone bills, much like 911. These funds would go toward running 988, ensuring that the call line has the personnel, resources, and training necessary to support any increased call volume, including specialized resources for high-risk populations. Another potential funding source is a proposed new 5 percent set aside in the SAMHSA Mental Health Block Grant to support evidence-based crisis care programs.168 Partnerships that combine federal and state funding, such as SAMHSA’s state capacity grants administered through the National Suicide Prevention Lifeline, will be needed for the new 988 crisis line to achieve its full potential.
Action 5: Priorities for Action
• The federal government and the private sector should address gaps, opportunities, and resource needs to achieve standardization among crisis centers in interventional approaches and quality assurance in preparation for the launch of 988.
• The federal government, states, and the private sector should work together to optimize system design, system operations, and system financing for 988 as the hub of an enhanced, coordinated crisis system, and enhance coordination between Lifeline 988 centers and 911 centers to reduce overreliance on 911 services and ED boarding (the practice of keeping admitted patients on stretchers in hallways due to crowding).
• The federal government should fund the necessary infrastructure to support crisis care (e.g., Congressional support for the 5 percent SAMHSA Mental Health Block Grant set-aside; core services identified in SAMHSA’s National Guidelines for Behavioral Health Crisis Care) and should provide technical assistance to states looking to evolve crisis systems of care.
• The federal government and foundations should support research to identify effective models of mental health crisis response (e.g., coordinated efforts among mental health specialists, peers, and law enforcement) to improve short- and long-term effects on communities of color and other marginalized populations.
• The federal government and private sector payers should support the use of follow-up phone calls or texts within 24 hours of discharge from psychiatric hospitalization or emergency room discharge to check in with the patient, provide support, and maintain contact until the person’s first outpatient appointment.
• The federal government should establish universally recognized coding for behavioral health crisis services, and public and private sector partners should collaborate with payers and health systems to increase adoption of the new coding.
• The federal government should support the development of an essential benefits designation that will encourage health care insurers to provide reimbursement for crisis services, thus reducing the financial burden on state and local governments to pay for those services, delivered within a structure that supports the justice system and ED diversion.
Action 6. Improve the Quality, Timeliness, and Use of Suicide-Related Data
Know who is impacted and how to best respond.
Suicide prevention efforts must be guided by timely and reliable data on the extent of suicide in a specific community or setting, the groups most affected, and relevant risk and protective factors that prevention strategies can address. Data collection at the national, state, and local levels is critical to monitoring trends, guiding suicide prevention efforts, informing public policy, and assessing the effects of programs and policies.169 The various systems currently being used to track the pandemic (e.g., daily reports of new cases, hospitalizations, and deaths) clearly demonstrate the importance of capturing and sharing near real-time data to guide an informed public health response.
Goal 11 of the National Strategy calls for improvements in the quality and timeliness of suicide data and in the use of these data to inform prevention.8 The need for timely data related to suicide has become more pronounced with the COVID-19 crisis, which is increasing various stressors that can affect mental health and suicide risk, including social isolation, traumatic losses of family members and friends, and economic hardship—particularly among communities of color.170 Although the impact of these risk factors on mental health and suicide is still being explored, the pandemic has added urgency to an existing need to improve the timeliness and quality of suicide-related data to implement an effective response at the federal, state, tribal, and local levels.
6.1 Increase access to near real-time data related to suicide.
Access to near real-time data on suicide is critical to detecting and responding to increases in suicide attempts and deaths by suicide, identifying emerging populations at risk, and assessing the effectiveness of suicide prevention efforts over time. Since the National Strategy was updated in 2012, the quality and timeliness of national suicide data have somewhat improved, and the gap between the close of the calendar year and when the national data for that year become available has narrowed. However, more work is needed to achieve near real-time access to this information.
While some states are able to contribute mortality data to the National Vital Statistics System (NVSS) on a fairly rapid basis, others continue to experience delays in certifying and reporting these deaths, thereby delaying the release of national statistics. These states, and the local death investigation system within each state that provides the data, need additional support and resources to collect and report their data more efficiently, consistently, and quickly. States should also ensure that mortality and attempt data are shared in real time with their state and local suicide prevention leaders and other key stakeholders. In addition, states should facilitate wider linkages to mortality data, especially by health systems and health plans, to enable better public health surveillance regarding patterns and correlates of mortality, and should support implementation of clinical quality improvement programs that will increase survival.
Data on the circumstances surrounding each suicide are collected through CDC’s National Violent Death Reporting System (NVDRS). Although NVDRS has recently been expanded to all states, several states are still working to fully build their statewide data collection systems. A lack of centralized data systems and various logistical challenges associated with the collection of vital statistics; reports from law enforcement, coroners, and medical examiners; and other records continue to impact many states’ capacity to rapidly collect information for the NVDRS. Thus, even when all state systems are up and running, the compiling of national data will encounter delays. These systems need to be improved so that the data can be reviewed annually to guide suicide prevention efforts at the state and federal levels.
6.2 Improve the quality of data on causes of death.
Studies suggest that suicide rates may be underestimated by as much as 30 percent. Suicides may be misclassified as homicides, accidents (unintentional deaths), or undetermined deaths (primarily deaths by drug overdose).171 Many factors may contribute to the misclassification problem, including family reluctance to report the death as a suicide; legal, religious, and political pressure; and a lack of resources and training to adequately investigate the manner of death.
Moreover, each state has its own system, requirements, infrastructure, and resources related to death scene investigations and the preparation of death certificates. Challenges include a lack of consistency in definitions, burden of proof standards, and procedures across jurisdictions, and poor implementation of existing guidelines and best practices. Potential solutions include better standardizing of terms and definitions, procedures, and death certificate completion practices within and across states; improving and expanding training; improving communication across jurisdictions and disciplines; developing job aids to enhance consistency; and conducting additional research to better understand and address variations in practices across counties and states.171 Death certificates and death investigation reports also need to be improved to better identify the characteristics of the person who died by suicide (e.g., sexual orientation, gender identity,172 Veteran status,173 and race or ethnicity, including Hispanic174 and American Indian or Alaska Native175).
6.3 Expand the accessibility and use of existing federal data systems that include data on suicide attempts and ideation.
Data related to suicidal thoughts, plans, and attempts; risk factors; health care use; and other relevant outcomes are critical to identifying emerging trends, planning suicide prevention efforts, and assessing progress. These suicide-related data are currently available from a number of sources (see the following box on page 60 for examples). However, in many cases the data may not be available in formats that can be easily accessed and used by state and local suicide prevention programs.
Existing systems must continue to be strengthened and improved. For example, EDs should routinely use the external cause of injury code to identify suicide attempts (as opposed to self-harm with unspecified intent). Although a field to code cause of injury exists, it often is not completed uniformly across states. CDC’s Youth Risk Behavior Surveillance System (YRBSS) survey should be expanded to more middle schools and should seek additional data, such as information on protective factors for suicide (e.g., school connectedness). New questions related to suicide—including questions that better identify specific groups, such as sexual and gender minority populations—should be added to existing data collection tools, such as state-level health surveys. Other variables of interest, such as risk and protective factors for suicide, should also be added to existing data collection instruments. States should make a concentrated effort to improve participation in these surveys; for example, in some states, schools in the largest metropolitan areas do not participate in the YRBSS or similar state surveys.
Access to and use of existing suicide-related data must also be improved. Existing data should be made openly available to state and local programs in formats that can be easily used to inform suicide prevention efforts. Although some sources may make raw data available to researchers, the data must be analyzed by epidemiologists and presented in formats (e.g., reports, tables, dashboards) that allow the information to be easily reviewed and applied. State and local suicide prevention programs need better access to usable data, or to experts who analyze these data, so that the information can be used to guide prevention actions.
6.4 Improve coordination and sharing of suicide-related data across the federal, state, and local levels.
Although national data provide an overall view of the suicide problem, state and local data are key to planning effective prevention efforts. Suicide rates and risk groups at the regional, state, territorial, tribal, and local levels often vary considerably from national estimates. Now that NVDRS funds all 50 states, the information on circumstances associated with suicide deaths needed to guide state and local suicide prevention efforts will become increasingly available. However, there is still a need to create systems and to dedicate resources to improve coordination and near real-time availability between the local, state, and federal levels regarding the reporting of data related to suicide.176 It is also critical to increase the capacity of all systems to provide near real-time data that are easily accessible and routinely used to guide decision making at every level.
Improved access to information on suicide attempts is also needed. CDC is currently funding 10 states to conduct Emergency Department Surveillance of Nonfatal Suicide-Related Outcomes (ED SNSRO) and is using the National Syndromic Surveillance Program to monitor suicide attempts during the COVID-19 pandemic.
States should consider ways to disseminate suicide-related data in useful formats so that these data may be more widely applied. For example, the state of Colorado makes suicide data from the Colorado Violent Death Reporting System available online, in a data dashboard format, so that every county can access the information and apply this knowledge to guide their suicide prevention efforts. In Connecticut, the state purchases hospital claims data to pinpoint localities and populations with elevated risk for suicide attempts. Other states should consider similar ways to support the dissemination and use of data on suicide attempts and deaths.
6.5 Use multiple data sources to identify groups at risk and to inform action.
Diverse data sources can help suicide prevention planners identify groups most at risk and allocate resources appropriately. For example, state data on suicide death and attempt rates can help decisionmakers identify populations or geographic areas where rates are particularly high and formulate solutions. A study that used NVDRS data to map county-level distribution of suicides among members of the military and Veterans found that suicides were concentrated in a small number of counties.177 By triangulating multiple sources of data, researchers were able to better understand the circumstances surrounding these deaths and identify potential intervention sites in the affected counties. To expand these types of analyses, CDC is linking NVDRS data to the Department of Defense Suicide Event Report to better understand the circumstances of suicide among active duty military, Veterans, and civilians. The Surgeon General’s Call to Action TO IMPLEMENT THE NATIONAL STRATEGY FOR SUICIDE PREVENTION PAGE 64 Linking data available from local, state, and national data systems (e.g., those used for medical service billing) to existing data from suicide prevention efforts could facilitate program planning and outcome assessment. For example, research on youth suicide prevention has identified many existing data systems that could be potentially linked to suicide prevention efforts.178, 179 Programs should also establish links to existing data on societal-level factors that impact suicide prevention, including unemployment and food insecurity, available from external sources, such as the U.S. Census.
Medical records are another source of data that can be used to guide prevention efforts. The VA uses risk algorithms that examine medical record data (also referred to as predictive modeling) to identify patients at high suicide risk and inform decisions about care.180, 181 Its Veterans Health Administration, the largest integrated health care system in the United States, has started a program that uses predictive modeling to identify patients who can benefit the most from interventions aimed at preventing suicide.
Objective 8.1 of the National Strategy indicates that health care systems should conduct root cause analyses (a structured process to determine the causes of suicide attempts and deaths among patients served) to continually improve service quality by identifying and addressing system-related factors that affect patient safety. The VA has successfully used this approach following discharge from not only inpatient hospitalization,158, 182 but also nursing home care units and long-term care facilities.183 VA research also suggests that combining information obtained through root cause analyses with data available from other sources, such as the National Death Index, may help improve the classification of deaths by suicide.184 The Internet and social media sites can also provide data that can be useful to suicide prevention. For example, metrics on the volume of Internet searches related to suicide can help identify increases in information- or help-seeking related to suicide. A recent study found that these searches increased following the release of a popular TV series about a young person’s suicide.185 These data can be useful in identifying times when increased capacity to provide information and crisis support may be needed. Other sources of data needed to inform prevention efforts include qualitative studies (e.g., focus groups, key informant interviews), which can increase understanding of risk and protective factors for suicide among particular groups and inform the development of culturally tailored prevention programs. The first-hand experience of people with lived experience is another type of information that must guide the implementation of suicide prevention efforts.
Action 6: Priorities for Action
• The federal government should support near real-time collection of data on deaths by suicide and nonfatal suicide attempts in a group of sentinel states to develop the framework for a national early warning system for suicidal behavior in the U.S. The system would create a central database that links multiple data sources and would build state and local capacity to translate data trends into prevention efforts in a timely manner. In addition, the federal government should expand ED SNSRO to monitor nonfatal suicide-related outcomes, track spikes and potential clusters in suicide attempts, and identify patterns, all of which can then inform prevention activities.
• The public and private sectors should collaborate on a near real-time suicide dashboard that pulls data from existing national, state, tribal, and community databases to make data on deaths by suicide and suicide attempts timelier and more accessible, thus linking the dashboard to prevention actions on the ground.
• The federal government should implement Recommendation 1.8 of the Interagency Serious Mental Illness Coordinating Committee, which calls on public and private health care systems to routinely link mortality data for serious mental illness (SMI) and serious emotional disturbance (SED) populations, and supports the standardization of similar data gathering across state and local systems for SMI and SED populations within the justice system.
• Professional organizations connected to coroners and medical examiners at the state and national levels should release guidance on and support wide-scale implementation of coding sexual orientation and gender identity in death investigations.
• The federal government should implement the PREVENTS Executive Order recommendation for the U.S. Department of Health and Human Services and the VA to propose legislative changes that mandate a standardized process for uniform ED data reporting across the United States specific to the external cause of injury (e.g., suicide attempt).
• Health care systems should work with public sector agencies to support the linkage of mortality data with health record, social, geographic, education, and criminal justice data systems to strengthen data quality and increase accountability for patient outcomes across key systems.
• State suicide prevention coordinators and community suicide prevention leaders should routinely monitor available data to identify trends and evaluate their own efforts.
- choosing a selection results in a full page refresh