I attempted to take my life because of a breakup when I was 16. I woke up and I was fine, but I was really mad. I just didn’t want to live! I’d been trying to get a gun, and word got around. The school called my mom and a social worker came to talk to me. But what really changed my mind was my dad. I could feel his love, and it felt like he would lay down his life for me. Thinking about that would snap me out of it—suicide would hurt my family more than I’m hurting now.
In my worst moments the thought lingers, but now I know I could never go through with suicide. My faith gets me through those times—knowing that something bigger is out there and I shouldn’t rob myself of what is yet to come. My kids give me a sense of purpose. I’m able to say to myself, “No, that’s not an option, you can’t do that.” And I was really lucky to have that connection with my dad.
Annie Ost, Spokane
Source: WSDOH, 2016
Certain protective factors, such as having robust social supports or having strong problem solving skills, diminish the risk of suicide. A person’s support network can be a source of strength in times of crisis and during recovery. Strong social ties can decrease stress and increase a person’s ability to cope with the stressful event or situation (WSDOH, 2016).
Some believe the health of a society is reflected in its incidence of suicide and that a society sustains itself through well-defined norms and customs that govern interactions; when a person is immersed in the life of the community there are shared ideas of what is inappropriate and appropriate. If regulation or integration is too high or low, then suicides and other social ills will occur (WSDOH, 2016).
A care network can offer general support (positive contact, transportation and childcare during appointments, messages of love and concern), crisis support (getting a person to a hospital or crisis center and visiting them while there, arranging for care of the home, children, or pets during crisis care or recovery) and ongoing attentiveness to signs of a new crisis. Supports such as these are a key part of care for people at risk of suicide (WSDOH, 2016).
Laypeople with appropriate training can also be critical in helping to prevent suicides. Gatekeepers (individuals who are in a position to recognize someone at increased suicide risk) may include clergy, first responders, and those employed in institutional settings such as the military. Review of programs providing education and training in suicide prevention strategies to gatekeepers has demonstrated positive effects. For example, implementation of the U.S. Air Force suicide prevention program was associated with significant declines in suicide (Hassamal et al., 2015).
Peer Support Programs
Promoting connectedness among individuals and within communities through modeling peer norms and enhancing community engagement may protect against suicide. Peer norm programs seek to normalize protective factors for suicide by encouraging help-seeking, talking to trusted adults, and promoting peer connectedness. By leveraging the leadership qualities and social influence of peers, these approaches can be used to shift group-level beliefs and promote positive social and behavioral change. These approaches typically target youth and are delivered in school settings but can also be implemented in community settings (Stone et al., 2017).
Programs such as Sources of Strength can improve school norms and beliefs about suicide that are created and disseminated by student peers. In an RCT of Sources of Strength conducted with 18 high schools (6 metropolitan, 12 rural), researchers found that the program improved adaptive norms regarding suicide, connectedness to adults, and school engagement. Peer leaders were also more likely than controls to refer a suicidal friend to an adult. For students, the program resulted in increased perceptions of adult support for suicidal youths, particularly among those with a history of suicidal ideation, and the acceptability of help-seeking behaviors. Finally, trained peer leaders also reported a greater decrease in maladaptive coping attitudes compared with untrained leaders (Stone et al., 2017).
Community Engagement Activities
Community engagement is an aspect of social capital. Community engagement approaches may involve residents participating in a range of activities, including religious activities, community clean-up and greening activities, and group physical exercise. These activities provide opportunities for residents to become more involved in the community and to connect with other community members, organizations, and resources, resulting in enhanced overall physical health, reduced stress, and decreased depressive symptoms, thereby reducing risk of suicide (Stone et al., 2017).
Among the groups disproportionately affected by suicidal ideation and behaviors, a one-size-fits-all approach to suicide prevention does not work. These guidelines can help tailor messages, interventions, and programs to a specific community:
- Involve community members and leaders from the beginning and respect them as experts on their own experience.
- Become familiar with the community’s history, risk and protective factors, cultural norms around language and communication, beliefs about death, and definition of the problem.
- Avoid viewing one or a few members of a community as representative of an entire demographic group.
- Put values of inclusion and equity front and center in decision making and program design.
- Include accessibility concerns such as transportation, cost, language translation, location, space, and materials for people with disabilities. (WSDOH, 2016)
A recent workshop held in Iqaluit, Nunavut (Arctic Canada) provided guidance on ways to prevent suicide among Indigenous peoples—much of which can be applied to any community engagement effort. Key themes included:
- Acknowledge the impact of colonization.
- Recognize the effects of rapid social and environmental changes on mental wellness and suicide that have taken place in the past two decades.
- Be aware of the great variation of suicide rates across communities, even within a single jurisdiction, and the importance of understanding the role of resilience in this variation.
- Understand that successful prevention strategies must be community-based and should integrate Indigenous ways of knowing.
- Recognize the importance of involving youth in developing solutions, tightening their relation to the land, and creating strong linkages with Elders and culture.
- Acknowledge the need to move from intention to action and from action to impact. (NIMH, 2017)
Healing of the Canoe
The Healing of the Canoe Project is a collaborative project between the Suquamish Tribe, the Port Gamble S’Klallam Tribe, and the Alcohol and Drug Abuse Institute, University of Washington. It is a curriculum for Native youth focused on suicide and substance abuse prevention. The program uses the Canoe Journey as a metaphor, providing youth the skills needed to navigate their journey through life without being pulled off course by alcohol or drugs—with tribal culture, tradition, and values as compass to guide them and anchor to ground them (Healing of the Canoe, 2017).
Rising Sun (Reducing the Incidence of Suicide in Indigenous Groups—Strengths United through Networks) is an initiative of the Arctic Council, coordinated by the Sustainable Development Working Group, and designed as a follow-on activity to the mental wellness project of 2013–2015, led by Canada and collaborating countries. Rising Sun is designed to identify a toolkit of common outcomes to be used in evaluating suicide prevention efforts to assess the key correlates associated with suicide prevention interventions across Arctic states. Common outcomes and their measures, developed through engagement with Indigenous peoples’ organizations and community leaders, as well as mental health experts, will facilitate data sharing, assessments, and interpretation of interventions across service systems in the Arctic region (NIMH, 2017).
The ultimate goal is to generate shared knowledge that will aid health workers in better serving their communities, and help policy-makers measure progress, evaluate interventions, and identify regional and cultural challenges to implementation. Arriving at common outcomes, through their measures and reporting systems, is especially important in the Arctic, where the vast geography, high number of remote communities, and breadth of cultural diversity pose challenges for systematic approaches to suicide prevention (NIMH, 2017).
Reducing Access to Lethal Means
Lethal means are the instruments or objects used to carry out a self-destructive act (ie, firearm, poison, medication). Although it is difficult to predict who will attempt suicide, the availability of lethal means may increase the risk for suicidal ideation and behavior. Lethal means assessment is necessary for both overall risk assessment and for safety planning for patients being discharged (Betz et al., 2016). This assessment is critically important because certain lethal means such as firearms, hanging/suffocation, or jumping from heights provide little opportunity for rescue and have high fatality rates (Stone et al., 2017).
Reducing access to lethal means can reduce suicide rates, especially in times of crisis or during stressful transitions. Research indicates that:
- The interval between deciding to act and attempting suicide can be as short as 5 or 10 minutes.
- People tend not to substitute a different method when a highly lethal method is unavailable or difficult to access.
- Increasing the time interval between deciding to act and the suicide attempt by making it more difficult to access lethal means, can be lifesaving. (Stone et al., 2017)
Various strategies to reduce access to lethal means have been developed and implemented in several countries. Means restriction is considered a key component in a comprehensive suicide prevention strategy and has been shown to be effective in reducing suicide rates (DVA/DOD, 2013).
If a lethal method is not immediately available, the crisis will often pass, and the person may never attempt suicide. Others may still make an attempt but use a less deadly method. A suicide attempt using a gun leads to death in 85% to 90% of cases; an attempt by medication overdose or a sharp instrument leads to death about 1 to 2% of the time. It is important to understand that most people who attempt suicide once, and survive, never attempt again. Putting time, distance, and other barriers between a person at risk and the most lethal means can make the difference between life and death (WSDOH, 2016).
Though limiting access to materials used for hanging is difficult, even in restrictive places such as jails and hospitals, limiting or reducing access to other lethal means is possible at both the individual and community levels. Safe storage of firearms and medications, reduced access to common poisons, and placement of suicide barriers at the edges of tall buildings and bridges are proven strategies (WSDOH, 2016).
Model for Reducing Access to Highly Lethal Suicide Methods
Conceptual model of how reducing access to a highly lethal and commonly used suicide method saves lives at the population level. Drop in overall suicide rate is driven by decline in rate of suicide by the restricted method.
Highly lethal, commonly used suicide method is made less accessible or less lethal
Attempter substitutes another method; on average, substituted methods are less lethal
Fewer attempts prove fatal
Suicidal crisis passes for many
Attempt is temporarily or permanently delayed
Healthcare providers should routinely assess the presence and availability of lethal means in a patient’s home and provide education about how to reduce risks and limit access to lethal means. For patients at highest risk, make sure firearms are made inaccessible to the patient. For patients at intermediate to high acute risk of suicide, discuss the possibility of safe storage of firearms with the patient, command, and family. This can include locking up firearms, using trigger locks, or storing firearms at the military armory, at a friend’s home, or local police station. Ammunition should be stored separately (DVA/DOD, 2013).
When clinically possible, limit access to medications that carry risk for suicide, at least during the periods when patient is at acute risk. This may include prescribing limited quantities, supplying the medication in blister packaging, providing printed warnings about the dangers of overdose, or ensuring that currently prescribed medications are actively controlled by a responsible party. Also provide information on how to secure chemical poisons, especially agricultural and household chemicals, to prevent accidental or intentional ingestions. Many of these chemicals are highly toxic (DVA/DOD, 2013).
Continuity of Care
Because a variety of healthcare providers, friends, and family members may be associated with the care of a person determined to be at risk for suicide, continuity of care is critical. Maintaining continuity across facilities and providers is difficult and may be helped by electronic medical records; however, not everyone has access to this information. Mental health information has higher levels of consent in order to access records.
Continuity of care should be maintained when patients who are or have been at risk for suicide, in transition between care facilities or between other health systems or provider organizations. Providers must pay attention to several potential risks for discontinuities during transitions between care settings. These may include transitions:
- From primary care to behavioral health
- From the emergency department to ambulatory care
- From inpatient units to other settings such as nursing homes, rehabilitation, or other residential treatment settings
- From nursing homes and residential care units to ambulatory services (DVA/DOD, 2013)
A multidisciplinary approach to the treatment of suicidal patients maximizes providers’ ability to provide optimal management and services to their patients. Mechanisms for bridging transitions and for providing information to new providers must be developed on a system-by-system basis. Continuity of care is enhanced during transitions when providers directly contact other providers and followup appointments are scheduled. Transition support services (such as telephone contact with behavioral health providers) may improve continuity of care should there be a delay in followup services (DVA/DOD, 2013).
All patients who present to the ED for a suicide attempt or who are at risk for suicide require mental health evaluations. However, these patients may receive only limited mental health services, may not receive adequate treatment for underlying mental health or substance use disorders, and frequently do not receive any followup care. If patients do not require inpatient care, they should be informed about risks and be referred for mental health services before discharge. However, although a simple referral is important, it may not be sufficient (HHS, 2012).
Patients leaving the ED or hospital inpatient unit after a suicide attempt, or otherwise at a high risk for suicide, require rapid proactive outreach and followup. Having survived a suicide attempt is one of the most significant risk factors for later death by suicide. The risk is particularly high in the weeks and months following the attempt, including the period after discharge from acute care settings such as EDs and inpatient psychiatric units (HHS, 2012).
For patients who are transferred from the ED to medical-surgical services for the treatment of injuries related to a suicide attempt, followup mental health evaluations should be conducted before discharge to decide between transfer to a mental health inpatient unit or referral to outpatient care. These evaluations should consider the support available from family and friends and the patient’s clinical status. Before a decision to discharge is made, followup appointments for mental health care should be made and patients (and families or friends) should be coached about the importance of continuity in care (HHS, 2012).
All patients who are admitted to an inpatient mental health unit require followup mental health services after discharge, as well as connections to community-based supports. Healthcare systems should seek to dramatically shorten the time between inpatient discharge and followup outpatient treatment. For example, EDs and others providing services to these patients could set a goal of ensuring that followup occurs within 48 hours or, at most, within a week of discharge (HHS, 2012).
Continuity of care following a suicide attempt should represent a collaborative approach between patient and provider that gives the patient a feeling of connectedness. Strategies may include telephone reminders of appointments, providing a “crisis card” with emergency phone numbers and safety measures, and sending a letter of support. Motivational counseling and case management can also be used to promote adherence to the recommended treatment (HHS, 2012).