Keywords

Mental illness; stigma; caregiver fatigue; zero suicides; suicide prevention; warning signs; suicide attempters

Resources Already Available

The American Foundation for Suicide Prevention (AFSP), 2016 has links on its website to prevent those considering suicide from completing the act and to help people who fear for a loved one. At https://afsp.org/find-support/ phone numbers and links to support services are provided. The National Suicide Prevention Lifeline has a lifeline help number 1-800-273-8255, as well as instructions for how to set up a safety plan for those who feel suicidal: http://www.suicidepreventionlifeline.org/learn/safety.aspx. Crisis Chat is an online service in which crisis centers across the United States have joined together to form one national chat network for emotional support, crisis intervention, and suicide prevention services. Those who are suicidal or who are dealing with someone who may be suicidal can go to http://www.crisischat.org and immediately chat with someone at a crisis center.

Veterans can seek out help at https://www.veteranscrisisline.net, with a phone number to call, 1-800-273-8255, as well as an online chat service and a text messaging function. This center is also able to support those who are deaf and hard of hearing. All of the crisis centers are available 24/7, every hour of every day.

Innovative intervention methods are also being introduced, and only time will tell how well they work. For instance, the father of a young man who was involved in the fatal shooting of a police officer and was subsequently killed by police has developed an app called #Strikeback. Ronald Hummons believes his son committed suicide by cop after battling with severe depression, and he devoted his time to figuring out how to have an instant intervention. The app allows an individual contemplating suicide to get immediate social support as well as a direct reminder of his or her reason for living. The app sends a text message to three or more people in three categories (spiritual, family, and friend) that the user sets up in a profile. After the user’s support community receives the text explaining his or her suicidal ideation or depression, they will also get a GPS location so they can find the person. As the texts go out, an automatic slide show will appear on the phone displaying a picture of loved ones, family, or friends (Hummons, 2016). This app is not available as of the date of publication of this book, but it represents one of the possibilities of connecting technology’s ability to quickly deliver messages and information with those who are able to intervene effectively to save lives.

These resources are excellent avenues of assistance. Nevertheless, hotlines, apps, and peer counseling should not substitute peers or family members for trained professionals. No layperson without experience in counseling suicidal people should try to help someone by themselves. In situations where there is no time—it is an emergency—or when someone wants to intervene but does not want to call 911 or a hospital, contacting hotlines, chats or apps can provide help that is both immediate and future-oriented. Sometimes, though, it is necessary to simply dial 911 and ask for an ambulance or the police. While hospitalization is not always the best alternative for a suicidal person, and police officers are not always the best equipped to interact with mentally ill or suicidal people, in an emergency situation sometimes no other choice exists.

Right now, no standard protocol for training police and no optimal plan for treating patients who are suicidal exists. We need to do more as a nation for those who are suicidal than provide crisis intervention. We must develop a long-term, national prevention plan. That plan must go beyond words. It will involve a substantial financial commitment from the governments—local, state, and federal—as well as high-impact practices that use the financial resources efficiently and innovatively.

A National Agenda

What we are missing in the United States is a national agenda or an action plan for suicide prevention. Since 2001 we have had a National Strategy for Suicide Prevention under the supervision of the US Surgeon General, but it has not provided successful leadership on the question of suicide. Moreover, in the decade between its formation and the second report on its progress issued in 2012, suicide rose by 29% (Hogan & Clymer, 2014). The World Health Organization (WHO) indicates that a national agenda is key. They suggest that in order to create social change, there must be strong leadership, public support, and a strategy. Unfortunately, in the United States we do not have strong leadership, or a top-down directive, maintaining a focus on suicide prevention. With other health crises, such as HIV/AIDS, an action plan comes from the President (National HIV/AIDS Strategy Federal Action Plan, 2015). There is no presidential commission on suicide prevention. Although there is a presidential proclamation of World Suicide Day each September, no single action plan is coordinated by the executive branch. Without such a plan it is difficult to have unified public support. Public support also continues to be undermined by the stigma of suicide and the lack of open dialogue.

Any suicide action plan would need to be comprehensive, integrated, and synergistic (WHO, 2014). It should include multiprofessional teams who work together. In 2010, former Health and Human Services Secretary Kathleen Sebelius and former Defense Secretary Robert Gates launched a Zero Suicide campaign to try to make suicide a national priority while they were in office. The National Action Alliance for Suicide Prevention maintains a website, http://zerosuicide.sprc.org. A report, “Zero Suicide: An International Declaration for Better Healthcare,” was issued by the Crisis Services Task Force of the National Action Alliance for Suicide Prevention that explains the initiative to change assumptions about suicide (Zero Suicide, 2016).

While the Zero Suicide approach is a model for integrated and synergistic prevention, it has only been implemented in a few areas; in a following section we discuss one of those implementations in Detroit, Michigan. Zero Suicide has hosted an annual “academy” for health care organizations and national suicide prevention organizations. Sebelius and Gates claimed they wanted to save 20,000 lives in 5 years, but currently little information about progress toward that goal is available. Some researchers see hope for future studies that enable “prioritization of high-risk subgroups for targeted suicide prevention efforts, identification of effective interventions ready for deployment, estimation of the implementation impact of effective interventions in real-world settings, and assessment of time horizons for taking implementation to scale” (Pringle et al., 2013, p. 71). Although there is a National Strategy for Suicide Prevention and a Zero Suicide partnership between the US government and national community partners, no actual single national agenda exists, as the WHO recommends.

A strong coordinated national action plan could provide funding to expand such endeavors. Any endeavor would need to create objectives and generate data that could be used to evaluate the success of the plan, something the WHO deems essential. Until an action plan exists, we are left with numerous suicide prevention projects that are often funded for a short period of time and cannot be sustained. WHO (2014) submits that, “In the long-term, importantly, reducing risk will go only part of the way towards reducing suicide. Furtherance of protective factors will help build for the future—a future in which community organizations provide support and appropriate referrals to those in need of assistance, families and social circles enhance resilience and intervene effectively to help loved ones, and there is a social climate where help-seeking is no longer taboo and public dialogue is encouraged” (The Way Forward section, para. 4). Thus far the US “action plans” that do exist, like Zero Suicide, seem focused on identifying and reducing risk.

The Relationship Between Risk Factors and Motivations

In this book, we have focused almost entirely on motivations for suicide, but one cannot understand how suicide occurs or engage in its prevention by examining motivation alone. Risk factors are those attributes a person has, or circumstances in which a person finds himself or herself, that may make one more likely to commit suicide. Risk factors play an important role in assessment of the necessity for suicide intervention. Often social workers, therapists, and even family and friends are not privy to a person’s mental state or mindset, or to the motivations that may exist, such as escape from pain or interpersonal relationship issues. Moreover, the precipitant that is hardest to deduce—an ability to overcome the fear of death coupled with a desire to die—is often a deliberately hidden state. Thus, the most identifiable markers for suicide are risk factors.

Yet risk factors are ubiquitous. In the United States, being white and male is the single biggest risk factor for suicide, but most white men will not commit suicide. The Harvard School of Public Health’s “Means Matter” website (2016) hosts several studies that show both guns and rurality increase the risk of suicide. Risk factors do not cause suicide, and they are not perfect predictors, as they can be present in people who will never attempt, let alone commit, suicide. Risk factors may also be a poor way to allocate resources in suicide prevention. The crucial work for a national agenda is to target those risk factors that will be most efficacious.

The WHO identified eight individual risk factors for suicide including previous attempts, mental disorders, harmful use of substances, job or financial loss, hopelessness, chronic pain or illness, family history of suicide, and genetic or biological factors. These risk factors, such as previous suicide attempts and substance abuse, can be seen throughout our cases. In fact, some formed the basis of our categories. Those struggling with job or financial loss are represented in our cases, and it was the driving force behind suicides in the Escape–Financial category. Similarly, mental illness is prevalent in our sample; those who were trying to escape the pain from mental disorders can be found in the Escape–Psychological section of Chapter 4, Escape as a Motivation for Suicide, and severe mental illness is discussed in Chapter 7, Severe Mental Illness. Hopelessness is a common characteristic associated with suicide, but those individuals in the Failure category had a sense of doom, an inability to see a light at the end of the tunnel. Finally, the individuals who had chronic pain and illness are embodied in the Escape–Pain section of Chapter 4, Escape as a Motivation for Suicide.

In addition to individual risk factors, the WHO also presents a spectrum of other risk areas including relationships, society, community, and health systems. The impact of relationship factors, such as social isolation and conflict, have been previously discussed. Societal risk factors include stigma associated with mental illness or help-seeking and access to means. Community factors relate to the stress of acculturation, discrimination, and trauma or abuse. Finally, the risk factors related to health systems are primarily due to barriers to accessing health care and quality of care.

Societal Risk Factors: Opening the Dialogue Regarding Suicide and Mental Illness

A disability rights activist once suggested that what makes disability such a difficult topic is that we all have the potential to become disabled. At any given point anyone could succumb to a disease or accident that would leave them physically or mentally impaired. Death and suicide are similar. We will all die, and we could all get to the point where we would consider suicide. These topics become even more anxiety arousing when we shut them out of our lives and conversations. This makes it difficult to talk about, or sometimes even to take it seriously, when others reveal they are contemplating suicide.

Doughty (2014) argues that we have a structural denial of death in our society and that we avoid thinking and talking about it. In her book she discusses how we have evolved from a society where death was a part of life and when individuals died they remained in the home in a natural state, to one where our loved ones are whisked away as soon as they die and kept at a facility until ready for burial or cremation. Distancing ourselves from death, she points out, creates anxiety and fear of death.

Suicide is a form of death and we distance ourselves from conversations about it, even after it occurs. In the obituary she wrote for her sister Eleni Pinnow wrote, “Aletha Meyer Pinnow, 31, of Duluth (formerly of Oswego and Chicago, Ill.) died from depression and suicide on February 20, 2016” (Pinnow, 2016). Because it was unusual to be so candid in an obituary, the editors of the Washington Post reached out to Pinnow to tell her sister’s story. Pinnow states that she arrived at her sister’s house to find a note on the door indicating she should not go into the basement but call emergency personnel. In the aftermath she told friends and family about the wonderful characteristics that her sister had, but she also told them about her depression. She wrote,

Pinnow highlighted the deafening silence surrounding suicide and mental illness. The shame, stigma, and ignorance can be heard in our private conversations and public forums. When rhythm and blues performer Kehlani Parrish attempted suicide in March 2016, instead of being supportive, Chris Brown, a fellow performer, made comments on social media indicating there is no “attempting” suicide and suggesting that such “attempts” are for sympathy (Howard, 2016). Howard wrote that “his comments on suicide arguably could set back an important conversation that has been brewing in communities of color about the internal stigma regarding mental health.” This stigma may very well stem from relating mental illness to weakness. Stigma stifles conversations and leads to denial of mental illness and suicide. Ultimately it is very difficult to battle or eliminate something that is invisible.

That said, endeavors to reduce the stigma of mental illness have been gaining momentum. When he was in college Brian Malmon began experiencing symptoms of depression and psychosis, but he concealed them. He was later diagnosed with schizoaffective disorder and committed suicide during his senior year. His sister Alison formed Active Minds, an organization that promotes open dialogue about mental health, specifically on college campuses (Active Minds, 2016). Alison formed the organization shortly after Brian’s death in March 2000. Today, over 400 chapters are on college campuses. The goal of Active Minds is to change the culture on campuses through education and advocacy. Perciful and Meyer (2016) found that stigma toward those with mental illness can be relatively easily influenced. They examined the impact of films on college students’ attitudes toward mental illness and found that exposure to a brief film clip with an inaccurate portrayal of mental illness enhanced stigma while exposure to an accurate portrayal reduced stigma. As Active Minds continues to enhance awareness of mental illness and available resources, the stigma toward college students with mental illness should be lessened and help-seeking from those in crisis increased.

These efforts are opening the dialogue and reducing some of the stigma related to mental illness, and it may be having an impact. In August 2015, Harris Poll conducted a Mental Health and Suicide Survey with 2020 individuals (Harris Poll, 2015). They found that 38% of adults believed seeing a mental health professional was a sign of strength. However, in terms of attitudes towards suicide, although about half of the respondents thought people committed suicide as a way to escape pain, many saw it as a selfish (39%) or cowardly (20%) act. The lack of empathy for those perceived to be in pain who then kill themselves suggests that we are not teaching the right information about why people commit suicide.

As previously discussed, when a spate of mass killings occurred during the fall of 2015, Speaker of the US House of Representatives, Paul Ryan, said, “People with mental illness are getting guns and committing these mass shootings.” Although no evidence supports that people with mental illness are violent (The Editorial Board, 2015), as Perciful and Meyer (2016) found, it is fairly easy to influence the public’s perception of a stigma positively or negatively. Paul Ryan’s misinformation, which negatively stigmatizes those with mental illnesses, is being heard in national settings. Almost half of the respondents to a recent survey indicated that they believed people with mental illness were more dangerous than the general population (Barry, McGinty, Vernick, & Webster, 2013). This inaccurate information supports the views of many in the general public who have distanced themselves from mental illness and suicide. Like death, such distancing just increases fear and anxiety related to those with mental illness. It makes people afraid to talk and those who listen are often at a loss as to how to respond or what to do. We have many examples of mental illness in our popular culture but very few examples of how to respond to it effectively.

In terms of other societal interventions, the WHO also suggests that impeding access to suicidal means would also decrease risk. In his note, one of the people in our study told the story of how he acquired a gun. He went to a gun shop, but there was a waiting period, so he looked in a local newspaper and had one right away. He said, “So the weird part is, all I do is go get a trading post, make one phone call & 15 minutes later, with no paperwork I’m holding a weapon that can kill people. What a fucked up country we live in.”

The Means Matter

It is beyond the scope of this book to enter into a discussion about the rights of citizens to own guns. Acknowledging a right to own guns and supporting measures to remove firearms in life-threatening situations are not mutually exclusive positions. In many cases, the victim had threatened suicide or was currently threatening suicide, and despite the fact that someone knew a gun was in the house, s/he did not remove it. Their excuses for not removing it were varied: “I did not think he could get to it,” “I did not think it worked,” or, sadly, “I did not think he really meant to do it.” A few actually handed the victims the gun and dared them to kill themselves. If one restricts access to guns, people may still choose to kill themselves by another means, but when one has to consider other means, s/he loses the impulsivity that is characteristic of so many suicides. While some people plan their suicides for days, weeks, months or years, the vast majority contemplate the act for less than a day and almost a fourth for less than five minutes. In general, having to find a substitute for the gun creates a delay and will almost always result in the choice of a less lethal means for the suicide attempt and a greater chance for survival.

Since the primary means of suicide in the United States is firearms, reducing access to guns is a preventative measure for suicide. The Harvard School of Public Health has collected data on the use of firearms in suicide. Their website “Means Matter” has a page for firearms dealers and range owners. In 2009, “Means Matter” took the unusual approach of reaching out to gun shop owners in New Hampshire (NH) on the role that they can play in suicide prevention. The NH Firearm Safety Coalition, a group of mental health and public health practitioners, worked with firearm retailers and firearm rights advocates to develop materials that other owners could use to help prevent suicide. Nearly 50% of gun shop owners in NH had disseminated the materials by 2012. By 2015, the program had spread to other states. While it is too soon to say what effect these programs have had, many owners realize the important role they have to play.

The Suicide Prevention Resource Center (SPRC) sponsors talks between individuals which focus on suicide prevention, innovation and action. In one of these talks between Cathy Barber, the director of the “Means Matter” project, and Ralph Demicco, a gun shop owner, they discussed reducing access to lethal means (“SPARK Talks,” 2016). Demicco was “deeply impacted” after he found out that he had sold guns to three individuals who, within the span of a week, committed suicide. He said, “Let’s not get on the antigun, let’s not get on the progun bandwagon, but let’s get on the antisuicide bandwagon.” Demicco is part of the Firearm Safety Coalition in NH. Their “Gun Shop Project” has two prongs for intervention, family and friends and gun dealers. The responsibility of family and friends is to overcome prohibitions and stigma and ask family members who seem to be struggling how they are doing. The Harris Poll (2015) found the majority of adults (74%) indicated that “most people who die by suicide usually show some signs beforehand.” Family and friends then have to be prepared to have the difficult conversation that may follow if the person is suicidal. Demicco frames it well when he says, “Uncle Harry, look, you’re having a rough time. We’re here to help. Can we hold onto your guns until you feel better?” The results of the Harris Poll indicated that most adults said they would intervene if someone close to them was thinking of suicide, but some said they might not help because the person may feel worse (24%) or they would not know what to do or say (23%).

The second prong is to heighten gun dealer awareness. Demicco says this can be accomplished quite simply by putting posters in shops, encouraging clerks to ask more questions and scrutinizing sales. In Washington State, legislators proposed a bill setting up a task force to create suicide prevention training for gun dealers, owners of shooting ranges and pharmacists (Kramer, 2016). Like Demicco’s project, the bill is a collaborative effort and has the support of the National Rifle Association. The training may take the form of an online course and would be required for pharmacists to be accredited. As for gun shop owners, Alan Gottlieb, executive director of the Second Amendment Foundation said, “I have not spoken to any gun retailer in Washington State that doesn’t want to be a part of this … It’s in their interest to do it and they want to do it. People are very hungry for this” (Bach, 2016). The WHO also advocates for “gatekeeper” training where a “gatekeeper” is anyone who is in a position to identify those who may be contemplating suicide. In Colorado a Gun Shop Project began in 2014 that was modeled after Demicco’s project. It was started in rural communities where the rate of suicide by firearm is higher than the national average.

Many people who buy guns do so for protection. Having a gun in the home, however, increases the risk of a violent death in the home (Dahlberg, Ikeda, & Kresnow, 2004). In addition, the risk of suicide was higher for males in homes with guns than those without guns, regardless of storage practice, type of gun, or number of firearms in the home. In a country where warning labels are on virtually everything, a simple warning label on guns might create the delay needed to allow someone to rethink their plans for suicide. More importantly, it may make friends and relatives, who are buying guns for their loved ones, consider the stability of the individual before they do so. This would not infringe on the rights of gun owners and may help gun shop owners, like Demicco, to enhance the antisuicide message. Currently, California requires child safety warnings on guns, and New York requires a label about locking devices. No state has a suicide warning label on guns at this time.

In 1988, Britain changed the packaging for an over-the-counter medication, similar to acetaminophen, to blister packs (Emanuel, 2013). Although results of studies were mixed, there is some support that it was related to a reduction in suicides. The packaging also makes it more difficult for accidental overdoses to occur. However, it is more expensive to produce blister packs than to package pills in bottles, and companies may be reluctant to take on such a burden. Creating barriers, even if they are only small barriers, may have a tremendous impact on impulsive suicides (Seupel, 2015).

While engaged in research on mothers who kill their children, the author, Cheryl Meyer, was approached by a woman in her sixties wanting to tell her story. When she was younger, she had quit her profession to take care of her two children who were under 5 years old. One day her husband, a successful attorney, came home to tell her he had begun another relationship and was leaving her. He had removed all money from their bank accounts and he was suing her for full custody. She had no money to fight the custody challenge and no job. Her children were her life, and she believed no one could ever care for them the way she did. She made a decision to kill herself and felt she had to take her kids with her, because they were an extension of her. As she explained it, you could not die without killing your arm and the children were like an appendage. She mixed some potent narcotics with ice cream and went to take her children their final snack. On the way, the phone rang and it was her pastor. As she talked, the ice cream melted and she lost her desire to die and instead chose to fight. Years later, she recalls this experience with sadness but also a sense of pride—she and her children lived. She retained custody, regained her profession, and remarried. At the time we met, she was happily approaching retirement and looking forward to being able to spend more time with her grandchildren. The point is, it only takes a minute, or even a small act or reminder to interrupt a suicide attempt.

One final societal risk factor that WHO discusses is inappropriate media reporting. There are extensive guidelines available for media reporting of suicides (Samaritans, n.d.). In general, suicides, especially high-profile suicides such as Robin Williams, can lead to imitative behavior. Therefore, responsible reporting by the media and social media can have an impact on suicide rates. The tone of reporting, detailing of methods and extent of coverage can all influence people who may be contemplating suicide. Ohio unveiled a comprehensive suicide prevention initiative in 2016, and one facet of this initiative involves sponsoring training for schools of journalism and communication to promote the use of these guidelines when reporting on suicides (Wandersleben, 2016). The suicide prevention initiative will receive two million dollars in funding and will focus on prevention measures such as reducing stigma, improving treatment with evidence-based practices and postvention measures such as responsible media reporting and support for survivors.

Health and First-Responder Systems Risk Factors

In July 2013, police were called to the home of Paul Schenck in the small village of Yellow Springs, Ohio, for a domestic disturbance (Bachman, 2014). The first responders knew Paul, who had grown up in the village, and they knew that he suffered from mental illness and was heavily armed. A standoff began with the police which ended in an exchange of gunfire. Paul was killed, and local residents decided to use this opportunity to form a local affiliate of the National Alliance on Mental Illness (NAMI). They now have monthly family support meetings and, working in conjunction with the village human relations commission, were able to raise enough money to cover the costs of a mental health first-aid training. This training teaches first responders, family members, and friends how to respond to someone having a mental health crisis. NAMI has also been raising awareness by using an educational bus to travel to events and communities. Schenck’s death highlights the importance of support and education for first responders, professionals, and families.

Many professionals were involved in the lives of the individuals we studied. These ranged from therapists to clergy to medical doctors. Although many professionals were exemplary in their care of these individuals, others fell short. This could be related to the stigma surrounding mental illness and suicide. Approximately eight percent of emergency department admissions are for attempting or contemplating suicide (Preidt, 2016). Yet when Betz et al. (2013) examined the attitudes of emergency room health-care professionals, specifically nurses and physicians, toward suicidal behavior, they found that less than half of the respondents believed “most” or “all” suicides were preventable. Even when the risk of suicide was identified, despite the fact that national guidelines urge physicians to assess whether the patient has access to firearms or other lethal means, only about half of the physicians did so. Betz et al. found that “Many E[mergency] D[epartment] providers are skeptical about the preventability of suicide and the effectiveness of means restriction, and most do not assess suicidal patients’ firearm access except when a patient has a firearm suicide plan. These findings suggest the need for targeted staff education concerning means restriction for suicide prevention (p. 1013).” If they asked patients about suicidal ideation and found they were contemplating it, they could work with the family to reduce access to means, such as firearms and poisons, in the home.

In the Harris Poll (2015), among those who knew someone who had attempted or completed suicide or had suicidal ideation, their top response for reducing the number of people who die by suicide was not psychotherapy or medication but rather better training for health-care providers. They found that most adults (89%) felt that mental and physical health were equally important to their overall health, but over half thought that in our current health-care system physical health was treated as more important. The WHO (2014) also points to better assessment and management of suicidal behavior and mental illness as key to prevention. Some physicians may be reluctant to ask questions about mental health when it is not the presenting problem, but if it were simply part of a standardized assessment then it would become routine. WHO also recommends that once patients are identified as at risk, regardless of whether they are hospitalized or not, there should be some protocol for follow-up. Ideally, some form of psychotherapy care should be available to all patients in the emergency room.

When an individual has identified that s/he is at risk for suicide, there is a standardized protocol available for health professionals. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a publication outlining a five-step evaluation and triage plan (SAMHSA, 2009). These include identifying risk and protective factors, conducting a suicide inquiry, determining risk level/intervention, and documenting the suicidal ideation. However, assessment for suicide should be included in routine emergency room admissions. Although emergency room procedures require screening for a number of health-related illnesses, there is no routine screening for suicide. This would be especially relevant to assess for high utilizers of the emergency room. Betz et al. (2013) report, “In the year before their death, 40% of suicide victims visit an ED at least once and they are more likely to have multiple ED visits than those who die by other causes” (p. 1014).

When a universal screening for suicide risk was implemented in emergency rooms, the detection rate almost doubled (University of Massachusetts, 2016). Nurses at eight hospitals administered a screening tool that focused on three suicidal risk factors: symptoms of depression, previous suicide attempts, and active suicidal ideation. These patients were then further evaluated and either admitted or sent home with resources including a safety plan or information about community services.

There have been similar recommendations to routinely screen all adults over 18 years old for depression. In 2016, the United States Preventative Services Task Force (Siu et al., 2016) suggested that the benefits of such screenings outweigh the potential risks. Screenings could be administered by general practitioners as part of yearly physical exams. The physician is then tasked with determining what to do if a patient is depressed. The process would resemble the same one a physician would use if s/he found any physical anomaly—make a referral to an expert. If the patient-centered medical home (PCMH) approach continues to gain momentum, this process would be even more streamlined. In the patient-centered model, comprehensive care is provided by a team of experts (“Defining the PCMH,” n. d.). Care is coordinated between professionals and the focus is on the patient as a whole person, not aspects of his/her health. If routine screenings were conducted, a record could also be established to determine changes in depression levels over time. When other yearly tests are conducted, such as blood work, the results are compared to previous and subsequent years to determine patterns. The same could be done with assessments of depression.

At the Henry Ford Health System in Detroit, Michigan, they have implemented a successful patient-centered program with the goal of “Zero Suicides” mentioned previously. Primary care physicians screen for mental health problems at every visit. If a patient exhibits signs of suicide, mental health professionals begin treatment, help him create safety plans, involve family and schedule immediate follow-up appointments. “Zero Suicide” is based on the premise that suicide deaths under health care are preventable and that many individuals “fall through the cracks” using a fragmented approach. The SPRC provides training on the process, including strategies and tools. They identify seven essential elements of suicide care. These include leadership that is committed to reducing suicide, a well-trained work force, systematically identifying at-risk people, engaging the person in a pathway to care, treating with evidence-based practices, transitioning the person into the community with support systems in place, and using data to improve patient outcomes. The WHO also emphasizes data collection and evaluation as integral parts of suicide prevention.

Not all individuals who are suicidal have a chronic course. As previously discussed, a large percentage of suicide attempts are impulsive and such screenings would not benefit these individuals. The WHO (2014) suggests that interventions can be universal, selective, or indicated. Universal preventions are designed to reach an entire population. Selective preventions target vulnerable groups within a population. Indicated prevention strategies target individuals at risk. Using a “Zero Suicide” approach is indicated or individualistic. As we showed in Chapter 6, The Complexity of Suicide Motivation, not all people considering suicide are alike in terms of the stability or chaos in their lives, or in how much they truly want to die, so tailored interventions and prevention strategies are necessary. However, universal approaches can solve universal problems. Creating obstacles to means is a universal approach. In other words, overall prevention must involve a multifaceted course.

Localizing the National Agenda

For any national agenda to take shape, it will need to be implemented on a local level. One danger of having a national agenda is that it will not be fully funded, and localities will find it hard to institute programs. The days of large federal programs such as those initiated during the New Deal in the 1930s are long past. Today, a national agenda will undoubtedly involve a coalition of federal, state, and local government entities as well as private for-profit and private nonprofit organizations implementing the model of “Zero Suicide.”

Two very different states, California and Ohio, have made suicide prevention a priority. These states both have large numbers of liberals and conservatives. Their governorships frequently go from Republican to Democrat and back again. At this writing, California has a Democratic governor, Jerry Brown, and Ohio has a Republican governor, John Kasich. Their plans reflect bipartisan approaches to prevention.

The California Strategic Plan on Suicide Prevention (California Department of Mental Health, 2008) begins with a premise that “every Californian is part of the solution.” It has a set of frameworks from which have evolved best practices that are assessed and published. The state provides opportunities for training using its own resources as well as those from national agencies. It provides toolkits for working with special populations, from LGBT Youth to Elderly Living Communities. Its strategic plan (California Mental Health Services Authority, n.d.) has four prongs to reach across the lifespan, beginning from youth to old age: Statewide Suicide Prevention Network; Regional and Local Suicide Prevention Capacity Building Program; Social Marketing; and Training and Workforce Enhancement. The plan is to create information that can be used at various government and corporate levels by people with different skill levels. It adheres closely to the WHO program.

In 2015, the California Mental Health Services Administration began two statewide suicide prevention and intervention strategies. The first strategy involves a mass media campaign to encourage people to “Know the Signs” related to suicide (Research and Development Corporation (RAND), 2015). This information and an educational website are widely advertised in many places including television and online. The mass media effort is designed to make people more confident in their abilities to handle a person who is suicidal. The second strategy involves providing intensive training to first responders and other gatekeepers about risk factors, how to intervene and how to link those at risk to resources. These efforts are intended to reduce stigma and discrimination, prevent suicides and improve the mental health of residents of California, especially students. Although it is estimated that these efforts will be successful, it is yet to be determined whether this program will be effective and whether it will be too costly. Without hard data, it will be difficult to sustain.

Ohio’s pathway to a strategic plan to eliminate suicide is different from California’s, but its strategies are similar. Ohio’s 2016–17 strategic plan is ambitious and focuses on “access.” Access to crisis centers, mental health services, multimedia application, and development of a student communication plan are all central. The plan involves data surveillance and LossTeams as part of its capacity-building program. These teams consist of trained survivor and mental health professionals acting as volunteers to bring immediate support to survivors of suicide, and the idea is to have teams in every community. Ohio will have a yearly conference on suicide prevention to train people in evidence-based practices to in order to enhance workforce capacity. Ohio’s plan never mentions the WHO report or references its frameworks, though it has some features that the WHO highlighted as important.

Assessment data is important to see whether programs are working. At a park in Australia, which is known to be a “hotspot” for suicide, several measures were undertaken to prevent people from jumping off a cliff (Lockley et al., 2014). These included constructing a fence, installing phones that connect with no-wait crisis lines and installing closed circuit televisions so emergency personnel could arrive more quickly. These efforts were admirable but will not be able to be sustained without evidence of effectiveness to justify funding. It generally takes time to measure the impact of such measures. In 2012, the measures to prevent jumping from a cliff in Australia were completed and, although reported jumps and suicides have decreased, these trends are not yet statistically significant.

Similarly, Minnesota took action to see where in the state people were committing suicide. A bridge suspected of being a place where people went to die was confirmed as the place with the largest single number of suicide deaths in the state. The bridge was due for renovation, so a committee began working on ways to build suicide prevention into plans for roads, bridges, and highways. The state is also constructing a large database to identify patterns and is using the data to react more quickly to prevent a phenomenon known as “contagion,” in which clusters of suicides occur in the same place or community (Serres, 2016). Both California and Ohio, as well as other states, can benefit from what Australia and Minnesota have learned from their initiatives.

The disparity between the California and Ohio programs is emblematic of the problem the United States faces. While suicide can indeed have regional aspects and prevention does need to be tailored to localities, the ability of localities to get access to funds, to follow the mandates of outcomes assessment, and to provide proper training to all of those involved in prevention, is not equal. Both Ohio and California have small, rural communities in addition to large cities, but California in 2004 passed a Mental Health Services Act that imposed an additional one percent tax on individuals. This act was unprecedented, and it made it possible for California to fund mental health programs that otherwise might be subject to cuts. It is consumer directed and consumer oriented, and it was passed by referendum. It focuses on developing preventive and innovative programs providing integrative wraparound services. The greatest obstacle facing the kind of national agenda program that the WHO recommends is funding. If states followed California’s model, the United States could proceed with having both a local and a national agenda that implemented best practices based on WHO frameworks.

Working at the Local Level to Help Families and Survivors

Conclusions and Recommendations

Most people who kill themselves do so for interpersonal reasons or to escape pain. No suicide is inevitable. Suicides are both impulsive and planned, but in both cases limiting or delaying access to lethal means is a preventive public health measure. Manufacturers and sellers of not only guns but pills and other means can take steps to aid in suicide prevention. Education efforts must reach all levels in appropriate ways, and efforts between public and private entities in disseminating materials can make sure that education is universal. Funding must come from dedicated money at the state level with federal subsidies for additional prevention efforts and intervention among special populations.

Those at the forefront of education efforts should complete training offered by the National Center for Suicide Prevention, the CDC, or the SPRC or similar nonprofits, so that both volunteers and professionals become familiar with key concepts of primary prevention, the public health approach, and the social-ecological model, as well as youth prevention. Most of these trainings are free and online, and often several trainings are available.

Education efforts should focus on familiarizing people with warning signs and teaching them to recognize signs of constricted thinking or preparation for death. Yet education must go further, using practical demonstration techniques to show people how to have conversations about suicide. The NAMI, for example, has used such techniques to help caregivers of the mentally ill have hard conversations with their loved ones. If people do not know how to talk about suicide or how to raise the issue with those they fear might kill themselves, they cannot intervene effectively. People must also be taught when and how to seek professional help.

“Getting-the-word-out” efforts need to be seasonally targeted. While people can and do kill themselves at all times of the year, demonstrable seasonal peaks occur. It makes sense to target additional prevention messages at these times. Universities, e.g., often hold suicide awareness activities in the early fall. Autumn can be a peak time for suicide, but April and May are even more so. Additional awareness days should be instituted in the spring. At workplaces suicide awareness should also be addressed. Toolkits and media kits need to be produced for specific populations and not as one-size-fits-all.

Research needs to be funded. We have seen a spike in suicides between 1999 and 2014. Even though suicide has been around since time immemorial and has some unchanging, universal characteristics, it also has many changeable, culturally specific characteristics. Research on both risk factors and protective factors is necessary. If there are partners in research, such as university–faith-based-organization partnerships, they must be shown how to perform outcomes-based assessment so that meaningful data is generated. Studies must be funded for periods that have a chance of showing real results. Too often grants are for 3 to 5 years, but short of 10 years it can be difficult to obtain and assess data. Even though it is essential to have data assessment, it is also important to have a smooth flow of information between researchers and community partners, so bureaucracy should be kept to a minimum.

The President of the United States should appoint a commission on suicide prevention that is well funded, can work across federal agencies, and has the task of helping states to create strategic plans for suicide prevention. The commission should be available to assist states and to facilitate interstate communication. The commission needs strong leadership and should draw on the expertise of community activists and scholars across the natural sciences and social sciences.

Every effort should be made to create communities that support healthy lives. This too takes financial commitment. Some cities and towns have been able to invest in green spaces, bike lanes, and public improvement, but many have not. Innovative thinking and collaboration between workplaces and public groups can find ways to reduce stress and pull together for civic engagement. We know that to prevent suicide, people need both social support and a reason to live. Social support is something that can be given, but a reason to live has to come from within. Helping individuals build resiliency and other protective factors must be maintained in schools and after graduation, in workplaces and in communities.

Suicide is a problem that affects all people in the United States and around the world. Despite the magnitude of the problem, it is possible to reduce suicide through simple but persistent efforts. That effort is not wasted. One August morning in 1985, Ken Baldwin told his wife he was going to be home late from work. He knew that was not true. He knew he was going to die that day. He drove to the Golden Gate Bridge and did a “cannonball” off the side of the bridge. It was a four-second drop to the water, and the second his hands left the bridge he knew he did not want to die, but it was too late. He hit the water. The Coast Guard arrived quickly and picked up his body. Miraculously, Baldwin was alive, bruised and battered, but breathing. It changed his life completely (Wheeler, 2016). Nearly eight million Americans have attempted suicide. Baldwin’s jump should have placed his death among the statistics of completed suicides. Baldwin had convinced himself he was a loser and that his family would be better off without him. Baldwin said he survived in the aftermath of the jump, because he got help for his depression. Before the jump, Baldwin said, “I had no intervention.” His tunnel vision increased and he thought his death was the best thing for everyone. After the jump he recovered and went on to teach school. He watched his daughter grow up. In the seconds that he was falling from the bridge, his present life flashed before his eyes, and he saw the faces of his family and his friends, and thought, “I can’t leave all this.”

Postscript