The IOM's Reducing Suicide described suicide as "a major national and international public health problem with about 30,000 deaths in the United States and 1,000,000 deaths in the world each year and every year."
In view of the magnitude of the problem, the IOM report called for development, testing, expansion, and implementation of programs for suicide prevention funded by appropriate agencies, including the National Institute of Mental Health (NIMH), the Department of Veterans' Affairs (DVA), the CDC, and the Substance Abuse Mental Health Services Administration (SAMHSA). Specific recommendations about prevention programs included:
- Creating partnerships among federal, state, and local agencies to implement effective suicide prevention programs
- Collaborating with professional societies, including the American Psychiatric Association and the American Psychological Association, and nonprofit organizations dedicated to the prevention of suicide, such as the American Association of Suicidology
- Expanding programs that have demonstrated success in select populations. For example, the Air Force program (see below) should be adopted by comparable organizations that experience increased suicide rates such as police and emergency rescue workers. There should be a systematic identification of high suicide risk groups for targeted intervention.
- Including coping and resiliency training in the curricula for school-aged children and intensifying or expanding these when feasible. In view of the link between cumulative life stresses and suicide and the existing data supporting the efficacy of these programs, it is expected that this training will act to reduce the frequency of suicidal behavior as well as other mental health disorders.
- Restricting access to common means of suicide by enacting or strengthening legislation to ensure gun safety, building barriers on bridges, modifying contents of cooking gas, reinforcing packaging of commonly used pills, and poison control
- Evaluating public education campaigns to determine and quantify their effectiveness to change knowledge and attitudes and to reduce suicide and suicidal behaviors
The Air Force Suicide Prevention Program
The IOM report considered a variety of prevention programs that address risk factors and aim to enhance protective factors in order to reduce the incidence of suicide and suicidal behaviors. It observed that programs that appear effective, such as one initiated by the U.S. Air Force, are comprehensive and simultaneously act to increase knowledge and change attitudes within a community, dispel barriers to treatment, and improve access to support and intervention.
The Air Force Suicide Prevention Program is a population-based, community approach to suicide risk prevention and behavioral health promotion that was named a "best practice initiative" by the assistant secretary for health of the HHS. It integrated human, medical, and mental health services, uniting a coalition of community agencies from within and outside of the health care delivery system to significantly reduce suicide among air force personnel, which had risen to an all-time high during the mid-1990s. Figure 2.5 shows suicide rates among air force personnel from 1990 to 2002.
The program attempted to reduce risk factors, such as problems with the law, finances, intimate relationships, mental health, job performance, substance abuse, social isolation, and poor coping skills. It simultaneously sought
FIGURE 2.5 Suicide rate of Air Force members, 1990–2002
To improve surveillance, a Web-based database was established to capture demographic, risk factor, and protective factor information about individuals who attempted or completed suicide. This extremely secure tool protected privacy and permitted timely detection of changes in patterns in suicidal behavior that could be used to strengthen policies and enhance practices throughout the air force community. To improve crisis management, critical incident stress management teams were assembled and poised for deployment to installations hard hit by potentially traumatizing events such as combat deployments, serious aircraft accidents, and natural disasters, as well as suicides within the units.
When the program commenced in 1995, suicide was the second-leading cause of death among air force personnel. After its inception, the suicide rate declined significantly for three consecutive years. During the first six months in 1999 the rate dropped to less than 3.5 per one hundred thousand—more than 50% less than the lowest rate on record prior to 1995 and an 80% drop from the peak rates in the mid-1990s. Although the suicide rates increased in 2000 and early 2001, they declined again after and remained much lower than rates prior to 1995. (See Figure 2.5.)
The air force experience is not necessarily applicable to the general population, because the air force is a tightly controlled and relatively homogenous community with identifiable leaders readily able to influence community norms and priorities. It can still serve as a model for comparable hierarchical organizations and offers insight into prevention program planning. The program's overarching principles, such as engaging community leaders to change cultural norms, improving coordination of diverse human and health services, and providing educational programs to community members, can inform national efforts and may be replicable in other populations.
School-Based Prevention Programs
After reviewing eleven universal prevention strategies targeting high school students and more than fifteen programs aimed at younger students, the IOM report confirmed that school-based programs have demonstrated success in reducing suicidal behavior, but it also observed that effective school-based interventions were far more than simply awareness or education programs. Successful programs offer services such as screening, support, and skills training groups, and establish school-based crisis response plans and teams of professionals to enact the plans. They emphasize the importance of telling adults about emotional distress and seeking help for oneself or friends, as well as cultivation of the competence and skills that offer protection from the adverse effects of stress.
The IOM cited Reconnecting Youth, a personal competency training program piloted in five urban high schools as a model selective prevention program that uses a combination of support and skills training. Between 35% and 40% of youth at risk for academic failure are also at risk for suicide, so the program targeted potential high school dropouts. The program was offered as a single-semester, daily, fifty-five-minute elective class with one facilitator or teacher and about ten students. Participants completed a comprehensive suicide-risk assessment and learned a variety of skills that produced measurable gains in increasing personal control—self-efficacy, self-esteem, and reliance on social supports. Participants also reported decreased depression, hopelessness, anger, and stress.
The school-based prevention programs for youth identified as being at risk focused on enhancing students' feelings of personal control. The IOM report presented two programs, Counselors Care (C-CARE) and Project CAST (Coping and Support Training). C-CARE interventions targeted potential high school dropouts who had shown specific early signs of suicide and related risk factors and offered them an in-depth motivational interview that assessed a list of direct suicide risk factors, related risk factors, and protective factors. Following a one-on-one, two-hour assessment interview, participants received an additional two-hour counseling session and meetings with parents and school personnel, intended to strengthen social connections. A booster session, consisting of further assessment and counseling, was provided between six and eight weeks following the initial intervention.
Project CAST provided twelve sessions of small group skills training and case management along with the initial and booster sessions provided by C-CARE for a comparable target population. In addition to addressing school performance and drug use, the twelve sessions emphasized building personal resources such as self-esteem, personal control of moods, positive coping strategies, staying on track, and monitoring and setting goals. The sessions also concentrated on empathy and motivation as well as identifying support needs and resources, and how to access help and support.
Participants from both programs were followed and assessed on four different occasions, including nine months after completion of either program. Both programs were found to enhance self-esteem and reduce depression, anxiety, hopelessness, and anger. Each also decreased the use of "hard" drugs, but CAST was more effective at reducing alcohol and marijuana use and produced more enduring increases in problem solving, coping, and personal control. There were no measurable changes in suicide rates, but this finding is not surprising in view of the low risk of suicide during the limited follow-up period and the relatively small sample sizes of the populations.
Do Telephone Hotlines and Crisis Centers Prevent Suicide?
Although crisis centers and telephone hotlines that aim to prevent suicide attempts are ubiquitous, the IOM report observed that their effectiveness is unknown. The IOM recommended research to determine not only whether such services are effective preventive measures or deterrents but also which model of crisis counseling or telephone service is most effective. Is anonymous telephone counseling preferable to telephone counseling in which the caller must disclose his or her identity? Is face-to-face counseling a better intervention than telephone counseling in terms of connecting persons in crisis to mental health services they might otherwise fail to seek or obtain? Should crisis centers and telephone hotlines be staffed by professional mental health workers or trained volunteers? Finally, the IOM report encouraged researchers to consider whether provision of crisis intervention services via the Internet is a workable alternative, especially for youths who may be more comfortable seeking help online than in person or by telephone.
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