Addressing Self-Directed Violence Prevention for Preventive Medicine Practitioners

Problem Description

Mortality

In 2007 (the most recent year of complete US mortality data), 34 598 suicides were counted in the United States. ^* From 2006 to 2007, the age-adjusted death rate for suicide increased by 3.7%, a statistically significant increase. ⁵ Years of potential life lost before the age of 75 years (YPLL-75), one measure of premature mortality, is another way of defining the burden of a health problem in the population. In terms of YPLL-75, suicide was the fifth leading cause of YPLL for US residents in 2007. It accounted for 1 009 224 years of potential life lost, which represents approximately 4.9% of YPLL-75 for all causes of death and was preceded in rank by the following causes, in order: cancer, unintentional injury, heart disease, and conditions of the perinatal period. These summary data do not illustrate the variation with which suicide risk and the methods of suicide occur across age, sex, racial/ethnic groups, and geographic regions within the United States.

Age- and sex-specific suicide rates

In 2007, the highest rate of suicides occurred among adults aged 45 to 54 years, whereas children aged 10-14 years had the lowest rates. This pattern differs when suicides are examined by sex. Approximately 80% of suicide victims are males, and their rates are 3.9 times greater than those of females. For males in the United States, the highest rate of suicide is among those aged 75 years and older, and the highest number of suicides occur among middle-aged males aged 40 to 49 years. Among females, the highest rate and the highest number of suicides are among women aged 45 to 54 years.

Race/ethnicity- and age group–specific suicide rates

Despite the widespread impact of self-directed violence in the United States, the problem has frequently been misperceived as solely a problem affecting non-Hispanic European American males^8,9 and the affluent. ¹⁰ Data on suicide rates are available for 5 major ethnic groups: white non-Hispanic, black non-Hispanic, Hispanic, Asian Pacific Islander (A/PI), and American Indians and Alaskan Natives (AI/AN). All references to a specific race refer to non-Hispanic members (eg, non-Hispanic black, non-Hispanic Asian Pacific Islander). Examining the 2007 suicide rates by age group along with race/ethnicity demonstrates several patterns, with the highest rates occurring among AI/AN adolescents and young adults. Rates among AI/ANs, blacks, and Hispanics were highest among adolescents and young adults, then declined or leveled off with increasing age. In contrast, rates among whites were highest among those aged 40 to 54 years. Among A/PIs, rates were highest for those aged ≥65 years. Although the overall rates for AI/ANs are similar to those of whites, the rates among adolescent and young adult AI/ANs aged 15 to 29 years were substantially higher. In each of the racial and ethnic groups, suicide rates were higher for males than for females.

Method of suicide

Firearms are the most common method used in suicides in the United States and accounted for 50.2% of all suicides in 2007. The next most commonly reported methods were suffocation (23.6%), poisoning (18.4%), falls (2.1%), and cutting (1.8%). Other, or unspecified, means accounted for 3.9% of all suicides in 2007. The methods of suicide vary by sex. Among males, firearms accounted for the majority of suicides (55.7%) in 2007, followed by suffocation (24.4%), poisoning (12.5%), and then other methods. Poisoning was the leading means of suicide used by females (40.2%), followed by firearms (29.5%), suffocation (20.6%), and then other methods. The methods of suicide also vary by race/ethnicity. In 2007, firearms were the leading method of suicide among whites (52.2%) and blacks (50.9%). Among Hispanics (40.0%), A/PIs (45.0%), and Native Americans (48.1%), suffocation was the leading method.

Geographical variation

In 2007, age-adjusted suicide rates varied substantially across states, from 22.1 per 100 000 population in Alaska to 5.8 in the District of Columbia (see Figure 1). As in previous decades, age-adjusted suicide rates in the Northeastern states were generally lower than those in other regions (8.3 per 100 000), followed by the Midwest (11.1). The states in the South (12.0) and West (12.8) had the highest rates. When state-specific age-adjusted suicide rates for the United States were ranked from highest to lowest, 10 of the top 11 were states from the western region. ^**

OPEN IN VIEWER

Figure 1.

Age-Adjusted Suicide Rates Among All Persons by State: United States, 2007 (US Average 11.26).

Risk and Protective Factor Research

Fatal and nonfatal suicidal behavior are influenced by many factors, including biological, psychological, social, cultural, political, and economic issues. ² In this section, we provide a brief description of the risk and protective factors associated with suicidal behavior for various age groups.

Suicidal behavior is complex. Although we do not yet have complete understanding of the causes of suicidal behavior, we do know that, in general, individuals with any of the following characteristics may be at greater risk: have a diagnosable mental and/or substance abuse disorder (eg, clinical depression, manic depressive illness, schizophrenia, anxiety disorders, and alcohol abuse); have experienced violence (physical, sexual, intimate partner violence, or child maltreatment); are experiencing difficulty adjusting to adverse life events, such as separation or divorce; have attempted suicide previously; have access to a lethal method; have been incarcerated, or were recently arrested. ² Research has indicated that it is the interaction of these along with some other factors that increase the risk of suicidal behavior. In other words, the more of these characteristics an individual has, the greater his or her risk of suicide. We will discuss in brief some of the factors associated with suicidal behavior in 3 selected age groups where there are important recognized transition periods.^21,22

Prevention Strategies

Although several publications^2-4 have documented the widespread impact of suicidal behavior in the United States and around the globe, 2 important questions come to mind: “Can we prevent it?” and if so, “How do we prevent it?” Unlike some other fields of injury research and other areas of health-related research, the field of suicidal behavior prevention has been stifled by numerous barriers, some unique to the nature of this phenomenon,^2,34 including lack of application of sound empirical theories. This has left many within the health care profession skeptical about the preventability of suicide.^35,36 How much less willing might the public be to commit resources to this area if health care professionals themselves are unconvinced?

In this section, we describe general models for prevention strategies and then specific suicide prevention programs that could be categorized into the models. We also describe programs that are not suicide-specific but address factors related to suicidal behavior. The majority of strategies for preventing suicidal behavior have historically focused on individuals who have expressed suicidal thoughts and behaviors (eg, made an attempt) using a clinically based, provider-to-patient model. ² Fewer strategies have focused on primary prevention. Moreover, recent comprehensive reviews of suicidal behavior prevention programs have shown only a limited number of programs, whether clinically oriented or focused on primary prevention, with evidence of having an impact on suicidal acts.^38,39 We describe the types of suicide prevention programs, including those with minimal prevention evidence if there is some indication of potential benefit. The programs meeting this criterion have at least one of the following:

Public health strategies are traditionally characterized in terms of 3 levels of prevention: primary prevention approaches, which aim to prevent a problem before it occurs; secondary prevention approaches, which focus on the more immediate responses to a problem, such as emergency services following an injury sustained as a result of violence; and tertiary prevention approaches, which focus on long-term care such as rehabilitation and reintegration, attempts to lessen trauma or reduce the long-term disability associated with violent acts. These levels of prevention are defined by their temporal aspect—whether prevention takes place before violence occurs, immediately afterward or over the longer term. However, prevention specialists have increasingly been using a definition of prevention that focuses on the target groups of interest. This definition of prevention characterizes target populations into 3 groups using the terms universal, selected, and indicated. ⁴⁰

Universal strategies, particularly those aimed at broad segments of the general population, may have a greater impact on decreasing morbidity and mortality than those focused only on a small number of high-risk persons. ⁴¹ Universal strategies could include media campaigns^42,43 that seek to provide information, modify negative social norms, change the way suicide is portrayed in the media or news stories,^44,45 or create environmental change. These campaigns often address an aspect of suicidal behavior called contagion, defined as the process by which one suicide facilitates the occurrence of a subsequent suicide. The pathway of contagion can be direct (imitating someone else’s suicidal behavior) or indirect (occurrence of suicides in the community or coverage in the general broadcast or print media may produce a familiarity with and acceptance of the idea of suicide). ⁴³ Policy and environmental-related efforts for the general population that aim to reduce access to means, such as firearms,^46,47 self-poisoning, ⁴⁸ gas, ⁴⁹ or high places such as bridges ⁵⁰ are other examples of universal approaches. Many school-based programs have used a universal approach with awareness and skills training projects.^39,51 These programs are designed to educate all students about suicide and available resources and teach various skills such as decision making or social problem-solving skills.

Several types of strategies have been directed at individuals who are at a higher risk for suicidal behavior or in a position to assess risk for suicidal behavior within specific at-risk groups. ⁵¹ Programs using a gatekeeper training model instruct participants to identify and refer persons at risk for suicidal behavior. The purpose of gatekeeper training is to develop the knowledge, attitudes, and skills to identify individuals at risk, determine the levels of risk, and make referrals when necessary. Those who are trained can be school staff, community members, or physicians. ⁵² School-based prevention programs that offer support and skills training for high-risk students (eg, those who have had a friend or relative complete suicide) are another example of a selected strategy. ⁵³ Similar efforts have been directed at families who have experienced the loss of a loved one to suicide. Some efforts have lowered access to proximal risk factors for suicidal behavior such as alcohol misuse.^54,55

Indicated prevention strategies include clinical or medical interventions^56,57 and skill-building support groups for individuals who have experienced suicidal ideation or behavior, ⁵⁸ case management, and referral resources for crisis intervention and treatment. ⁵⁹ Two important approaches for suicidal individuals are dialectic behavior therapy (DBT) and cognitive therapy.^60,61 There is some overlap in the specific interventions used in either approach, both usually include behavioral analysis and therapy that focuses on problem solving, skills training, and addresses social competence and adaptive coping. Included in this indicated category are programs that address suicidal behavior prevention among the incarcerated population with suicidal ideation or behavior.^62,63 Hotlines and crisis centers are other examples. There are few studies that have evaluated the latter strategies, and those that have reach inconsistent findings.^64,65

Several organizations have used integrated approaches in which they incorporate universal, selected, and indicated approaches. Although these are challenging to design, execute, and evaluate, because activities occur on multiple levels of prevention, they may have the best chance of success.^66,67

There are also programs designed to address other health problems that have potential for reducing suicidal behavior. These programs are not suicide specific but may apply to a range of suicide-inclusive factors, for example, factors that may relate to several health issues such as early antisocial behavior, substance abuse, or child maltreatment.^68-70 Interventions for suicide-inclusive factors have the promise to bring a wider range of health benefits in that they may reduce more than one adverse outcome.^71,72 Strategies that address the social determinants of health would fit into this category since these determinants are relevant to the factors associated with suicide such as social isolation, population growth, discrimination, addictive behaviors, mental health crises, and stigma associated with help seeking.^73,74 Some communities have adopted programs using social determinants of health as a framework for their suicidal behavior prevention efforts.^75,76

Role of Preventive Medicine Practitioners

Preventive medicine practitioners approach health in a manner that looks at systemic and population-based interventions to improve the health of individuals. ⁷⁷ This basic tenet of preventive medicine lends itself to a public health approach for suicide prevention, ⁷⁸ and preventive medicine practitioners can serve several roles in the prevention of suicide. These roles include clinical responsibilities, advocacy for individual patients and communities, research, and education.

As a clinician, the preventive medicine practitioner may have clinical responsibilities from both the individual patient and population-based perspectives. Preventive medicine practitioners who work in primary care settings, schools, community centers, homeless shelters, and other related locations have the access and opportunity to play a pivotal role in suicide prevention. ⁷⁹ For guidance on appropriate assessment of suicidal ideation, depression, and other risk factors, preventive medicine practitioners should be aware of specialty organization policy statements and guidelines related to suicide prevention and use them to guide decision making. It is important for practitioners to consider and establish a suicide prevention protocol involving anticipatory guidance, appropriate assessment, and counseling of patients during health maintenance visits. ⁷⁹

Practitioners should seek evidence-based assessment tools and best-practice models. Resources such as the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices (NREPP) may be helpful. NREPP is a searchable online registry of mental health and substance abuse interventions that have been reviewed and rated by independent reviewers. ⁸⁰ The registry is designed to assist practitioners in identifying approaches to preventing and treating mental and/or substance use disorders that have been scientifically tested and that can be readily disseminated to the field. A search of the registry reveals several prevention programs associated with suicide and/or its risk factors but many of these programs would likely be considered promising ⁸¹ by more rigorous evaluation standards.

Some preventive medicine practitioners who work in local or state health departments or in federal health agencies have a critical opportunity to influence suicide prevention through application of the public health approach.7,9 There is an increased need for assessment priorities to focus on the collection, analysis, and dissemination of data associated with suicide and its risk factors. A supporting focus on community health needs related to suicide is also warranted. Preventive medicine practitioners in public health agencies also serve an important function in comprehensive suicide prevention policies. They may do this by supporting the use of evidence-based research studies in decision-making about suicide prevention policies as well as by participating in the development of such policies. Practitioners who work in public health agencies also have a duty to assure the public that services necessary to achieve suicide prevention goals are provided. This may occur through direct service provision or via partnerships with other governmental agencies, private organizations, or academic institutions.

Clinicians can extend beyond the provision of good clinical care to advocacy on behalf of patients and communities to collaborate with individuals and organizations in order to prevent suicide. Because of their unique training and practical experience, preventive medicine practitioners can serve as compelling advocates regarding suicide prevention in their communities. A clinician’s obligation to advocacy is grounded in this professional experience and expertise as well as a duty to patients. ⁸² Their insight can provide a unique perspective to decision makers in the business, private, and government sectors. Advocacy activities may include communicating with regulatory, legislative, and administrative bodies on national, state, and local levels. Activities may focus on policy development, suicide prevention media campaigns, or funding to support suicide prevention education programs and research both for implementation of those approaches with solid evidence and/or promoting evaluation of pilot programs. ⁷⁸ Prevention specialists with an interest in advocacy may seek opportunities and learn by doing, but they should also consider mechanisms to obtain formal advocacy training. Several regulatory physician organizations recognize the role of clinicians in health advocacy and the need for them to obtain the skills required for effective advocacy.^83,84 Preventive medicine practitioners may find such training experiences through seminars or conference sessions at professional specialty conferences or through fellowship experiences. For example, the Physician Advocacy Fellowship sponsored by the Institute of Medicine as a Profession supports physicians in developing or enhancing their advocacy skills by implementing a project in partnership with an advocacy organization. ⁸⁵ The unique skill set possessed by prevention practitioners also lends itself to active involvement with professional organizations in developing a suicide prevention policy statement on behalf of the organization.

Preventive medicine practitioners are needed to address the deficits in research associated with suicide prevention programming and risk assessment tools. Numerous suicide prevention programs have been created for the primary care and community setting. However, few programs have been evaluated using rigorous, scientifically controlled mechanisms.^86-88 Although the importance of primary prevention for suicidal behavior is widely accepted, and there is a need for multiple options to address suicidal behavior such as screening for suicide risk, additional research is needed to develop evidence-based screening tools and practices.^89-91 The research deficits have practical implications, as they affect recommendations for screening for suicide risk. The US Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population.^91-93 Practitioners can address these research needs by contributing rigorous, evidence-based models to the extant body of literature and to program repository programs such as NREPP. Practitioners engaged in research may also conduct studies using intentional injury data systems such as the National Electronic Injury Surveillance System (NEISS) and the National Violent Death Reporting System (NVDRS).^94-96

Prevention practitioners encompass a broad array of expertise in a variety of areas. However, some practitioners may not have developed proficiency in the subject of suicide prevention. In these cases, practitioners should employ every available opportunity to gain knowledge, including information about suicide risk and protective factors, and the latest evidence for screening, treatment, and prevention modalities. Formal learning options include professional development and continuing education conferences. Noon seminars and journal clubs may also be used. Practitioners should also become aware of community resources for patients and population-based activities. ⁸⁰ In addition, practitioners must be sensitive to the unique characteristics of the population with whom they interact. Understanding these cultural differences is critical for communicating with people from diverse geographic, ethnic, racial, cultural, economic, sexual orientation, and spiritual or social backgrounds.^97,98

Conclusion

Injury from SDV, which includes suicidal behavior, is a major cause of recorded mortality and morbidity throughout the world. The measurable human and economic costs of suicide are enormous; compounding these costs are the unquantifiable costs of loss of life, and the emotional trauma experienced by surviving family, friends, and communities affected by each person’s fatal or nonfatal suicidal behavior. Because of the complex nature of this health risk, it should be approached systematically and with a focus on population-based approaches if we are to make an impact on its reduction. Population-based approaches include several roles for the preventive practitioner. These include responsibilities related to direct clinical service provision and access, research, education, and policy. In this manner, prevention practitioners may contribute to the reduction of access to mechanisms to inflict lethal injury, identification of and treatment for those with modifiable risk factors, and the adjustment of social–cultural–behavioral determinants that contribute to suicide as an alternative.

Prevention practitioners are trained to approach health concerns from the broad scope of an entire community as well as the context of the individual patient. This combined perspective is essential to addressing the population-based, subgroup, and individual issues that are such a prominent part of modern life in the United States.