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Summary of National Strategy for Suicide
Prevention: Goals and Objectives for Action
Table of Contents
Summary
The suffering of the suicidal is private and
inexpressible, leaving family members, friends, and colleagues to deal
with an almost unfathomable kind of loss, as well as guilt. Suicide
carries in its aftermath a level of confusion and devastation that is, for
the most part, beyond description.
Kay Redfield Jamison
Suicide has stolen lives around the world and
across the centuries. Meanings attributed to suicide and notions of what to
do about it have varied with time and place, but suicide has continued to
exact a relentless toll. In the United States, suicide is the eighth leading
cause of death and contributes–through suicide attempts–to disability and
suffering for hundreds of thousands of Americans each year. There are few
who escape being touched by the tragedy of suicide in their lifetimes; those
who lose someone close as a result of suicide experience an emotional trauma
that may take leave, but never departs.
Suicide: Cost to the Nation
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Every 17 minutes another life is lost to suicide.
Every day 86 Americans take their own life and over 1500 attempt suicide.
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Suicide is now the eighth leading cause of death
in Americans.
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For every two victims of homicide in the U.S.
there are three deaths from suicide.
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There are now twice as many deaths due to suicide
than due to HIV/AIDS.
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Between 1952 and 1995, the incidence of suicide
among adolescents and young adults nearly tripled.
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In the month prior to their suicide, 75% of
elderly persons had visited a physician.
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Over half of all suicides occur in adult men,
aged 25-65.
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Many who make suicide attempts never seek
professional care immediately after the attempt.
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Males are four times more likely to die from
suicide than are females.
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More teenagers and young adults die from suicide
than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia
and influenza, and chronic lung disease, combined.
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Suicide takes the lives of more than 30,000
Americans every year.
Only recently have the knowledge and tools become
available to approach suicide as a preventable problem with realistic
opportunities to save many lives. The National Strategy for Suicide
Prevention: Goals and Objectives for Action (NSSP or National
Strategy) is designed to be a catalyst for social change, with the power
to transform attitudes, policies, and services. It reflects a comprehensive
and integrated approach to reducing the loss and suffering from suicide and
suicidal behaviors in the United States. The effective implementation of the
National Strategy will play a critical role in reaching the suicide
prevention goals outlined in the Nation's public health agenda, Healthy
People 2010. Representing the combined work of advocates, clinicians,
researchers and survivors, the National Strategy lays out a framework
for action and guides development of an array of services and programs yet
to be set in motion. It strives to promote and provide direction to efforts
to modify the social infrastructure in ways that will affect the most basic
attitudes about suicide and that will also change judicial, educational,
social service, and health care systems. The NSSP is highly ambitious
because the devastation wrought by suicide demands the strongest possible
response.
Because suicide is such a serious public health
problem, the National Strategy proposes public health methods to
address it. The public health approach to suicide prevention represents a
rational and organized way to marshal prevention efforts and ensure that
they are effective. Only within the last few decades has a public health
approach to suicide prevention emerged with good understanding of the
biological and psychosocial factors that contribute to suicidal behaviors.
Its five basic steps are to clearly define the problem; identify risk and
protective factors; develop and test interventions; implement interventions;
and evaluate effectiveness.
As conceived, the National Strategy requires
a variety of organizations and individuals to become involved in suicide
prevention and emphasizes coordination of resources and culturally
appropriate services at all levels of government–Federal, State, tribal and
community–and with the private sector. The NSSP represents the first attempt
in the United States to prevent suicide through such a coordinated approach.
The Goals and Objectives for Action
articulates a set of 11 goals and 68 objectives, and provides a blueprint
for action. The next step for the National Strategy will be to
prepare a detailed plan that includes specific activities corresponding to
each of the 68 objectives.
Aims of the National Strategy
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Prevent premature deaths due to suicide across
the life span
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Reduce the rates of other suicidal behaviors
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Reduce the harmful after-effects associated with
suicidal behaviors and the traumatic impact of suicide on family and
friends
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Promote opportunities and settings to enhance
resiliency, resourcefulness, respect, and interconnectedness for
individuals, families, and communities
Goal 1: Promote
Awareness that Suicide is a Public Health Problem that is Preventable
In a democratic society, the stronger and broader
the support for a public health initiative, the greater its chance for
success. If the general public understands that suicide and suicidal
behaviors can be prevented, and people are made aware of the roles
individuals and groups can play in prevention, the suicide rate can be
reduced.
The objectives established for this goal are
focused on increasing the degree of cooperation and collaboration between
and among public and private entities that have made a commitment to public
awareness of suicide and suicide prevention. They include:
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Developing public education campaigns
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Sponsoring national conferences on suicide and
suicide prevention
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Organizing special-issue forums, and
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Disseminating information through the Internet.
Goal 2: Develop
Broad-based Support for Suicide Prevention
Because there are many paths to suicide, prevention
must address psychological, biological, and social factors if it is to be
effective. Collaboration across a broad spectrum of agencies, institutions,
and groups–from schools to faith-based organizations to health care
associations–is a way to ensure that prevention efforts are comprehensive.
Such collaboration can also generate greater and more effective attention to
suicide prevention than can these groups working alone. Public/private
partnerships that evolve from collaboration are able to blend resources and
build upon each group's strengths. Broad-based support for suicide
prevention may also lead to additional funding, through governmental
programs as well as private philanthropy, and to the incorporation of
suicide prevention activities into the mission of organizations that have
not previously addressed it.
The objectives established for this goal are
focused on developing collective leadership and on increasing the number of
groups working to prevent suicide. They will help ensure that suicide
prevention is better understood and that organizational support exists for
implementing prevention activities. The objectives include:
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Organizing a Federal interagency committee to
improve coordination and to ensure implementation of the National
Strategy
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Establishing public/private partnerships
dedicated to implementing the National Strategy
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Increasing the number of professional, volunteer,
and other groups that integrate suicide prevention activities into their
ongoing activities, and
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Increasing the number of faith communities that
adopt policies designed to prevent suicide.
Goal 3: Develop and
Implement Strategies to Reduce the Stigma Associated with Being a Consumer
of Mental Health, Substance Abuse, and Suicide Prevention Services
Suicide is closely linked to mental illness and to
substance abuse, and effective treatments exist for both. However, the
stigma of mental illness and substance abuse prevents many persons from
seeking assistance; they fear prejudice and discrimination. The stigma of
suicide itself–the view that suicide is shameful and/or sinful--is also a
barrier to treatment for persons who have suicidal thoughts or who have
attempted suicide. Family members of suicide attempters often hide the
behavior from friends and relatives, and those who have survived the suicide
of a loved one suffer not only the grief of loss but often the added pain
stemming from stigma.
Historically, the stigma associated with mental
illness, substance abuse, and suicide has contributed to inadequate funding
for preventive services and to low insurance reimbursements for treatments.
It has also resulted in the establishment of separate systems for physical
health and mental health care. One consequence is that preventive services
and treatment for mental illness and substance abuse are much less available
than for other health problems. Moreover, this separation has led to
bureaucratic and institutional barriers between the two systems that
complicate the provision of services and further impede access to care.
Destigmatizing mental illness and substance use disorders could increase
access to treatment by reducing financial barriers, integrating care, and
increasing the willingness of individuals to seek treatment.
The objectives established for this goal are
designed to create the conditions that enable persons in need of mental
health and substance abuse services to receive them. They include:
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Increasing the number of suicidal persons with
underlying mental disorders who receive appropriate mental health
treatment, and
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Transforming public attitudes to view mental and
substance use disorders as real illnesses, equal to physical illness, that
respond to specific treatments and to view persons who obtain treatment as
pursuing basic health care.
Goal 4: Develop and
Implement Suicide Prevention Programs
Research has shown that many suicides are
preventable; however, effective suicide prevention programs require
commitment and resources. The public health approach provides a framework
for developing preventive interventions. Programs may be specific to one
particular organization, such as a university or a community health center,
or they may encompass an entire State. While other goals in the NSSP address
interventions to prevent suicide, a special emphasis of this goal is that of
ensuring a range of interventions that in concert represent a comprehensive
and coordinated program.
The objectives established for this goal are
designed to foster planning and program development work and to ensure the
integration of suicide prevention into organizations and agencies that have
access to groups of individuals for other purposes. The objectives also
address the need for systematic planning at both the State and local levels,
the need for technical assistance in the development of suicide prevention
programs, and the need for ongoing evaluation. Objectives include:
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Increasing the proportion of States with
comprehensive suicide prevention plans
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Increasing the number of evidence-based suicide
prevention programs in schools, colleges and universities, work sites,
correctional institutions, aging programs, and family, youth, and
community service programs, and
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Developing technical support centers to build the
capacity across the States to implement and evaluate suicide prevention
programs.
Goal 5: Promote
Efforts to Reduce Access to Lethal Means and Methods of Self-Harm
Evidence from many countries and cultures shows
that limiting access to lethal means of self-harm may be an effective
strategy to prevent self-destructive behaviors. Often referred to as "means
restriction," this approach is based on the belief that a small but
significant minority of suicidal acts are, in fact, impulsive and of the
moment; they result from a combination of psychological pain or despair
coupled with the easy availability of the means by which to inflict
self-injury. Thus, a self-destructive act may be prevented by limiting the
individual's access to the means of self-harm. Evidence suggests that there
may be a limited time effect for decreasing self-destructive behaviors in
susceptible and impulsive individuals when access to the means for self-harm
is restricted. Controversy exists about how to accomplish this goal because
restricting means can take many forms and signifies different things to
different people. For some, means restriction may connote redesigning or
altering the existing lethal means of self-harm currently available, while
to others it means eliminating or limiting their availability.
The objectives established for this goal are
designed to separate in time and space the suicidal impulse from access to
lethal means of self-harm. They include:
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Educating health care providers and health and
safety officials on the assessment of lethal means in the home and actions
to reduce suicide risk
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Implementing a public information campaign
designed to reduce accessibility of lethal means
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Improving firearm safety design, establishing
safer methods for dispensing potentially lethal quantities of medications
and seeking methods for reducing carbon monoxide poisoning from automobile
exhaust systems, and
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Supporting the discovery of new technologies to
prevent suicide.
Goal 6: Implement
Training For Recognition of At-Risk Behavior and Delivery of Effective
Treatment
Studies indicate that many health professionals are
not adequately trained to provide proper assessment, treatment, and
management of suicidal patients, nor do they know how to refer clients
properly for specialized assessment and treatment. Despite the increased
awareness of suicide as a major public health problem, gaps remain in
training programs for health professionals and others who often come into
contact with patients in need of these specialized assessment techniques and
treatment approaches. In addition, many health professionals lack training
in the recognition of risk factors often found in grieving family members of
loved ones who have died by suicide (suicide survivors).
Key gatekeepers–people who regularly come into
contact with individuals or families in distress– need training in order to
be able to recognize factors that place individuals at risk for suicide, and
to learn appropriate interventions. Key gatekeepers include teachers and
school personnel, clergy, police officers, primary health care providers,
mental health care providers, correctional personnel, and emergency health
care personnel.
The objectives established for this goal are
designed to ensure that health professionals and key community gatekeepers
obtain the training that will help them prevent suicide. They include:
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Improving education for nurses, physician
assistants, physicians, social workers, psychologists, and other
counselors
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Providing training for clergy, teachers and other
educational staff, correctional workers, and attorneys on how to identify
and respond to persons at risk for suicide, and
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Providing educational programs for family members
of persons at elevated risk.
Goal 7: Develop and
Promote Effective Clinical and Professional Practices
One way to prevent suicide is to identify
individuals at risk and to engage them in treatments that are effective in
reducing the personal and situational factors associated with suicidal
behaviors (e.g., depressed mood, hopelessness, helplessness, alcohol and
other drug abuse, among others). Another way to prevent suicide is to
promote and support the presence of protective factors, such as learning
skills in problem solving, conflict resolution, and nonviolent handling of
disputes. By improving clinical practices in the assessment, management, and
treatment for individuals at risk for suicide, the chances for preventing
those individuals from acting on their despair and distress in
self-destructive ways are greatly improved. Moreover, promoting the presence
of protective factors for these individuals can contribute importantly to
reducing their risk.
The objectives established for this goal are
designed to heighten awareness of the presence or absence of risk and
protective conditions associated with suicide, leading to better triage
systems and better allocation of resources for those in need of specialized
treatment. They include:
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Changing procedures and/or policies in certain
settings, including hospital emergency departments, substance abuse
treatment centers, specialty mental health treatment centers, and various
institutional treatment settings, designed to assess suicide risk
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Incorporating suicide-risk screening in primary
care
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Ensuring that individuals who typically provide
services to suicide survivors have been trained to understand and respond
appropriately to their unique needs (e.g., emergency medical technicians,
firefighters, police, funeral directors)
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Increasing the numbers of persons with mood
disorders who receive and maintain treatment
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Ensuring that persons treated for trauma, sexual
assault, or physical abuse in emergency departments receive mental health
services
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Fostering the education of family members and
significant others of persons receiving care for the treatment of mental
health and substance abuse disorders with risk of suicide.
Goal 8: Improve
Access to and Community Linkages with Mental Health and Substance Abuse
Services
The elimination of health disparities and the
improvement of the quality of life for all Americans are central goals of
Healthy People 2010. Some of these health disparities are attributable to
differences of gender, race or ethnicity, education, income, disability,
stigma, geographic location, or sexual orientation. Many of these factors
place individuals at increased risk for suicidal behaviors.
Barriers to equal access and affordability of
health care may be influenced by financial, structural, and personal
factors. Financial barriers include not having enough health insurance or
not having the financial capacity to pay for services outside a health plan
or insurance program. Structural barriers include the lack of primary care
providers, medical specialists or other health care professionals to meet
special needs or the lack of health care facilities. Personal barriers
include cultural or spiritual differences, language, not knowing when or how
to seek care, or concerns about confidentiality or discrimination. Reducing
disparities is a necessary step in ensuring that all Americans receive
appropriate physical health, mental health, and substance abuse services.
One aspect of improving access is to better coordinate the services of a
variety of community institutions. This will help ensure that at-risk
populations receive the services they need, and that all community members
receive regular preventive health services.
The objectives established for this goal are
designed to enhance inter-organizational communication to facilitate the
provision of health services to those in need of them. They include:
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Increasing the number of States that require
health insurance plans to cover mental health and substance abuse care on
par with coverage for physical health care
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Implementing utilization management guidelines
for suicidal risk in managed care and insurance plans
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Integrating mental health and suicide prevention
into health and social services outreach programs for at-risk populations
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Defining and implementing screening guidelines
for schools, colleges, and correctional institutions, along with
guidelines on linkages with service providers, and
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Implementing support programs for persons who
have survived the suicide of someone close.
Goal 9: Improve
Reporting and Portrayals of Suicidal Behavior, Mental Illness, and Substance
Abuse in the Entertainment and News Media
The media–movies, television, radio, newspapers,
and magazines–have a powerful impact on perceptions of reality and on
behavior. Research over many years has found that media representations of
suicide may increase suicide rates, especially among youth. "Cluster
suicides" and "suicide contagion" have been documented, and studies have
shown that both news reports and fictional accounts of suicide in movies and
on television can lead to increases in suicide. It appears that imitation
plays a role in certain individuals engaging in suicidal behavior.
On the other hand, it is widely acknowledged that
the media can play a positive role in suicide prevention, even as they
report on suicide or depict it and related issues in movies and on
television. The way suicide is presented is particularly important. Changing
media representation of suicidal behaviors is one of several strategies
needed to reduce the suicide rate.
Media portrayals of mental illness and substance
abuse may also affect the suicide rate. Negative views of these problems may
lead individuals to deny they have a problem or be reluctant to seek
treatment--and untreated mental illness and substance abuse are strongly
correlated with suicide.
The objectives established for this goal are
designed to foster consideration among media leaders of the impact of
different styles of describing or otherwise depicting suicide and suicidal
behavior, mental illness, and substance abuse, and to encourage media
representations of suicide that can help prevent rather than increase
suicide. They include:
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Establishing a public/private group designed to
promote the responsible representation of suicidal behaviors and mental
illness on television and in movies
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Increasing the number of television programs,
movies, and news reports that observe recommended guidelines in the
depiction of suicide and mental illness, and
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Increasing the number of journalism schools that
adequately address reporting of mental illness and suicide in their
curricula.
Goal 10: Promote and
Support Research on Suicide and Suicide Prevention
All suicides are highly complex. The volume of
research on suicide and its risk factors has increased considerably in the
past decade and has generated new questions about why individuals become
suicidal or remain suicidal. The important contributions of underlying
mental illness, substance use, and biological factors, as well as potential
risk that comes from certain environmental influences are becoming clearer.
Increasing the understanding of how individual and environmental risk and
protective factors interact with each other to affect an individual's risk
for suicidal behavior is the next challenge. This understanding can
contribute to the limited but growing information about how modifying risk
and protective factors change outcomes pertaining to suicidal behavior.
The objectives established for this goal are
designed to support a wide range of research endeavors focused on the
etiology, expression, and maintenance of suicidal behaviors across the
lifespan. The enhanced understanding to be derived from this research will
lead to better assessment tools, treatments, and preventive interventions.
The objectives include:
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Developing a national suicide research agenda
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Increasing funds for suicide prevention research
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Evaluating preventive interventions, and
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Establishing a registry of interventions with
demonstrated effectiveness for prevention of suicide or suicidal behavior.
Goal 11: Improve and
Expand Surveillance Systems
Surveillance has been defined as the systematic and
ongoing collection of data. Surveillance systems are key to health planning.
They are used to track trends in rates, to identify new problems, to provide
evidence to support activities and initiatives, to identify risk and
protective factors, to target high risk populations for interventions, and
to assess the impact of prevention efforts.
Data on suicide and suicidal behavior are needed at
national, State and local levels. National data can be used to draw
attention to the magnitude of the suicide problem and to examine differences
in rates among groups (e.g., ethnic groups), locales (e.g., rural vs. urban)
and whether suicidal individuals were cared for in certain settings (e.g.,
primary care, emergency departments). State and local data help establish
local program priorities and are necessary for evaluating the impact of
suicide prevention strategies.
The objectives established for this goal are
designed to enhance the quality and quantity of data available on suicide
and suicidal behaviors and ensure that the data are useful for prevention
purposes. They include:
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Developing and implementing standardized
protocols for death scene investigations
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Increasing the number of follow-back studies of
suicides
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Increasing the number of hospitals that code for
external cause of injuries
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Increasing the number of nationally
representative surveys with questions on suicidal behavior
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Implementing a national violent death reporting
system that includes suicide
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Increasing the number of States that produce
annual reports on suicide, and
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Supporting pilot projects to link and analyze
information on self-destructive behavior from various, distinct data
systems.
The National Strategy for Suicide Prevention
creates a framework for suicide prevention for the Nation. It is designed to
encourage and empower groups and individuals to work together. The stronger
and broader the support and collaboration on suicide prevention, the greater
the chance for the success of this public health initiative. Suicide and
suicidal behaviors can be reduced as the general public gains more
understanding about the extent to which suicide is a problem, about the ways
in which it can be prevented, and about the roles individuals and groups can
play in prevention efforts.
The National Strategy is comprehensive and
sufficiently broad so that individuals and groups can select those
objectives and activities that best correspond to their responsibilities and
resources. The plan's objectives suggest a number of roles for different
groups. Individuals from a variety of occupations need to be involved in
implementing the plan, such as health care professionals, police, attorneys,
educators, and clergy. Institutions such as community groups, faith-based
organizations, and schools all have a necessary part to play. Sites for
suicide prevention work include jails, emergency departments and the
workplace. Survivors, consumers and the media need to be partners as well,
and governments at the Federal, State, and local levels are key in providing
funding for public health and safety issues.
Ideally, the National Strategy will motivate
and illuminate. It can serve as a model and be adopted or modified by
States, communities, and tribes as they develop their own, local suicide
prevention plans. The NSSP articulates the framework for national efforts
and provides legitimacy for local groups to make suicide prevention a high
priority for action.
The National Strategy encompasses the
development, promotion and support of programs that will be implemented in
communities across the country designed to achieve significant, measurable,
and sustainable reductions in suicide and suicidal behaviors. This requires
a major investment in public health action.
Now is the time for making great strides in suicide
prevention. Implementing the National Strategy for Suicide Prevention
provides the means to realize success in reducing the toll from this
important public health problem. Sustaining action on behalf of all
Americans will depend on effective public and private collaboration–because
suicide prevention is truly everyone's business.
SMA01-3518
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