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Wisconsin Suicide Prevention Strategy Report

 

Part 1: Introduction

Part 2: Goals, Objectives, Ideas for Action

Part 3: Looking Ahead

 

Part 1
Overview of the Wisconsin Suicide Prevention Strategy

Suicide claims thousands of lives in the United States every year. Nationwide, there is one suicide every 17 minutes.[1] In 2000, there were 588 suicides in Wisconsin, three times more than the number of homicides. Only recently has the issue of suicide been recognized as a public health problem and become the focus of a national agenda aimed at its prevention. In 1999, the U. S. Surgeon General, David Satcher, MD, PhD, issued a "Call to Action to Prevent Suicide," which identifies suicide as a major public health problem and recommends steps to reduce suicide.  A comprehensive National Strategy for Suicide Prevention was developed and released in May 2001. In it, Dr. Satcher emphasizes that more suicides could be prevented if our country would better focus its resources and its attention on this problem.

The Wisconsin Department of Health and Family Services (DHFS) Bureaus of Community Mental Health and Emergency Medical Services and Injury Prevention are committed to addressing the problem of suicide in Wisconsin. The DHFS along with other public and private partners has responded to the Surgeon General’s Call to Action by developing this guide for suicide prevention that addresses the needs of Wisconsin residents. The Wisconsin Suicide Prevention Strategy[2] (referred to throughout this document as the Wisconsin Strategy) provides a framework to guide individuals, agencies and organizations in local communities and at regional and state levels in suicide prevention efforts.

The Wisconsin Suicide Strategy seeks to increase knowledge and change attitudes about suicide and to promote suicide prevention in all sectors of society, including education, health care, media, the workplace, faith communities, and criminal justice.

The overall aims of the Wisconsin Strategy are:

  1. to prevent deaths due to suicide across the life span,

  2. to reduce the occurrence of other self-harmful acts,

  3. to reduce the suffering associated with suicidal behaviors and the traumatic impact of suicide on loved ones, and

  4. to provide opportunities and settings to enhance resilience, resourcefulness, respect, nonviolent conflict resolution, and interconnectedness for individuals, families, and communities.

This Wisconsin Strategy document lists 11 goals with related objectives and activities that interested persons and organizations can select from to implement suicide prevention in their communities.

The Wisconsin Strategy calls upon people in local communities all over the state to take action to prevent suicide. Effective suicide prevention efforts have to take place at the local level, where local needs and resources are best understood. State and regional organizations can provide guidance and support, but it is up to local communities to take action. The Wisconsin Suicide Prevention Strategy is a guide for communities to engage partners, develop a structure and implement and evaluate suicide prevention activities. This document is not a manual on suicide prevention techniques, a source of knowledge on evidence-based interventions for suicide prevention or a one-size-fits all formula for implementing suicide prevention activities in a community. Rather, it is the framework on which local partnerships can build to define the most appropriate strategies for their communities.

According to the National Strategy for Suicide Prevention, suicide is an outcome of complex interactions among neuro-biological, genetic, psychological, social, cultural, and environmental factors. Multiple risk and protective factors interact in suicide prevention. Development of a state suicide prevention strategy can bring together multiple disciplines and perspectives to create an integrated system of interventions across multiple levels, such as the individual, the family, schools, the community, and the health care system. Collaborating in a comprehensive suicide prevention strategy can help communities identify and develop priorities. Resources are always finite and priorities direct resources to projects that are likely to address the greatest needs and achieve the greatest benefits. Collaborative efforts such as public and private partnerships increase the likelihood of success in generating support for and improving suicide prevention efforts. It is important for public health agencies to play a key role in coordinated suicide prevention efforts because public health agencies have experience in organizing efforts and resources in such a way that they reach large groups of people systematically and effectively. In addition, because mental health and substance abuse problems represent some of the greatest risks for suicide, it is especially important that local mental health and substance abuse service providers be part of integrated suicide prevention efforts.

There are many benefits of a state suicide prevention strategy. They include raising awareness and helping make suicide prevention a statewide priority, providing opportunities to use public-private partnerships as well as the energy of survivors and others to engage people who may not consider suicide prevention part of their mission, linking information from different prevention programs to avoid duplication and to share information about effective prevention activities, and directing attention to efforts that benefit all people in Wisconsin. By that means, the likelihood of suicide can be reduced before vulnerable individuals reach the point of being at risk for suicide.

All it takes to start mobilizing a local community for suicide prevention is one person, any person, from any walk of life. The Suicide Prevention Advocacy Network (SPAN USA), a national non-profit advocacy organization, was started by one family that lost a daughter to suicide. It grew to become a nationwide organization that mobilized efforts resulting in the National Strategy for Suicide Prevention. A similar process could be used in any community. The starting point doesn't matter; getting started does. It matters that the persons or groups are determined to address the problem of suicide where they live and that they build a coalition of interested community and professional partners for action.

 

The Problem of Suicide in Wisconsin

Suicide is one of the leading causes of death among Wisconsin residents of all ages. The following facts about suicide taken from Wisconsin Deaths, 2000, and from the Department of Public Instruction’s 2000 Youth Behavioral Risk Survey show that suicide is indeed a serious public health problem in Wisconsin:

Suicide: Cost To The State

  • In 2000, Wisconsin lost 588 lives to suicide.

  • Ten suicides were young people under the age of 15.

  • Suicide is the second leading cause of death among young people aged 15 to 34.

  • One in five Wisconsin high school students reported seriously considering suicide.

  • Suicide attempts are much more common than death by suicide. Attempts are estimated to be 20 times the number of deaths.

  • Of the total number of Wisconsin suicides, 390 are men and women in the prime of life, aged 25 to 64.  

  • Each suicide death is estimated to affect at least six others in the person’s family, school, workplace or community. This means approximately 3600 Wisconsin people are affected by a loved one’s suicide each year.  

  • Suicide is three times more prevalent than homicide in our state.

  • Elderly Wisconsin males (age 75 and older) are three times more likely to die by suicide than  the general population in the state.

  • Firearms are the most common and lethal means of suicide, accounting for 52% of all suicide deaths in Wisconsin.

  • Suicide accounts for 24, 194 years of potential life lost before age 85.

These numbers do not include information on those who attempt suicide, unreported suicides, or deaths that may have been misclassified as accidental or undetermined.  In addition, there may be pressure to not report a death as suicide because many people wrongly see suicide as a mark of disgrace or shame, a stigma on themselves and their families.

Many suicides are preventable. Suicide victims usually give some clue or warning of their intentions. Persons having suicidal thoughts often have had recent contact with loved ones, medical professionals, mental health professionals, and sometimes law enforcement. These are all potential points of intervention. The good news is that we all can play a role in preventing these tragic deaths.

 

The Public Health Approach for Suicide Prevention

The foundation for developing and implementing the Wisconsin Suicide Prevention Strategy is the five-step public health approach presented in the National Strategy for Suicide Prevention: Goals and Objectives for Action. The public health approach is designed to organize prevention efforts and resources in such a way that they reach large groups or populations of people systematically and effectively. The steps can and often do occur at the same time and depend on one another. They can be used by groups of interested people, single agencies, regional collaborations and in state-level activities as well. The five-step public health approach is outlined below.

Clearly Defining the Problem

Identifying Causes through Risk and Protective Factors Research

Developing and Testing Interventions

Implementing Interventions According to Sound Prevention Principles

 

Principles of Suicide Prevention Effectiveness

  • Prevention programs should be designed to enhance protective factors. They should also work toward reversing or reducing known risk factors. Risk for negative health outcomes can be reduced or eliminated for some or all of a population.

  • Prevention programs should be long-term, with repeat interventions to reinforce the original prevention goals.

  • Family-focused prevention efforts may have a greater impact than strategies that focus solely on individuals.

  • Community programs that include media campaigns and policy changes are more effective when individual and family interventions accompany them.

  • Community programs need to strengthen norms that support help-seeking behavior in all settings, including family, work, school and community.

  • Prevention programming should be adapted to address the specific nature of the problem in the local community or population group.

  • The higher the level of risk of the target population, the more intensive the prevention effort must be and the earlier it must begin.

  • Prevention programs should be age-specific, developmentally appropriate and culturally sensitive.

  • Prevention programs should be implemented with no or minimal differences from how they were designed and tested.

 

Evaluating Effectiveness

 

Using the Public Health Approach to Suicide Prevention

There are broad public health themes interwoven throughout the Strategy that need to be considered as groups and individuals across Wisconsin move forward in designing and strengthening their suicide prevention activities. These themes are as follows:

Applying the Public Health Approach to Suicide Prevention

  • Draw attention to a wide range of possible actions so that specific activities to promote suicide prevention can be developed to fit the resources and areas of interest of people in everyday community life as well as professionals, groups, and public agencies.

  • Seek to integrate suicide prevention into existing health, mental health, substance abuse, education, and human services activities. Settings that provide related services, such as schools, workplaces, clinics, medical offices, correctional and detention centers, care facilities for older adults, faith communities, and community centers are all important areas for integrated suicide prevention activities.

  • Guide the development of activities that will be tailored to the cultural contexts in which they are offered. While population-based interventions are applicable without regard to risk status, it does not mean that one size fits all. The cultural and developmental appropriateness of suicide prevention activities is a vital consideration.

  • Seek to eliminate disparities that erode suicide prevention activities. Health care disparities can be attributable to such differences as race or ethnicity, gender, education or income, mental illness or other disability, age, stigma, sexual orientation, geographic location, or inadequate coverage for treatment of mental illness and substance abuse.

  • Emphasize early interventions to promote protective factors and reduce risk factors for suicide.  As important as it is to recognize and help suicidal individuals, progress depends on measures that address problems early and promote strengths so that fewer people become suicidal.

  • Seek to build statewide capacity to conduct integrated activities to reduce suicidal behaviors and prevent suicide.  Capacity building will ensure the availability of the resources, experience, skills, training, collaboration, evaluation, and monitoring necessary for success.

 


 

Part 2:
Goals, Objectives and Ideas for Action

The building blocks of the Wisconsin Strategy are eleven goals with related objectives based on the National Strategy for Suicide Prevention: Goals and Objectives for Action. The following section of the Wisconsin Strategy lists the goals, along with ideas for activities that individuals and communities can use. Activities that are proposed here may not necessarily be adopted by all communities. The information offered is not to be considered a "prescription" for what must be done. Rather, the ideas below are proposed as those from which suitable interventions within a particular community can be selected. Comprehensive suicide prevention programs are believed to have a greater likelihood of reducing the suicide rate than are suicide programs that address only one risk/protective factor or action step. By acting on combinations of the ideas listed in this section, individuals and groups can have a direct impact on suicide prevention efforts in their community.

 

GOAL 1:

PROMOTE AWARENESS THAT SUICIDE IS A PUBLIC HEALTH PROBLEM THAT IS PREVENTABLE

The stronger and broader the support for a public health initiative, the greater its chances for success. If the general public understands that suicide and suicidal behaviors can be prevented and if people are made aware of the roles individuals and groups can play in prevention, the suicide rate can be reduced. The objectives for this goal focus on increasing cooperation and collaboration within and between public
and private entities committed to public awareness of suicide and suicide prevention.

Objectives

1.      Develop and implement public information campaigns designed to increase the knowledge of all persons and communities regarding suicide prevention and to increase an understanding of the role of risk and protective factors in prevention.

2.      Establish regular suicide prevention activities such as conferences, regional meetings and public forums designed to foster collaboration with stakeholders on prevention strategies.

Sample Implementation Activities

  • Access existing materials or develop information materials that community members can distribute to neighbors, friends, and co-workers. Materials should describe suicide risk and protective factors, present available community resources, explain how to join in the effort to prevent suicide in Wisconsin, and discuss how to increase help-seeking behaviors.

  • Work with local media to develop and disseminate media guides and public service announcements describing a safe and effective message about suicide and its prevention.  Material is available from the American Foundation for Suicide Prevention and from the federal Centers for Disease Control.

  • Incorporate suicide awareness and prevention messages into employee assistance program activities.

  • Hold public forums across the state at the regional level and in local communities. These forums should present the Wisconsin Strategy and encourage regions and communities to act on implementing the Wisconsin Strategy.

  • Identify foundations and other stakeholders to contribute to the support of conferences and forums on suicide prevention.

 

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. Taking action to prevent suicide is more than just the job of mental health and substance abuse professionals. Every Wisconsin resident has a part to play in saving lives. Collaboration is a way to ensure that prevention efforts are comprehensive and it generates more attention to suicide prevention than does working alone. Objectives for this goal work to ensure that suicide prevention is better understood and that organizational support exists for implementing key activities.

Objectives

1.      Increase the number of people in Wisconsin actively involved in some aspect of suicide prevention.

2.      Increase the number of local communities actively working to implement the Wisconsin Strategy.

3.      Include suicide prevention education in ongoing programs and activities carried out by prevention organizations along with professional, volunteer, and other groups across Wisconsin.

4.      Increase the number of faith communities that adopt policies and programs promoting suicide prevention.

Sample Implementation Activities

  • At the community level, put in place outreach activities that build on community education and public information campaigns.

  • Actively recruit people from all parts of the community to participate in suicide prevention efforts.

  • Encourage organizations to consider ways they could integrate suicide prevention into their ongoing work.

  • Recruit and train at least one member of each interested community to be a community organizer for suicide prevention.

  • Visit leaders of these community groups to engage their participation and support in integrating suicide prevention into ongoing programs. Types of groups include neighborhood centers, youth groups, senior centers, child abuse, substance abuse, domestic violence, tobacco, and gambling prevention organizations.

  • Identify faith communities at both the state and community level. Visit their leaders to ask for their cooperation and support. Provide suggested policies and programs promoting suicide prevention, and ask the faith leadership to implement them in their organizations.

  • Coordinate with existing prevention programs in related areas such as substance abuse, child abuse, aging services, gambling prevention, faith communities, Cooperative Extension Service, Human Service Associations and others.

 

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 substance abuse, and both can be effectively treated. However, the stigma of mental illness and substance abuse prevents many people from getting the treatment they need. Stigma has been identified as a strong barrier to progress in the area of suicide prevention. The view that suicide is shameful and/or sinful is a barrier to treatment for persons who have suicidal thoughts or who have attempted suicide. In addition, family members of persons who attempt suicide often try to hide what is happening.

The stigma associated with mental illness, substance abuse, and suicide has contributed to inadequate resources for preventive services and to low insurance coverage for reimbursements for treatments, thus promoting the continuing separation of physical health care and mental health care. As a result, preventive services and treatment for mental illness and substance abuse are much less available than for other health problems. Barriers between the two systems can complicate provision of the services and further impede access to care. Destigmatizing mental illness and substance abuse disorders could increase access to treatment by reducing financial barriers, integrating care, and increasing the willingness of individuals to seek treatment.

Objectives

1.      Increase the proportion of the people in Wisconsin that views mental and physical health as equal and inseparable components of overall health.

2.      Increase the proportion of people in Wisconsin that view mental disorders and addictions as medical illnesses that can be diagnosed and respond to specific treatments.

3.      Increase the proportion of the people in Wisconsin who view consumers of mental health, substance abuse, and suicide prevention services as pursuing fundamental care and treatment for overall health.

4.      Increase the proportion of those suicidal persons in Wisconsin with underlying depression and other mental disorders who receive appropriate mental health treatment.

Sample Implementation Activities

  • Train community volunteers to give educational presentations at local civic groups. Include as presenters, consumers of mental health and substance abuse services and family members of consumers.

  • Review and modify (where indicated) school health curricula to ensure that mental health and substance abuse is appropriately addressed.

  • Develop a public awareness campaign that shows mental illnesses and addictions as treatable disorders and not character failings.

  • Encourage an educational campaign designed to help the community understand the implications of the brain research conducted over the past decade, with special emphasis on mental illness and addiction.

  • Develop a speaker’s bureau that can make community presentations. Include consumers of mental health and substance abuse services and family members of consumers.

  • Develop public service announcements with positive depictions of consumers of mental health and substance abuse services.

  • Work to ensure that mental health services are culturally sensitive.

 

GOAL 4:         

DEVELOP AND IMPLEMENT COMMUNITY-BASED SUICIDE PREVENTION PROGRAMS

Research has shown that many suicides are preventable, however, effective suicide prevention programs require commitment and resources. Programs may be specific to one particular organization, such as a university or a community heath center, or they may encompass the entire state. A special emphasis of this goal is that of ensuring a range of interventions that together represent a comprehensive and coordinated program.

Objectives

1.      Improve collaboration and coordination across government agencies and involve the public/private partners in developing and implementing the Wisconsin Strategy at the state, regional, and local levels.

2.      Establish agency policies and procedures for crisis response and referral of persons at risk.

3.      Increase the number of school districts, colleges and universities with evidence-based programs that are designed to address childhood, adolescent and young adult distress and prevent suicide. Evidence-based programs are programs that have some research showing that the programs were associated with the intended beneficial outcome(s).

4.      Increase the number of employers that make evidence-based prevention programs for suicide available to their employees.

5.      Improve suicide prevention programs for both adult and juvenile offenders in Wisconsin’s correctional institutions, jails, and detention centers.

6.      Increase the number of services for older people that include evidence-based suicide prevention programs designed to identify older people at risk for suicidal behavior and refer them for treatment.

7.      Increase the number of family, youth and community service organizations and providers in Wisconsin with evidence-based suicide prevention programs.

8.      Improve and coordinate crisis services.

Sample Implementation Activities

  • Provide knowledgeable presenters to assist with inservice education programs that will keep school system personnel updated about referral and crisis response procedures.

  • Support parent-teacher groups and schools in working with agencies such as the Department of Public Instruction to implement district-wide suicide prevention strategies.

  • Work with student counseling service directors at colleges and universities to select and implement programs.

  • Implement and evaluate a program that trains college resident advisors in principles of suicide risk identification, crisis intervention and referral.

  • Coordinate activities with employee assistance professionals and human resources directors at local companies.

  • Work with business associations to provide financial information about the costs and benefits of coverage for mental health and substance abuse treatment on a par with other health care.

  • Foster cultural changes in organizations that strengthen social support among workers and encourage help-seeking for emotional and health concerns.

  • Invite staff from correctional institutions to conferences and meetings on mental health and substance abuse services and suicide prevention.

  • Develop monitoring protocols for alcohol and drug detoxification programs in jail and detention facilities.

  • Work with directors of senior centers, area aging agencies, and nursing homes in communities to conduct needs assessments for suicide prevention programs for their residents.

  • Develop and implement a training program for employees of local aging programs to assist those workers and volunteers in identifying and referring persons at risk of suicide.

  • Establish round table meetings for local youth-serving organizations to exchange information and promote incorporation of suicide prevention into their ongoing programs.

  • Develop resource kits for service organizations that include suggestions for activities designed to strengthen connectedness.

  • Evaluate existing public safety and crisis coverage to identify areas for improvement.

 

GOAL 5:         

PROMOTE EFFORTS TO REDUCE ACCESS TO LETHAL MEANS AND METHODS OF SELF-HARM 

There is evidence that limiting access to lethal means of self-harm in many countries and cultures is an effective strategy to prevent self-destructive behaviors. A small but significant number of suicidal acts are impulsive. These suicides result from a combination of psychological pain or despair coupled with the easy availability of the means to inflict self-injury (medications, carbon monoxide, firearms, etc.) and often intoxication. Therefore, by limiting the individual’s availability to the means of self-harm, a self-destructive act may be prevented. The objectives for this goal are designed to separate in time and space the suicidal impulse from access to lethal means of self-harm.

Objectives

1.      Increase the proportion of primary care clinicians, other health care providers and health and public safety officials who routinely ask about the presence of lethal means of self-harm including firearms, drugs and poisons in the home, and provide education about actions to reduce associated risks.

2.      Develop and distribute materials providing education to identified high-risk populations about actions to reduce the accessibility of lethal means of self-harm.

Sample Implementation Activities

  • Collaborate with the Wisconsin Medical Society and with other health-related provider organizations to provide opportunities for physicians and other health care providers to learn about ways to decrease access to lethal means of self-harm in the home.

  • Develop standard practices for law enforcement response to domestic emergencies that assess for the presence of lethal means and advocate their safe removal or storage.

  • Promote improved safety designs in firearms and automobiles to prevent their use for self-destructive purposes.

  • Engage community leaders and prevention specialists in the development and distribution of appropriate educational materials.

  • Develop and disseminate educational materials to make parents aware of safe methods for storing and dispensing common pediatric and other medications.

  • Provide educational material to parents of young persons with substance abuse or mental health problems regarding the heightened likelihood that these youth may use lethal firearms or other means of self-harm.

 

GOAL 6:

IMPLEMENT TRAINING FOR RECOGNITION OF AT-RISK BEHAVIOR AND DELIVERY OF EFFECTIVE TREATMENT

Many of the conditions associated with suicidal behaviors, such as depression, have effective treatments. Unfortunately, many people are not trained to recognize persons at risk for suicide who could benefit from treatment. Studies indicate that many health professionals are not adequately trained to provide proper assessment, treatment and management of suicidal clients, nor do they know when and 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 in need of the specialized techniques and treatment approaches, including those providing services in schools and in correctional settings and services for older persons. In addition, many health professionals lack training in the recognition of risk factors often found in grieving family members of loved ones who died by suicide (suicide survivors).

This goal also addresses the need to provide training to key community gatekeepers as well as professionals. Community gatekeepers are people who may come into contact with persons who are in distress. They can include law enforcement and correctional personnel, primary health care providers, emergency health care providers, mental health and substance abuse treatment providers, clergy, school personnel, lawyers, funeral directors, coroners and others who regularly come into contact with people who may be at risk for suicide.

Objectives

1.      Provide continuing education for primary health care providers that includes the recognition of persons at risk for suicide, information on screening programs, assessment and management of suicide risk, effective treatments, and appropriate conditions for referral to specialty care.

2.      Incorporate suicide prevention materials in training programs for physician assistants, physicians, medical residents, nursing care providers, and other health professionals.

3.      Increase the number of clinical social work, counseling, and psychology graduate programs that include suicide prevention training.

4.      Increase the number of social workers, poison control center personnel, outreach workers, case managers, and home visitation program providers who receive job-related suicide prevention training.  This training should cover the assessment of and response to suicide risk and behaviors.

5.      Increase the number of clergy from all faith communities in Wisconsin who are trained in identification of and response to suicide risk and behaviors, who are trained to identify the difference between mental disorders and faith crises and who are comfortable talking to their congregations about suicide prevention.

6.      Increase the number of educational faculty and staff as well as youth development staff working outside school settings who have received training on identifying and responding to children and adolescents at risk for suicide.

7.      Increase the number of juvenile justice, justice, correctional and public safety system personnel who have received training on identifying and responding to persons at risk for suicide. Include divorce, family law and criminal defense attorneys.

8.      Increase effective education programs and support services available to survivors of suicide and to family members and others in close relationships with people who are at risk for suicide.

9.      Increase the number of re-certification or licensing programs in relevant professions that require or promote competencies in depression and addiction assessment and management of suicide prevention.

10.  Increase the number of “natural” community helpers, such as mail carriers or hairdressers, who are trained to recognize, respond to, and refer for help elderly people who are at risk of suicide and associated mental and substance abuse disorders.

Sample Implementation Activities

  • Include workshops on suicide prevention at annual meetings of professional associations.

  • Work with directors of education at professional schools to include suicide prevention training in the basic curriculum. This training should cover the assessment and management of suicide risk and identification and promotion of protective factors.

  • Work with the Department of Health and Family Services, Department of Public Instruction, Department of Corrections and other state agencies to incorporate training on the assessment and response to suicide risk and behaviors into contracts, standards and ongoing in-service education.

  • Provide speakers to the local ministerial alliance to assist in suicide prevention training programs.

  • Work with local school systems and youth-serving organizations to provide “gatekeeper” training for all staff, e.g., teachers, school counselors, bus drivers, custodians, coaches, playground supervisors, and after-school program staff.

  • Work with youth detention centers to provide gatekeeper training for all their staff.

  • Work with community mental health agencies and public health agencies to incorporate education and support programs for family members and others in close relationships with people at risk for suicide.

  • Work with local Meals on Wheels and other aging programs to provide gatekeeper training to staff and volunteers.

 
 

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, and alcohol and other drug abuse. Another way to prevent suicide is to promote and support the presence of protective factors (see the list in Appendix A). By improving clinical skills 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.

Mental health and substance abuse disorders present the greatest risk for suicidal behavior, yet research shows that each year eight million Americans with serious mental illness fail to receive adequate treatment.  In addition to the provision of effective mental health services, an important approach to prevent suicide and injuries from suicidal behavior is to address the problems of undetected and under-treated mental health disorders. Effective research-based treatments are available for treating a wide range of disorders. Yet these treatments unfortunately do not appear to be widely used by clinicians in the field. The National Strategy for Suicide Prevention emphasizes the importance of strategies to improve individual clinical care. Such efforts would include the development of critical care protocols for hospital emergency departments and for physicians’ offices, the establishment of optimal treatment protocols for psychiatric disorders and for the treatment of teenagers who attempt suicide, and the implementation of a public policy to increase the access to mental health care.

Objectives

1.      Increase the proportion of patients identified and treated for self-destructive behavior by Wisconsin hospital emergency departments who pursue their proposed mental health follow-up plans.

2.      Promote the incorporation of guidelines to use in assessing suicidal risk among people receiving care in primary health care settings.

3.      Increase the number of mental health and substance abuse treatment agencies that have clear suicide prevention policies and procedures designed to promote assessment of suicide risk and to intervene to reduce suicidal behaviors. Include also the means of evaluating these programs and policies.

4.      Enhance screening for depression, substance abuse and suicide risk as a basic standard of care in primary health care settings, hospices and skilled nursing facilities.

5.      Promote guidelines for discharge planning and aftercare treatment for individuals exhibiting suicidal behavior, especially those discharged from inpatient hospital units and mental health institutional settings.

6.      Provide training that specifically addresses the impact of suicide on suicide survivors as well as the impact of suicide on the first responder. (Certain people in Wisconsin provide key immediate services to suicide survivors as first responders, for instance, emergency medical technicians, public safety officers, funeral directors, and clergy.)

7.      Promote mental health and substance abuse disorder treatment services for persons with mental disorders, especially mood disorders, substance abuse disorders, or a history of trauma or abuse and for survivors of suicide.

8.      Increase the number of persons who complete their course of mental health or substance abuse treatment or continue indicated maintenance treatment.

9.      Increase the number of hospital emergency departments that routinely provide immediate post-trauma support education and/or mental health referral for all victims of sexual assault and/or physical abuse.

10.  Develop guidelines for providing education to family members and significant others of people receiving care for the treatment of mental health and substance use disorders that are at risk for suicide.  Implement the guidelines in facilities such as hospitals and mental health and substance abuse treatment agencies.

11.  Extend and improve comprehensive support services for survivors of suicide.

Sample Implementation Activities

  • Work with hospitals and health care delivery systems to develop guidelines for confirmation of mental health follow-up appointments.

  • Collaborate locally to establish processes that increase the proportion of patients who keep follow-up mental health appointments after discharge from the emergency department.

  • Sponsor the distribution of posters for emergency departments and doctors’ offices that list important steps in assessing suicide risk.

  • Develop standardized suicide assessment guidelines for primary health care physicians when assessing patients of all ages.

  • Work with local mental health and substance abuse agencies to offer community and staff in-service sessions in suicide prevention education.

  • Sponsor depression and substance abuse screening days. 

  • Work with local mental health and substance abuse agencies and offer community participation in developing guidelines that include education and psychological support to families and significant others of those who have exhibited suicidal behavior.

  • Organize suicide survivors in the community to provide seminars on recognizing and managing the personal impact of suicide on first responders and all survivors.

  • Promote follow-up calls or letters by local clinicians to encourage their clients with depression who have discontinued treatment to resume it.

  • Provide guidelines for specific educational messages to be provided to patients and caregivers in order to increase treatment adherence and relapse prevention.

  • Encourage volunteer training in suicide prevention and victim support.  Link volunteers to hospital emergency departments as a resource.

  • A partnership made up of service providers in a community can work together with some family members to develop education guidelines and implement them in their respective facilities.

  • Provide training and professional support for group facilitators and community meeting spaces for survivor of suicide support groups.

 

GOAL 8:         

INCREASE COMMUNITY LINKAGES WITH AND ACCESS TO MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

Services to prevent suicide must be available when and where people need them. That means providing services in many different places. A variety of outreach activities can address personal barriers, such as not knowing what to do or when to seek care, or concerns about confidentiality or discrimination.

Barriers to access to mental health and substance abuse services that must be addressed include structural barriers such as lack of health care professionals to meet the need for services. Financial barriers such as not having health insurance must also be addressed. The National Strategy for Suicide Prevention emphasizes the importance of promoting health insurance plans that cover mental health and substance abuse services on a par with coverage for other health care.

Objectives

1.      Compile and update a guide to Wisconsin suicide prevention resources and services (a Wisconsin Suicide Prevention Resource Directory).  Provide linkages to national prevention resources.

2.      Increase the number of Wisconsin counties with health and/or human services outreach programs for at-risk populations. These outreach programs should include mental health and substance abuse services and suicide prevention activities.

3.      Support guidelines for mental health and substance abuse screening with referral procedures for at-risk students in schools, colleges and universities.  Expand the availability of site-based professionals to provide assessment and referral after screening.

4.      Support consistent use of guidelines for mental health screening and referral in other sites with at risk populations such as correctional facilities, detention centers, crisis centers, family planning clinics, recreation centers, youth serving organizations, homeless shelters, employee assistance offices, and alcohol and drug treatment programs.

5.      Support quality care and use management guidelines that detail appropriate responses to suicidal risk or behavior.  Implement these guidelines in mental health, substance abuse and primary health care treatment settings.

6.      Promote health insurance plans that cover mental health and substance abuse services on a par with coverage for other health care services.

Sample Implementation Activities

  • Provide current suicide prevention information to Wisconsin's existing help lines.

  • Work with county health, human service and aging agencies to address the need for all staff who make home visits and/or provide case management services to the elderly to be trained to make appropriate referrals to mental health services.

  • Encourage parents to work with the local school board to institute policies and procedures for assessment, referral, and follow-up to local service providers that would offer same day initial appointments for high risk students.

  • Support ongoing continuing education in screening and referral for providers and the availability of licensed professionals to provide referral services.

  • Work with professional correctional organizations to identify and promote model suicide assessment guidelines for jails during the initial high-risk 48-hour period of incarceration.

  • Work with managed care organizations in Wisconsin to develop and implement clinical practice guidelines for suicide risk assessment and management.

  • Work with key policymakers in order to build the necessary support for substantial legislation for coverage for mental health and substance abuse treatment on a par with other health care. 

  • Work with employee organizations and local employers to provide benefits for mental health and substance abuse coverage at the same level as coverage for physical health care.

 

GOAL 9:         

IMPROVE REPORTING AND PORTRAYALS OF SUICIDAL BEHAVIOR, MENTAL ILLNESS, AND SUBSTANCE ABUSE IN THE ENTERTAINMENT AND NEWS MEDIA

Research indicates that the way suicide, mental illness, and substance abuse are presented in the media may increase suicide rates, especially among youth.  “Cluster suicides” and “suicide contagion” have been documented. Studies have shown that both news reports and fictional accounts of suicide in movies and television can lead to increases in suicide. In addition, negative views of mental health and substance abuse problems or inaccurate depictions of treatment may lead individuals to be reluctant to seek treatment, and untreated mental illness or substance abuse are strongly correlated with suicide.

Objectives

1.      Establish a coalition of public and private organizations to influence media practices. This group can promote the accurate and responsible representation of suicidal behaviors and mental illnesses and informed media coverage of suicides and suicide prevention. Resources are available from the American Foundation for Suicide Prevention and the federal Centers for Disease Control.

2.      Increase the proportion of entertainment and news programs and print coverage in Wisconsin that reflect accurate and responsible portrayal of suicidal behavior, mental illnesses, and related issues.

3.      Encourage Wisconsin journalism schools to include guidance in their course of study on the portrayal and reporting of depression and other mental illnesses, substance use disorders, suicide, and suicidal behaviors.

4.      Increase the number of news reports on suicide that follow the recommended media guidelines developed by Center for Disease Control-American Association of Suicidology. These guidelines entitled, “Reporting on Suicide: Recommendations for the Media” are available at http://www.afsp.org.

Sample Implementation Activities

  • Identify survivors, community advocates and the media who will be active participant members of the coalition.

  • Offer regular seminars for editors and producers that identify appropriate coverage and misleading or dangerous depictions of suicide, mental illnesses, and treatments.

  • Implement a media monitoring process to provide entertainment media and sponsors of television programming with information about appropriate coverage and with constructive critiques of hurtful depictions of suicide, mental illness, substance abuse disorders, or mental health and substance abuse treatments.

  • Bring survivors and prevention specialists together with journalism professors in developing curriculum materials.

  • Develop and provide press information kits that provide a resource for reporting on suicide and contact information for local spokespersons that may provide additional information and provide copies of the 2001 Center for Disease Control-American Association of Suicidology Media Guidelines.

 

 

GOAL 10:       

PROMOTE AND SUPPORT RESEARCH AND EVALUATION ON SUICIDE PREVENTION

All suicides are highly complex. Research on suicide and suicide prevention has increased considerably in the past decade and has generated new questions about why individuals become suicidal or remain suicidal. Important contributing factors of underlying mental illness, substance abuse, and biological factors, as well as potential risk that comes from certain environmental influences is 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 in building suicide prevention plans and strategies on solid scientific evidence.

Continued advancements in the prevention of suicidal behaviors can only come with solid support of a wide range of basic, clinical, and applied research endeavors designed to enhance understanding of the etiology, development, and expression of suicidal behaviors across the life span as well as those factors which enhance resiliency. Such enhanced understanding will lead to better assessment tools, treatments, and preventive interventions. It will also lead to more effective and efficient therapeutic interventions for survivors of suicide attempts.

Objectives

1.      Increase public and private funding for suicide prevention research and evaluation, and for studies on how to put scientific knowledge into practice at the state, regional, and community levels.

2.      Support development of and access to a registry of prevention activities around the state and nation with demonstrated effectiveness for preventing suicide and suicidal behaviors.

3.      Provide training and technical assistance on the evaluation of suicide prevention programs that are implemented.

4.      Increase the number of jurisdictions, e.g., human service agencies, coroners’ offices, etc., that will regularly collect and review information on suicides.

Sample Implementation Activities

  • Develop community-researcher-practitioner networks for better suicide prevention research and evaluation.

  • Local suicide prevention program planners could review the registry to help guide their selection of activities.

  • Develop and distribute user-friendly tool kits on program evaluation.

  • Follow-up studies of suicide gather additional information after a death that can be useful in prevention. Develop community support for these reviews, such as a child-fatality review team, so that local jurisdictions will be willing to participate and promote standardization for guidelines for the reviews. These reviews are sometimes called follow-back studies (see Appendix C: Glossary).

 

GOAL 11.       

IMPROVE AND EXPAND SYSTEMS FOR DATA COLLECTION, UNDERSCORING THE PUBLIC HEALTH EMPHASIS ON SURVEILLANCE OF SUICIDE AND SUICIDAL BEHAVIOR

Surveillance is defined as the systematic and ongoing collection of data. Surveillance systems are key to health planning. They can be used to track trends in rates, identify new problems, provide evidence to support activities and initiatives, identify risk and protective factors, target high risk populations for interventions and assess the impact of prevention efforts. Data are needed not only at the federal and state levels but also at the local levels. National data assists us to identify the magnitude of the suicide problem and to look at the high-risk populations. State and local data can help establish local program priorities and are necessary for evaluating the impact of suicide prevention strategies. The objectives for this goal are designed to enhance the quality and quantity of data on suicide and attempted suicide available at the state and local levels and to ensure that the data are useful for prevention purposes.

Objectives

1.      Develop and refine standard procedures for death scene investigations and implement these procedures in all Wisconsin counties.

2.      Promote and work with hospitals in collecting uniform and reliable data on suicidal behaviors by coding external causes of injury and determining associated costs.

3.      Implement a system of reporting violent deaths that includes suicides and collects information not currently available from death certificates.

4.      Produce regular reports on suicide and suicide attempts in Wisconsin, integrating data from multiple state data management systems.

5.      Establish surveillance systems of risk behaviors for suicide among youth, adults, and older persons in Wisconsin.

6.      Increase the proportion of jurisdictions that regularly completes follow-back studies (see Appendix C: Glossary) on completed suicides.

7.      Develop a data base that links and analyzes information on suicide and self-destructive behavior derived from separate data systems, including, for example, law enforcement, emergency medical services and hospitals.

Sample Implementation Activities

  • Provide scientific information about suicide to coroners and medical examiners developing procedures so the appropriate kinds of investigation evidence can be sought to accurately identify deaths that are suicide.

  • Develop or use existing local fatality review committees to provide additional information.

  • Support publication of regular Wisconsin suicide surveillance reports from the Department of Health and Family Services Divisions of Supportive Living and Public Health.

  • Promote requests by local community members for their school boards and superintendents to administer the Centers for Disease Control (CDC) Youth Risk Behavior Survey (YRBS) throughout the school system, including questions about suicidal thinking and behaviors.

  • Determine whether a local jurisdiction regularly completes follow-back studies on completed suicides and, if not, advocate for such studies.

 


Part 3: Looking Ahead

This Wisconsin Strategy is a living document.  That means it is expected to change and to further develop over time, as new opportunities, new community partners, new research, and new conditions arise. Whether you have been involved in the initial development of the Wisconsin Strategy or are just now joining, you can make a difference by contributing to the Wisconsin Strategy's continued development.  Suicide Prevention in Wisconsin is truly everyone's business.

The National Strategy for Suicide Prevention emphasizes that for any prevention activity to go forward, three things are necessary: a knowledge base, the public support for change, and a social strategy to accomplish change.

Plans are underway to launch the National Strategy for Suicide Prevention web site http://www.mentalhealth.org/suicideprevention so that available knowledge can be in the hands of those who will use it for effective decision-making in suicide prevention.  Up-to-date information can help shape public determination to prevent suicide. 

Implementing the Wisconsin Strategy requires broad participation and collaboration from each of us in our own communities. The strategy is just the beginning. Professionals and community volunteers must work side-by-side and public agencies and private organizations will have to expand their partnerships so that together the people of Wisconsin can make a lasting difference in suicide prevention. Each member of a partnership must work to build the knowledge base, the public support for change, and the social strategy to accomplish change in his or her community. For the Wisconsin Strategy to work, every one of us must be involved.


[1] One economic analysis has estimated the total economic burden of suicide in the U.S. in 1995 to be $111.3 billion; this includes medical expenses of $3.7 billion, work-related losses of $27.4 billion, and quality of life costs of $80.2 billion (Miller et al., 1999).
[2] The Wisconsin Strategy is based on recommendations and information from The 1999 Surgeon General’s Call to Action to Prevent Suicide; Mental Health: A Report of the Surgeon General; The National Strategy for Suicide Prevention: Goals and Objectives for Action; Center for Disease Control’s Suicide Prevention: Prevention Effectiveness and Evaluation; Wisconsin Deaths, 2000; Division of Supportive Living Annual Death Report; Wisconsin Injury Report, 2000; as well as input from many concerned individuals and groups in Wisconsin. The National Strategy for Suicide Prevention is recommended reading for all persons engaged in suicide prevention activities as it provides comprehensive documentation for the goals and objectives of the goals and objectives for action. A more complete history of the Wisconsin Strategy is available in Appendix B: Development of the Wisconsin Suicide Prevention Strategy.)
[3] For example, research shows that persons with mental health or substance abuse disorders are at high risk for suicide. Studies have shown that 90% of persons who have committed suicide had one or more psychiatric diagnoses (including substance abuse disorder) at the time of suicide. As a protective factor, effective clinical care for mental health and substance abuse disorders has been shown to be significant in preventing suicide. One example is that the success rate for the treatment of depression has been shown to be higher than the success rate for the treatment of heart disease. Yet research shows that 40% of Americans who have a severe mental illness do not seek treatment from either general medical or mental health specialty providers. Much remains to be learned, especially about how these risk and protective factors interact across the life span and how community suicide prevention programs can best integrate this information.

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