U.S. Surgeon General Jerome Adams on January 19 issued a “Call to Action” report to implement the 2012 National Strategy for Suicide Prevention, a detailed roadmap for preventing suicide in a comprehensive and coordinated way. “Much remains to be done,” the report warned. “Suicide prevention continues to lack the breadth and depth of the coordinated response needed to truly make a difference in reducing suicide.”
The report noted a new urgency behind suicide prevention efforts: the COVID-19 pandemic has now created conditions that may further suicide risk, such as increased social isolation, economic stress, and reduced access to community and religious support. “Problems resulting from the pandemic—including physical illness, loss of loved ones, anxiety, depression, job loss, eviction, and increased poverty—could all contribute to suicide risk,” Adams said.
The report said that in 2019 more than 47,000 Americans died by suicide, and that the national suicide rate increased 32 percent—from 10.5 to 13.9 per 100,000 people—in the 20-year period from 1999 to 2019. The report notes that for every person who dies by suicide, thousands more experience suicidal thoughts or attempt suicide—in a 2019 survey, 1.4 million U.S. adults reported attempting suicide in the past year and 3.5 million adults reported making a suicide plan.
“Although research has identified many strategies that can be effective in preventing suicide, these evidence-informed approaches have not yet been brought to scale,” the report said. Indeed, it added, an assessment of progress toward implementation of the National Strategy showed that few efforts have been comprehensive or strong enough to have a measurable impact on reducing suicidal behavior.
[If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.]
The report highlights the Zero Suicide Model as one of the key instruments for saving lives. In 2018, the Tompkins County Suicide Prevention Coalition and the Tompkins County Legislature endorsed the model, which incorporates recommendations for “a gold standard of care for people with suicide risk.” The model stresses the need to include suicide prevention as a core component of all health care services, rather than limit it to services provided by mental health specialists, and to improve professional and clinical training and practice for preventing suicides.
The report calls for increased use of a key component of the Zero Suicide Model: a suicide safe care pathway, to ensure that patients at risk for suicide are identified and provided with continuing care tailored to their needs.
“All patients are screened on past and present suicidal behavior, and positive screens are followed by a full assessment. Individuals identified as being at increased risk are entered into a suicide safe care pathway, thus ensuring that they are provided with the attention and support they need to stay safe and recover.
“Components include periodic assessments of suicidality and ongoing follow-up, including contacting patients who fail to show up for an appointment or withdraw from care. The inclusion of family members and other identified support persons in pathway implementation may help support patient engagement.
“Implementation of a suicide safe care pathway requires that protocols and systems be in place to collect and analyze data to track services, ensure patient safety, and assess treatment outcomes. The system should collect data on process measures, such as screening rates, safety planning, and services provided; care outcomes; suicide attempts and deaths; and any other relevant factors, such as sociodemographic characteristics, clinical history, and referrals to other sources of care.
The report noted that in response to the need for a minimum standard of care for individuals at risk for suicide, the National Action Alliance for Suicide Prevention in 2018 developed Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe. It identifies individual recommended practices—such as screening and assessment for suicide risk, collaborative safety planning, treatment of suicidality, and the use of caring contacts—that can be adopted in outpatient mental health and substance misuse settings, emergency departments, and primary care.
The surgeon general’s Call to Action states that while that all 13 goals and 60 objectives of the 2012 National Strategy remain relevant, it is time to focus on six key actions in order to reverse the current upward trend in suicide deaths in the United States.
The Call to Action identifies four strategic directions: Healthy and Empowered Individuals, Families, and Communities; Clinical and Community Preventive Services; Treatment and Support Services; and Surveillance, Research, and Evaluation.
Within those directions, the Call to Action identifies six main actions to pursue:
Activate a broad-based public health response to suicide
Address upstream factors that impact suicide
Ensure lethal means safety
Support adoption of evidence-based care for suicide risk
Enhance crisis care and care transitions
Improve the quality, timeliness, and use of suicide-related data
SUMMARY OF THE CALL TO ACTION REPORT
Action 1. Activate a Broad-Based Public Health Response to Suicide: Inspire and empower everyone to play a role in suicide prevention.
1.1 Broaden perceptions of suicide, who is affected, and the many factors that can affect suicide risk.
1.2 Empower every individual and organization to play a role in suicide prevention.
1.3 Engage people with lived experience in all aspects of suicide prevention.
1.4 Use effective communications to engage diverse sectors in suicide prevention.
Action 1: Priorities for Action
- State government and public health entities should implement the Suicide Prevention Resource Center’s Recommendations for State Suicide Prevention Infrastructure to support comprehensive (i.e., multi- component) suicide prevention in communities.
- Prevention leaders from the public and private sectors, at all levels (national, state, tribal, and local), should align and evaluate their efforts consistent with the Centers for Disease Control and Prevention (CDC) resource Preventing Suicide: A Technical Package of Policy, Programs, and Practices, to expand the adoption of suicide prevention strategies that are based on the best available evidence.
- Federal agencies and state, tribal, local, and county governments and coalitions should strengthen their prevention efforts by developing strategic suicide prevention plans based on available public health data. Mechanisms for the prompt sharing of innovations and best practices should be developed and supported.
- State and local suicide prevention coalitions and health systems should actively reach out to organizations serving populations at high risk for suicide; these systems should also reach out to individuals with lived experience in order to learn from them and engage them in designing prevention efforts.
- The public and private sectors should invest in patient-centered research and include people with lived experience in research design and implementation.
- Federal agencies, mental health and suicide prevention non-governmental organizations, and others conducting communication efforts should ensure that suicide prevention communications campaigns (1) are strategic, (2) include clear aims for behavior changes that support broader suicide prevention efforts, and (3) measure their impact.
- The federal government (Congress) should expand and sustain support for states, territories, communities, and tribes to implement comprehensive suicide prevention initiatives similar to the Comprehensive Suicide Prevention Program, funded by CDC, and the Garrett Lee Smith youth suicide prevention grants, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), which have been shown to reduce suicide in participating counties, particularly in rural areas. Funding targeting substance use disorder should be broad enough in scope to allow for interventions that address suicide prevention and related workforce and infrastructure needs.
Action 2. Address Upstream Factors that Impact Suicide: Focus on ways to prevent everyone from suicide.
2.1 Promote and enhance social connectedness and opportunities to contribute.
2.2 Strengthen economic supports.
2.3 Engage and support high-risk and underserved groups.
2.4 Dedicate resources to the development, implementation, and evaluation of interventions aimed at preventing suicidal behaviors.
Action 2: Priorities for Action
- Private companies and workplaces should leverage their health care benefits purchasing power to enhance employee mental health (e.g., invest in benefits and programs to prevent and treat behavioral health problems) and work to shape worksite values and culture to promote mental health by providing access to crisis support, support to employees following a suicide, and ongoing mental health wellness programming.
- Suicide prevention leads in federal, state, tribal, and local public health and behavioral health agencies should partner with their counterparts in labor and workforce, housing, health care, and other public assistance agencies to collaborate on strengthening economic supports for families and communities.
- Foundations and other philanthropic organizations that support early intervention programs— particularly those targeting (1) social determinants of health (e.g., reducing poverty and exposure to trauma, improving access to good education and health care, improving health equity) and/or (2) enhanced social interactions (e.g., improved parenting skills) and problem-solving and coping skills— should ensure that these programs include outcomes related to suicide (e.g., ideation, plans, attempts) and evaluation of those programs for suicide-related outcomes.
- Federal government and private sector research funders should support the analysis of existing data sets of longitudinal studies to determine the impact of various interventions (e.g., home visitation, preschool programs, substance misuse, child trauma) on suicidal ideation, plans, and attempts, and on deaths by suicide. This could include such projects as the CDC’s efforts to assess and prevent adverse childhood experiences and examine their effect on suicide-related problems, and National Institutes of Health (NIH) initiatives that focus on aggregating prevention trial data sets to better understand the long-term and cross-over effects of prevention interventions on mental health outcomes, including suicide risk,88 and to address suicide research gaps.
Action 3. Ensure Lethal Means Safety: Keep people safe while they are in crisis.
3.1 Empower communities to implement proven approaches.
3.2 Increase the use of lethal means safety counseling
3.3 Dedicate resources to the development, implementation, and evaluation of interventions aimed at addressing the role of lethal means safety in suicide and suicide prevention.
Action 3: Priorities for Action
- The federal government and private sector entities can support efforts to ensure that updated information on lethal means safety policies, programs, and practices (e.g., ERPOs, firearm owner and retailer education, bridge barriers, medication packaging, carbon monoxide shut-off sensors in vehicles) is incorporated into existing national clearinghouses and resource centers so that local municipalities, states, and tribes can adopt and evaluate them for their prevention benefits.
- States, communities, and tribes should collaborate with the private sector to increase awareness of and take action to reduce access to firearms and other lethal means of suicide, including opioids and other medications, alcohol and other substances or poisons, and community locations (e.g., railways, bridges, parking garages) where suicidal behaviors have occurred. This urgent multi-sector effort is key to saving lives by reducing access to lethal means for individuals in crisis.
- Health systems and payers should leverage their existing training and resources and collaborate on a national initiative to train general and specialty health care providers and care teams on safety planning and lethal means counseling.
- SAMHSA and the VA should coordinate to ensure that lethal means safety assessment and counseling are incorporated into the assessment and intervention procedures of the National Suicide Prevention Lifeline and Veterans Crisis Line call centers, particularly in preparation for the national launch of 988.
- The federal government can prioritize and fund research and program evaluation analyzing community and clinical lethal means safety interventions (e.g., ERPOs, firearm owner and retailer education, bridge barriers, medication packaging, carbon monoxide shut-off sensors in vehicles) at the population level.
- State and federal governments should collaborate with the private sector on a synchronized public health communication campaign addressing lethal means safety in the context of suicide prevention, which should then be evaluated to determine prevention benefits and inform future communication efforts.
Action 4. Support Adoption of Evidence-Based Care for Suicide Risk: Ensure safe and effective care for all.
4.1 Increase clinical training in evidence-based care for suicide risk.
4.2 Improve suicide risk identification in health care settings.
4.3 Conduct safety planning with all patients who screen positive for suicide risk.
4.4 Increase the use of suicide safe care pathways in health care systems for individuals at risk.
4.5 Increase the use of caring contacts in diverse settings.
Action 4: Priorities for Action
- The federal government, professional associations, and accrediting bodies should collaborate to address barriers to adopting the Action Alliance’s Suicide Prevention and the Clinical Workforce: Guidelines for Training to ensure increased clinical training in evidence-based care for suicide risk during graduate education and post-graduate training.
- State behavioral health licensing boards should add continuing education requirements for suicide prevention in order for clinicians to maintain licensure or certification.
- Payers from the public and private sectors should incentivize the delivery of evidence-based care via existing levers in contracting and reimbursement.
- Federal and state policymakers and commercial payers and health systems should take specific steps to improve outcomes for individuals with mental health and substance misuse conditions in primary care by using effective methods (e.g., CoCM) to integrate mental health and substance misuse treatment into primary care.
- To enhance workflows for suicide safe care, health systems should collaborate with EHR vendors to develop options for integrating screening, suicide safe care pathways, and safety planning into their EHR systems.
- Public and private health systems should adopt and/or implement the recommendations in Recommended Standard Care for People with Suicide Risk in all health care settings.
Action 5. Enhance Crisis Care and Care Transitions: Ensure that crisis services are available to anyone, anywhere, at any time.
5.1 Increase the development and use of statewide or regional crisis service hubs.
5.2 Increase the use of mobile crisis teams.
5.3 Increase the use of crisis receiving and stabilization facilities.
5.4 Ensure safe care transitions for patients at risk.
5.5 Ensure adequate crisis infrastructure to support implementation of the national 988 number.
Action 5: Priorities for Action
- The federal government and the private sector should address gaps, opportunities, and resource needs to achieve standardization among crisis centers in interventional approaches and quality assurance in preparation for the launch of 988.
- The federal government, states, and the private sector should work together to optimize system design, system operations, and system financing for 988 as the hub of an enhanced, coordinated crisis system, and enhance coordination between Lifeline 988 centers and 911 centers to reduce overreliance on 911 services and ED boarding (the practice of keeping admitted patients on stretchers in hallways due to crowding).
- The federal government should fund the necessary infrastructure to support crisis care (e.g., Congressional support for the 5 percent SAMHSA Mental Health Block Grant set-aside; core services identified in SAMHSA’s National Guidelines for Behavioral Health Crisis Care) and should provide technical assistance to states looking to evolve crisis systems of care.
- The federal government and foundations should support research to identify effective models of mental health crisis response (e.g., coordinated efforts among mental health specialists, peers, and law enforcement) to improve short- and long-term effects on communities of color and other marginalized populations.
- The federal government and private sector payers should support the use of follow-up phone calls or texts within 24 hours of discharge from psychiatric hospitalization or emergency room discharge to check in with the patient, provide support, and maintain contact until the person’s first outpatient appointment.
- The federal government should establish universally recognized coding for behavioral health crisis services, and public and private sector partners should collaborate with payers and health systems to increase adoption of the new coding.
- The federal government should support the development of an essential benefits designation that will encourage health care insurers to provide reimbursement for crisis services, thus reducing the financial burden on state and local governments to pay for those services, delivered within a structure that supports the justice system and ED diversion.
Action 6. Improve the Quality, Timeliness, and Use of Suicide-Related Data: Know who is impacted and how to best respond.
6.1 Increase access to near real-time data related to suicide.
6.2 Improve the quality of data on causes of death.
6.3 Expand the accessibility and use of existing federal data systems that include data on suicide attempts and ideation.
6.4 Improve coordination and sharing of suicide-related data across the federal, state, and local levels.
6.5 Use multiple data sources to identify groups at risk and to inform action.
Action 6: Priorities for Action
- The federal government should support near real-time collection of data on deaths by suicide and nonfatal suicide attempts in a group of sentinel states to develop the framework for a national early warning system for suicidal behavior in the U.S. The system would create a central database that links multiple data sources and would build state and local capacity to translate data trends into prevention efforts in a timely manner. In addition, the federal government should expand ED SNSRO to monitor nonfatal suicide-related outcomes, track spikes and potential clusters in suicide attempts, and identify patterns, all of which can then inform prevention activities.
- The public and private sectors should collaborate on a near real-time suicide dashboard that pulls data from existing national, state, tribal, and community databases to make data on deaths by suicide and suicide attempts timelier and more accessible, thus linking the dashboard to prevention actions on the ground.
- The federal government should implement Recommendation 1.8 of the Interagency Serious Mental Illness Coordinating Committee, which calls on public and private health care systems to routinely link mortality data for serious mental illness (SMI) and serious emotional disturbance (SED) populations, and supports the standardization of similar data gathering across state and local systems for SMI and SED populations within the justice system.
- Professional organizations connected to coroners and medical examiners at the state and national levels should release guidance on and support wide-scale implementation of coding sexual orientation and gender identity in death investigations.
- The federal government should implement the PREVENTS Executive Order recommendation for the U.S. Department of Health and Human Services and the VA to propose legislative changes that mandate a standardized process for uniform ED data reporting across the United States specific to the external cause of injury (e.g., suicide attempt).
- Health care systems should work with public sector agencies to support the linkage of mortality data with health record, social, geographic, education, and criminal justice data systems to strengthen data quality and increase accountability for patient outcomes across key systems.
- State suicide prevention coordinators and community suicide prevention leaders should routinely monitor available data to identify trends and evaluate their own efforts.