Pennsylvania Youth Suicide Prevention Plan

Introduction:

Youth suicide statistics reinforce the need for comprehensive youth suicide prevention efforts. Suicide is one of the leading causes of death for young people age 15-24. (CDC) Suicide rates for those 15-19 have tripled since 1960 (CDC, 1997). The American Association of Suicidology found that 4-8% of adolescents report an attempted suicide within the prior 12 months. Data from the Centers for Disease Control (CDC) indicates that approximately 500,000 teens attempt suicide each year.

Since the 1980's, Pennsylvania has made strong efforts toward the prevention of youth suicide through programs such as the Commonwealth Student Assistance Program (SAP), Services for Teens at Risk (STAR-Center), the Yellow Ribbon Program and a variety of other approaches in local areas.

SAP, a collaborative program started in 1985 between the state Departments of Education (PDE), Health (DOH), and Public Welfare (DPW), exists in all 501 school districts. Every secondary school building is required to have a student assistance program. DPW's Office of Mental Health and Substance Abuse Services (OMHSAS) funds county Mental Health/Mental Retardation (MH/MR) Programs and DOH's Bureau of Drug and Alcohol Programs (BDAP) funds Single County Authorities (SCAs) to provide SAP liaison services to all secondary buildings. Commonwealth Approved Trainers (CATS) provide training for all school core teams and ten Regional SAP Coordinators provide technical assistance to the state's nine regions. The core teams in each secondary building, comprised of teachers, principals, school counselors, school nurses, psychologists, social workers, and community liaisons from the mental health and drug and alcohol agencies, assist in identifying students at risk for suicide or other behavioral health problems.

The STAR-Center began in 1986 in Pittsburgh as a specialty program to address the increasing problems related to adolescent suicide and depression, and youth violence. The services were expanded in 1989 to include consultation and training for schools in the area of crisis responding and school safety. The center publishes STAR-Center Link, a newsletter featuring best practices on mental health treatment and violence prevention and its "Survivors of Suicide" program is nationally recognized.

The Yellow Ribbon Program originated in Colorado in 1994 and is now in every state and 44 countries. Youth are taught how to use "yellow ribbon" cards to ask for help. Some Pennsylvania counties are participating in this program.

In the summer of 2001, various professionals within Pennsylvania inquired as to why Pennsylvania did not have a "formal" youth suicide prevention plan. The professionals had encountered a national website that included plans from many other states. Pennsylvania was listed with two contacts from the Pennsylvania Department of Education (PDE), but has no formal plan. As a result, the Interagency Committee of SAP took the lead in convening a workgroup of about 50 stakeholders from across the Commonwealth to formalize a plan that includes not only what already exists in Pennsylvania, but also a strategy to address the possible gaps.

The workgroup decided to use the "National Strategy for Suicide Prevention: Goals and Objectives for Action" as a template to begin its work. Pennsylvania has borrowed generously from the national strategy by adopting the 11 national goals, where applicable, and adapting the objectives to fit Pennsylvania's needs. What follows is a summary from the national strategy, Pennsylvania's goals and objectives, and a 5-year work plan to begin to address the objectives.

Summary from the National Strategy for Suicide Prevention: Goals and Objectives for Action:

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

• Every 17 minutes another life is lost to suicide. Every day 86 Americans take their own life and over 1500 attempt suicide.
• Suicide is now the eighth leading cause of death in Americans.
• For every two victims of homicide in the U.S. there are three deaths from suicide.
• There are now twice as many deaths due to suicide than due to HIV/AIDS.
• Between 1952 and 1995, the incidence of suicide among adolescents and young adults nearly tripled.
• In the month prior to their suicide, 75% of elderly persons had visited a physician.
• Over half of all suicides occur in adult men, aged 25-65.
• Many who make suicide attempts never seek professional care immediately after the attempt.
• Males are four times more likely to die from suicide than are females.
• 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.
• 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 public health 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 behavior 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 behavior. 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 11 goals are:

Goal 1:Promote Awareness that Youth 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 behavior 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:

• Developing public education campaigns
• Sponsoring state, regional, and local conferences on suicide and suicide prevention
• Organizing special-issue forums
• Disseminating information through the Internet.

Goal 2: Develop Broad-based Support for Youth 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:

• Organizing a state interagency committee to improve coordination and to ensure implementation of the Pennsylvania Strategy
• Establishing public/private partnerships dedicated to implementing the Pennsylvania Strategy
• Increasing the number of professional, volunteer, faith community and other groups that integrate suicide prevention activities into their ongoing activities, and adopt policies designed to prevent suicide.

Goal 3: Develop and Implement Strategies to Reduce the Stigma Associated with Being a Youth 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 youth 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 youth who have suicidal thoughts or who have attempted suicide. Family members of youth 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. 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. SAP is a viable example of how interagency collaboration can reduce barriers for youth services. Although it is very successful, there is still a need to destigmatize seeking mental health and substance abuse services to prevent youth suicide.

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:

• Increasing the number of suicidal youth with underlying mental disorders who receive appropriate mental health treatment
• 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 youth who obtain treatment as pursuing basic health care.

Goal 4: Identify, Develop, Implement, and Evaluate Youth 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. 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 and evaluation at both the State and local levels, the need for technical assistance in the development and evaluation of suicide prevention programs, and the need for ongoing evaluation. Objectives include:

1. Increasing the proportion of local communities with comprehensive suicide prevention plans
2. Increasing the number of evidence-based suicide prevention programs in schools, colleges and universities, work sites, corrections institutions, aging programs, and family, youth, and community service programs
3. Developing technical support activities to build the capacity across the state 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 behavior. 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 youth's access to the means of self-harm. Evidence suggests that restricting access to the means for self-harm may have a limited time effect for decreasing self-destructive behavior in susceptible and impulsive youth. 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:

• Educating parents, health care providers, health and safety officials, and school personnel on the assessment of lethal means in the home, school, and community, and identifying actions to reduce the means of self-harm within their environments
• Implementing a public information campaign designed to reduce accessibility of lethal means.

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 youth, nor do they know how to refer youth 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 youth 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 youth or families in distress- need training in order to be able to recognize factors that place youth at risk for suicide, and to learn appropriate interventions. Key gatekeepers include parents, teachers and school personnel, clergy, police officers, primary health care providers, mental health care and substance abuse providers, corrections and juvenile justice 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:

• Improving education for nurses, physician assistants, physicians, social workers, psychologists, addictions and other counselors
• Providing training for clergy, teachers and other educational staff, corrections workers, staff of child-serving systems such as children and youth case workers, child welfare personnel, juvenile justice personnel, and attorneys on how to identify and respond to youth at risk for suicide
• Providing training for leaders of youth, community and faith-based organizations and groups, child care providers, athletic associations, "adult mentors" and "peer mentors" on how to identify and respond to youth at risk for suicide
• Providing educational programs for family members of youth at elevated risk
• Providing educational programs for all students for recognition of at-risk behavior and how to respond.

Goal 7: Develop and Promote Effective Clinical and Professional Practices

One way to prevent youth suicide is to identify youth at risk and to engage them in treatments that are effective in reducing the personal and situational factors associated with suicidal behavior (e.g., depressed mood, hopelessness, helplessness, low academic achievement, alcohol and other drug abuse, among others). Another way to prevent youth 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 youth at risk for suicide, the chances for preventing those youth from acting on their despair and distress in self-destructive ways are greatly improved. Moreover, promoting the presence of protective factors for these youth can contribute 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 youth suicide, leading to better triage systems and better allocation of resources for youth in need of specialized treatment. They include:

• Changing procedures and/or policies in certain settings, including primary care settings, hospital emergency departments, substance abuse treatment centers, specialty mental health treatment centers, and various institutional treatment settings, to include screening and assessment of youth suicide risk
• Ensuring that individuals who typically provide services to youth suicide survivors have been trained to understand and respond appropriately to their unique needs (e.g., emergency medical technicians, firefighters, police, funeral directors)
• Increasing the numbers of youth who receive support and continued treatment services (including consistent follow-up) for mood disorders and other behavioral health disorders difficult to detect such as substance abuse
• Ensuring that youth treated for trauma, sexual assault, or physical abuse in all healthcare settings, including in emergency departments receive consultation, referral, mental health services, and/or support services. These support services may include domestic violence centers, rape crisis centers, etc
• Fostering the education by providers of mental health and substance abuse services for family members and significant others of youth receiving care for the treatment of mental health and substance abuse disorders on the risk of suicide.

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 youth at increased risk for suicidal behavior.

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 Pennsylvanians 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 youth 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:

1. Exploring the benefits for health insurance plans to cover mental health and substance abuse care on par with coverage for physical health care
2. Implementing utilization management guidelines for suicidal risk in managed care and insurance plans
3. Integrating culturally competent mental health and suicide prevention into health and social services outreach programs for at-risk populations
4. Defining and implementing screening guidelines for schools, colleges, state professional organizations, and corrections institutions, along with guidelines on linkages with service providers
5. Implementing support programs for youth who have survived the suicide of someone close.

Goal 9: Improve Reporting and Portrayals of Suicidal Behavior, Mental Illness, and Substance Abuse in Media and Entertainment

Media and entertainment 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 youth suicide. It appears that imitation plays a role in certain youth 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 behavior is one of several strategies needed to reduce the suicide rate.

Media portrayals of mental illness and substance abuse may also affect the youth suicide rate. Negative views of these problems may lead youth 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:

• Increasing the number of local television programs and news reports that observe recommended guidelines in the depiction of suicide and mental illness
• Increasing the number of journalism schools that adequately address reporting of mental illness and suicide in their curricula
• Promoting awareness of the influence of the entertainment industry.

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 a youth'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 youth suicidal behavior.

The objectives include:

• Promoting youth suicide prevention research
• Evaluating preventive interventions
• 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 behavior and ensure that the data are useful for prevention purposes. They include:

• Improving analysis and availability of statewide child death review data.
• Increasing the number of hospitals that code for external cause of injuries
• Producing an annual report on youth suicide
• Encouraging the development of pilot projects to link and analyze information on self-destructive behavior from various, distinct data systems.

Looking Ahead

The Pennsylvania Strategy for Youth Suicide Prevention creates a framework for youth suicide prevention for Pennsylvania. It is designed to encourage and empower groups and individuals to work together. The stronger and broader the support and collaboration on youth suicide prevention, the greater the chance for the success of this public health initiative. Youth suicide and youth suicidal behavior can be reduced as the general public gains more understanding about the extent to which youth 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 Pennsylvania 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 youth 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 Pennsylvania Strategy will motivate and illuminate. It can serve as a model and be adopted or modified by local communities as they develop their own youth suicide prevention plans. The Pennsylvania Strategy articulates the framework for statewide efforts and provides legitimacy for local groups to make youth suicide prevention a high priority for action.

The Pennsylvania Strategy encompasses the development, promotion and support of programs that will be implemented in communities across the Commonwealth designed to achieve significant, measurable, and sustainable reductions in youth suicide and youth suicidal behavior. This requires a major investment in public health action.

Now is the time for making great strides in youth suicide prevention. Implementing the Pennsylvania 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 Pennsylvanians will depend on effective public and private collaboration-because youth suicide prevention is truly everyone's business.