Public Health Approaches to Suicide Prevention

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: an alarming increase in suicides in America, and the urgent work to save lives—

DR. DEBORAH STONE:
When we really dug down into the data to look at state-level increases, I think that's where we might've felt a little more surprised that some states were experiencing rate increases over the period of up to 58%.

JOHNSON:
—states searching for solutions—

JARROD HINDMAN:
We can't point to one thing and say, "If you do this, you're going to—I promise you you'll see a reduction in your suicide rate."

JOHNSON:
—and promise from a mobile app.

DR. JOSEPH MINER:
Having access to a smartphone—and kids particularly love it for social contact with friends—but also having it available when they're really feeling completely alone and suicidal, they can contact someone and get an immediate response.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we discuss the most pressing public health issues facing our states and territories, and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

Today, a difficult topic that seems to be getting worse—suicide in America. A June 2018 CDC Vital Signs report studied trends in state suicide rates from 1999 through 2016. Its conclusions were disturbing: not only is suicide one of the leading causes of death in our country, but rates increased in nearly every state during the years studied; in half the states, rates jumped by more than 30%.

Dr. Deb Stone was on the team that authored the report. She's a behavioral scientist in the CDC's Division of Violence Prevention. She spoke to us about the study from her office in Atlanta.

STONE:
Basically what's happening is that suicide is a growing public health problem and—for instance, nearly 45,000 lives were lost to suicide in 2016, which is approximately one suicide every 12 minutes. In our recent Vital Signs report in which we examined the rate increases across all 50 states, in that period of time—1999 and 2016—we found that suicide increased in nearly every state across the nation and that in actually 25 of those states, rates increased by more than 30%.

So, also according to that data, we've found that suicide is one of the three leading causes of deaths that have increased from the prior year; so, other two leading causes that increased were unintentional injuries and Alzheimer's disease. And we know that suicide is really just the tip of the iceberg—many more people, of course, attempt suicide and think about suicide. In fact, suicide and attempts cost the nation approximately $70 billion in direct medical and work loss costs.

So, it's a really big problem, and it's growing.

JOHNSON:
Why do you think it's a growing problem?

STONE:
Well, the vital statistics data that we use to track the trends are great for doing just that—tracking trends. Unfortunately, they don't really tell us about the causal factors that are driving the increases. But we do know we do know a few things, however.

We know that suicide is not caused by any one factor. Instead, it's typically caused by a combination or interaction of factors across multiple levels, such as the individual relationship factors at the community and societal levels all interacting together. Some of the factors that may be leading to suicide include economic conditions, or the opioid overdose epidemic, social media, and factors impacting more on rural areas.

So, for example, we look at the Great Recession in the late 2000s, and we know that there were subsequent financial challenges and concerns about economic instability that may have been contributing to suicide risk. And our past research indeed does show that suicide tends to wax and wane depending on the business cycles; and so, when there is a recession, we often see increases in suicide. And even though the recession has ended, some parts of the country really have taken longer to bounce back—for example, we see rates of suicide increasing in rural areas. And rural areas were already struggling with well-known suicide risk factors, such as greater social isolation and things like limited access to mental healthcare.

And we also can look at the opioid overdose epidemic and we know that, of course, the deaths from opioids have been increasing, and substance misuse is already an established risk factor for suicide. So that—if there's increased availability of opioids, we wouldn't be surprised to see increasing use and misuse, and that could be driving up the rate of suicide higher. And when we look at the people who are actually dying from suicide and those who are dying from opioid overdoses, we see that there is a rather large overlap there—for example, middle-aged white males come to mind.

Some of the other factors that we sometimes consider are social media—and social media is a little bit more complex because social media can have both a positive or a negative impact—and so, changes in social media content or use may be associated with suicide. So we know, for example, that suicide—or social media, rather, can be a negative factor when it's used to bully people, or is used to somehow romanticize suicide or provide even harmful content on how to actually take one's own life. But on the other hand, we know that social media and its intended use to increase social connectedness can be a very positive thing and help people to get the help that they need.

And so, more research on all of these factors is really needed to determine the reasons for the increases that we've been seeing.

JOHNSON:
How long did it take the team to put this Vital Signs report together?

STONE:
Many months—over six months.

JOHNSON:
Were you surprised? Was the group surprised as this trend started to develop in your research? I assume it was troubling, but was it shocking to you? Is it something you didn't expect to see?

STONE:
Well, CDC has been tracking suicide for many years, actually. And so, I wouldn't say this—what we found—was shocking. I think what I would say is that when we really dug down into the data to look at state-level increases, I think that's where we might've felt a little more surprised—some states were experiencing rate increases over the period of up to 58%. And then, even in the states that were experiencing the least, increases were from between 6-18%.

So, I think that's where we felt some surprise or saw some results that we hadn't necessarily expected 'cause we haven't necessarily been tracking all of the 50 states at any given time. So, when we really dug down into that data, we were, you know, we saw that these rates were increasing pretty dramatically. And, of course, we've known that the rates overall have been going up, so that would be in agreement with what we've seen before.

JOHNSON:
You said you thought that more research would be necessary in order to really get to the cause of all of this.

What kind of research should we be doing?

STONE:
I think that we really need to be, you know, studying multiple factors that are associated with suicide. So we know, for instance, that mental health problems are a very important contributor to suicide. We also found that—in our Vital Signs report—that actually more than half of the people who did die by suicide did not have a known mental health condition. So, I think it's really important to be looking into some of these other factors that are related to suicide.

Some of the things that we found in our Vital Signs report, for example, were that—regardless of a mental health condition or not—there were some very common factors that showed up. And these included relationship problems—these could include conflicts or arguments with an intimate partner or a family member, they could even include interpersonal violence.

Some of the other factors that we know are associated include—and that we saw were associated with suicide—were crises. So, people who are—many people experience a crisis in the recent weeks before their suicide. Or some people were actually anticipating a crisis, which is a little bit of maybe hard to really wrap your head around. But, for instance, if somebody had a court date that was pending, or they were just arrested for something, or they had a meeting that was coming up where perhaps there was going to be something negative coming out—any of these kinds of pending crises were also very relevant in the suicides.

And, of course, there's also—we know, as I mentioned, problematic substance use. Not just opioids, but could be other prescription drugs as well, and illicit drugs. And people also experienced physical health problems frequently. So, we know that these are oftentimes associated with suicide.

And one of the things that we talk less about, I think, in the suicide research itself is looking at job and financial problems. So, I think it's really important that we look at these factors a bit more to understand how they impact suicide and what can be done to make sure that there are effective interventions to reduce the risk of suicide among people who may be having trouble making ends meet or who have recently lost a job. And then, that would also be related to housing. So, we know that housing issues are also a concern for people.

So, really when we talk about doing more research, it means that we need to be looking into all of the factors that are impacting suicide and considering different interventions that can impact on all of those.

JOHNSON:
Is that how public health gets involved?

STONE:
Yes, that is how public health gets involved. So, public health starts with, you know, using data and tracking the problem of suicide. So, we first will do that to understand the nature of the problem, understand the nature of the risk. And then, we really need to look at those things that are impacting on suicide, such as that the things I just mentioned. And then, we need to test and to develop and have interventions for suicide prevention, and then get out the word of what works to the larger community.

But yes, public health is great because it provides a broad approach to suicide prevention that can look at both upstream and downstream factors associated with suicide. And what I mean by upstream would be those things that can actually affect suicide risk before it even happens. So, public health is interested in preventing the risks before they start.

So, for example, by promoting connectedness or being attuned to people's financial issues, by having greater access and delivery of care, making sure that that's available to all people where they live and work—those are really important things that can help prevent the risk in the first place. And then, of course, we are also interested in reducing the harm and reducing risk further down the stream when people are already have made an attempt or are thinking about suicide.

JOHNSON:
Western states seem to be most impacted by suicide. We're exploring the issue with two of them in this episode—Utah and Colorado.

Jarrod Hindman is the deputy chief of violence and injury prevention at the Colorado Department of Public Health and Environment. With Colorado always among the top ten states with the highest suicide rates, we asked him: why the west?

HINDMAN:
A lot of the discussion around this theoretical—we don't have a great sense of why the western U.S. has the highest suicide rates.

Some of the predominant theories include the ideas that we really embrace that Western mentality in Colorado and the western U.S.—that cowboy mentality that suggests, say, if you're struggling with something, particularly if it's an emotional or a mental health issue, you know, the theory is pick yourself, pull yourself up by your bootstraps, or take care of your problems on your own, or don't ask for help. And I certainly think that while that may be a good rugged individualism mentality for some parts of life, it's certainly not true if you're struggling with an emotional issue that you can't fix on your own.

You know, there's a research from Harvard that shows that states that have high in-home firearm ownership rates are also states that have higher suicide rates.

There are access issues in Colorado and the western U.S., so there are not enough behavioral healthcare providers and there are lots of mental health professional shortage areas. And so, people even who may want services have to drive; you know, if you live in Eastern Colorado, you may have to drive to the front range—so, to Colorado Springs or to Denver or to Fort Collins—to access services, which may be two hours away. And so, Colorado as a state is working to improve those systems. But the reality is for many people, accessing services is a challenge.

And so, those are some of the theories.

There's also some new research that talks about altitude and suicides. Some of that research has been disputed. So, I think that's still up in the air.

And then, in places like Colorado, we have higher substance abuse rates, which certainly can be contributing factors for things like suicide.

So, there are a lot of reasons why, but none of them that we can just put our finger on that says this is why Colorado has a higher suicide rate than Massachusetts, for example.

JOHNSON:
Now, all that said, the people who watch what states are doing, like the CDC, think that Colorado is a model based on some of the programs that you're implementing to try and address this issue.

So, give us an overview of what you're doing, and then we'll get into some of the details.

HINDMAN:
The Office of Suicide Prevention in Colorado has been around since the year 2000. And so, since 2000, we have had state funding set aside specifically to fund the Colorado Office of Suicide Prevention, so we have some consistency in funding. While the funding is small, it's allowed us to build some infrastructure and some consistency in how we do this work.

The reason I mentioned that is because that's part of why we were identified by some national partners, which now includes the CDC, but also includes the Suicide Prevention Resource Center, the American Foundation for Suicide Prevention, the Injury Control Research Center for Suicide Prevention, and the National Action Alliance.

A couple of leaders in the field approached me a few years ago to basically present this idea that they want to build a comprehensive suicide prevention strategy, and implement and evaluate it. And the idea was to start in one state, and we had the fortune of being given the first offer to partner with them on a full court press for suicide prevention. And of course I said, yes, we would gladly do that.

And so, we have been working towards developing a comprehensive suicide prevention strategy for the last couple of years in partnership with national partners, and now shifting our partnership attention to the local partners in Colorado. And so, that's the goal and the idea, and we're building that process now.

JOHNSON:
Your program has a number of goals. We've looked at those, and I thought it might be interesting to walk through each one of them and, you know, get into some detail, if we could.

The first one, I think—or at least the first one on the list I've seen—is fund local initiatives.

HINDMAN:
Yeah. We don't think anything can have success as we develop this process without a local buy-in, support, and leadership. And what I would argue in the suicide prevention world, which is also true in Colorado, is historically in suicide—and now, actually—suicide prevention is very piecemeal, very much underfunded. And so, even if we're doing programs that we think, and the research tells us, works—and I'll give you one example.

The Sources of Strength program iss a school-based suicide prevention program that focuses on resiliency and positive youth development and connectedness to students in school and adults, which has some evidence of effectiveness. You know, we implement that in at a really small scale in Colorado. And so, the idea of this is that's one program that we know works if implemented with fidelity. So, one of our strategies would be to implement that program in one community across all, for example, the high schools in that community.

So, instead of one high school or two high schools in a county, we want to find a way to implement it in every high school in that county as one component of a comprehensive plan.

JOHNSON:
And that allowed you to really jump in and see if it works, right?

HINDMAN:
Yeah, exactly. And so, if we actually are doing this across high schools, does it have an impact on the high school students in that community ,across that county? And yeah, so, that's a part of the evaluation piece as well.

JOHNSON:
The goal, I assume, would be—if it does work—go argue for dollars to do it statewide.

HINDMAN:
Yep, absolutely. So, we have decided as part of this initiative—because the initial push was like, "Hey, let's do this statewide in Colorado"—when we realized that we're talking about 64 counties, millions and millions and millions of dollars to implement most strategies across the state. So, we decided by looking at the data—and particularly looking at burden—to initially focus on six counties in Colorado that have high numbers of suicides each year, but also have suicide rates that are higher than the Colorado rates.

And so, that's where we are starting now. We're really going to focus efforts on the six counties to see if we can have an impact a bear. And then, if we do have impact—when we have impact—to then expand it to other parts of Colorado. And for our national partners, when we show an impact in those six counties, and as we take it to other counties in Colorado, they can take the model to other states in the U.S. to begin replication at that level.

JOHNSON:
Is that what you mean when you state, as a goal, focus on high-risk community?

HINDMAN:
That's correct. Yep, absolutely.

And so, we really landed right off the bat on the fact that we can't do everything for everybody. So, focus on the high-risk populations or segments of communities across the lifespan.

And so, we also historically have spent much, much of the funding for suicide prevention in the U.S. specifically for youth suicide prevention. But if our goal is to reduce the suicide rate 20% by 2025, we absolutely better be targeting more than just children and adolescents because when we talk about the number and the rates, that's one of the less high-risk groups; and so, we better be looking at working age adults and older adults, as well.

JOHNSON:
Other than the actual numbers of people who have taken their own lives, what other metrics are you reviewing to determine where to put your effort?

HINDMAN:
The suicide rate indicator is a longer term outcome. So, we're trying to decide, like, what are some key indicators that are interim or short-term that we can start looking at?

One good one that I think is important specifically for one high risk demographic is adult males. We know that males get diagnosed for things like depression at much lower rates than females. And we believe, and the research supports, that in part that's because males don't actually reach out for help, so they don't actually get an opportunity to be diagnosed with depression because they never show up at the therapist office to get a diagnosis.

And so, an early indicator would be to see an increase in the number of males diagnosed for depression, because that would suggest to us that more men are actually seeking professional help.

JOHNSON:
One of your programs in your toolkit, which we'll talk about shortly, is called Man Therapy—that's what you're talking about here, right?

HINDMAN:
Yeah, that's exactly what we're talking about; and Man Therapy was designed specifically to reach working age men who don't typically like to reach out for help. And so, there's three major goals for Man Therapy.

One, long-term, we want to see the suicide rate drop among working age males. But well before that, we just want to change the social norms around how men and society defines mental health as a core component of men's health. Too, we want to empower men to take ownership of their mental health.

And, so that's where the depression indicator would show up is like, if we can create a website and a space that encourages men to take care of themselves before they are in crisis, we think we might be able to have an impact on self-reported or even diagnosed cases of depression so that men who are learning and changing their behavior to include mental health as a core component of their overall health.

JOHNSON:
Another of the stated program goals has to do with training individuals to recognize warning signs and then respond. Are we talking about health professionals, physicians, the community at large? Who are the individuals in that statement?

HINDMAN:
I'll say yes, all of the above, but I think there's a tiered way to do it. Again, historically in suicide prevention, I would argue we've focused suicide prevention on what we call gatekeeper training, so teaching people the risk factors and warning signs and how to intervene. Really, the idea was give gatekeeper training to everybody in a community so that everyone is trained, and that's the ideal. That would be great if that were the case.

The challenge is we have done those trainings and a core component of those training programs is once you identify somebody who is suicidal, your job then is to refer them to the professionals. Well, we know from research that not all of the professionals are actually trained and comfortable or confident or competent to work with suicidal individuals.

So, key for us right now—Colorado—is to actually make sure that all of the mental health providers, primary care docs, healthcare professionals are actually competent and confident to work with suicidal folks so that when they do get referred to the professionals, they are equipped and feel comfortable to work with them. And so, we've focused a lot of our attention lately on doing real clear and deliberate suicide prevention specific training for clinicians and healthcare providers.

JOHNSON:
And then collaborative partnerships. Everyone talks about collaboration.

What are you doing in that area? Are you doing anything different?

HINDMAN:
I don't know if it's, yeah, different for sure. And in part, because of this Colorado-national collaborative, we have multilayers of partnership that we're trying to build, so national and state partnership, and now including local partnership in that.

And so, what we've been doing over the last several months is actually taking our state and national partners, and going and meeting in the six counties that we've identified as ideal partners to meet with the community leaders in those communities. Just last week, we were in southwest Colorado in La Plata and Montezuma counties to meet with leaders from those communities just to get buy-in and to build a partnership and to talk about shared priorities and shared strategies.

And my main goal from leaving those meetings was to leave with agreement from local partners that yes, they want to partner moving forward. And yes, we agree that we can find common ground and that we can come together towards a common goal. And in all six communities, as of last Friday, we have agreement that, yeah, absolutely, we want to move forward and we already have common goals and priorities.

And so, that's the collaborative piece because national partners and even the state partners—like I live in the Denver metro area, I don't know anything about the communities in southwest Colorado. And so, that's their work, and it can only be successful if they are leading the efforts with support from us. And so, that's our goal.

JOHNSON:
Earlier, you talked about the Wild West—and I'm an Arizonan, so I understand what you're talking about there—it's sort of that "man up" attitude. And then you talked about guns, which obviously have a big role to play in this issue.

And there is a project in Colorado called the Gunshot Project. Where did that idea come from, and what do you do as part of that effort?

HINDMAN:
Yeah, it's a project we actually borrowed from New Hampshire. The New Hampshire Gunshot Project is where this began.

It was originated by a gun shop owner in New Hampshire who had some customers over a short period of time who purchased firearms from this gentleman's gun shop and in a short amount of time used those firearms to take their lives. And so he, to his credit, reached out to suicide prevention and public health officials in New Hampshire and said, "I don't like this, and I don't want this to happen. What can we do about it?" And they built this program to educate firearms owners and firearms retailers about the importance of suicide prevention being a component of firearm safety.

And the basic message is if you are a gun owner and someone in your house, including yourself, is suicidal, you have to do everything in your power to ensure that that individual does not have access to your firearms while they're in crisis. And so, the message is a real simple safety one.

And what I've learned over the years since I—you know, I'm not in the firearms community, but I have taken some steps to become more familiar with the firearms community. What I have learned is that overwhelmingly the firearms community is hypersensitive to the concept of safety. That's the first thing you're taught and you're taught over and over and over again the safety rules of being a firearms owner. But the component that has not been traditionally a part of those safety rules is the suicide prevention component. And so this project adds that component, which is really, really cool.

And so, we simply connected with the folks in New Hampshire and at the Means Matter project at Harvard and asked them if we could borrow the project. And, like many other states, we have adopted and adapted the program and implemented it in Colorado. And what's really cool about it from a public health standpoint, particularly since I'm a state employee in a state that has some very contentious gun laws, is this is an approach that avoid the Second Amendment debate because it's about partnering with the firearms community with a message of safety that they've really genuinely embraced.

It it's been one of my favorite projects I've ever worked on just because the partnership is so unique and it's so different from traditional public health partnerships, it's been really rewarding.

JOHNSON:
And that's the kind of thinking that is required on a problem like this.

HINDMAN:
No doubt. Yeah, no doubt. So, to the credit of the original founders of this project it's—and they continue to consult with states who do this work—it's the approach of, "Let's do this in a way that works for everyone from both sides so that both sides are motivated to do the work."

And I think we've taken a similar approach with things like man therapy. It's like, "All right, it's going to be very difficult to change, you know, a thousand years of gender socialization of social norms, about what defines what masculinity is." So, there's important work and changing those social norms, but we chose instead to try to meet men where they are—not all men, of course, but to try to meet men who really embrace traditional gender roles and norms, and to try to change their way of thinking.

So, change the way that we define what masculinity means simply by saying, "Hey, you can be the manliest a man you can be without having totally dialed in mental health." And so, that's a similar approach that we've taken with that project.

JOHNSON:
What are the impacts you've noticed so far as a result of all of these programs?

HINDMAN:
Honestly, it's the—and this isn't a great impact, but it's a starting place—I think just the conversations that it's generated. I think people are paying attention to the work that we're doing in Colorado which, you know, that put quite a lot of pressure on us, but it's pressure I think that we welcome because it's such important work.

It's so frustrating to work in a field where, you know, you do the best you can with the limited resources that you have, and then every year of the day to come out and they show an increase in the suicide rate and an increased number of people dying by suicide because we haven't yet figured out what works.

JOHNSON:
Colorado has developed an eight-page toolkit packed with helpful resources for those hoping to do more to prevent suicide in their states and communities. The link to the toolkit is in the show notes for this episode.

In Utah, leaders have set an ambitious goal to reduce suicide rates by 10% by the year 2021. Dr. Joseph Miner is executive director of Utah's Department of Health. His team's aggressive plan to help people in crisis includes, among other components, a mobile app.

Is it helping, do you think, maybe head off some potential suicide attempts?

MINER:
Oh, absolutely. We call it—it's called Safe UT mobile app. It has been used—actually, several of our TV stations have picked up on this and reported how it has been used, and it's thought to have saved lives.

Don't know that we have a very good data on this yet, but certainly anecdotal experiences with it that definitely been felt to save lives.

JOHNSON:
When the app receives a call for help, a waiting crisis team responds.

MINER:
They staff that crisis line and actually have the crisis response teams that will go out with first responders if there's suspicion of a mental health issue or threats of suicide or homicide.

JOHNSON:
So the crisis teams are attached to the mobile app, not just the fire departments or the police.

MINER:
Oh, absolutely. They're the ones that actually—this crisis unit there with the Utah University neuropsychiatric unit actually receives these texts and the communications, all incoming chats, texts and calls, and these professionals provide supportive crisis counseling, suicide prevention, and referral services. And it's the same institution that does the mobile crisis outreach teams as well.

JOHNSON:
Utah has built what Miner believes is a first of its kind database of information about suicides in the state. The result of a recent five-year study into youth suicide in Utah provides unsettling but necessary insights.

MINER:
We have—particularly for the youth suicide, you know—we had the Centers for Disease Control and Prevention come out. It was a Utah epi aid investigation from CDC that analyzed all of our 150 suicide deaths of a youth age, 10–17, that died by suicide over a five-year period, 2011–2015. The majority were male, white, in the age group 15–17, and there was a hundred over this five-year period.

It was 136% increase from a year to a year—almost a 23% increase each year over that time period—whereas nationally, it was a only a 23% increase or about 6% a year. Dramatically higher than the national rate.

Most—92%—died by suffocation hanging or a firearm. Among 142 of those youth, common precipitating circumstances included mental health issues. A little over a third, about a third had depression.

So, some of these will overlap with the same individual—history of suicide ideation or a previous suicide attempt, and an experience of recent crisis. That was over half of them—55% had a recent crisis and over 68% had experienced two or more precipitating circumstances.

A third of them had disclosed some intent, 47% left a note.

20% had one or more of the following drugs in their system: alcohol, cocaine, amphetamine, marijuana, or an opiate.

13% had family conflict, which resulted into a result of technology restriction; this had never been seen before, been acknowledged, even though some may have suspected it—they had access to their smartphone or mobile phone restricted, and that was a contributing issue in 13% of these youth suicides.

A fifth of them, 20% had a history of cutting.

JOHNSON:
He admits getting the information needed to adjust programming is tough, especially when posing hard questions to grieving families. But here, again, Utah is working on a solution.

MINER:
I know a lot of times families don't want to talk to us following a suicide, and we have to call a few times to see if that changes. We're actually developing a method of data collection that will automate this collection, so they're answering at their own time on their own timeframe—data collection that they can give survivors to answer questions on their own time, take breaks, return to the survey later—as a partnership with the University of Utah School of Medicine, the department of psychiatry, and also the University of New Hampshire is participating with that as well.

JOHNSON:
Just a reminder: for more information about the work in Colorado or Utah, visit the show notes for this episode—you'll find the links there.

Thanks for listening to Public Health Review. If the show's interesting and helpful, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.