We discuss the prevention of suicide at the level of what can be done to help individual suicidal people in our other chapters - here and here. Though this is very important information, it is only half of the equation. While there is truth to the idea that people become suicidal in part due to personal difficulties they have in coping with circumstances, it is also true that social issues influence suicide rates. These issues could be addressed and at least partially remediated if there were effective policies and institutions in place to address those issues (and enough money to fund them). Proper health policy changes and cultural attitude shifts could very likely prevent more suicides from occuring than an army of dedicated psychotherapists or a sea of hospital beds.
The best, most wide-reaching suicide prevention techniques exert their effects by helping to make our country, communities, organizations and families as physically and mentally healthy as possible. Sane policy to accomplish such a health-motivated agenda would contain effective and reasonably-funded measures to:
- Combat stigma. The stigma surrounding suicidal thoughts and behavior, and other treatable factors linked to suicide risk (e.g., mental illness, subtance abuse, domestic violence, and child/elder abuse) creates several negative outcomes, resulting in diminished opportunities for employment and social relationships; lowered self-esteem; and a reluctance to seek help and/or treatment. Education about these issues is important to combat stigma as well as to promote knowledge of risk factors and treatment options.
Address necessary changes in our mental health care system. Untreated mental illness increases suicide risk. Approximately 50% of people who were mentally ill and committed suicide were not receiving treatment prior to their deaths. People who do receive mental health services are often undertreated, "lost" in the system (i.e., not followed across time as they move from different levels of care such as being discharged from an inpatient hospital setting to an outpatient clinic), and/or do not follow treatment recommendations. Many individuals do not have access to appropriate mental health care because the current system is disjointed and disorganized, and/or because they lack adequate insurance (or have no insurance at all).
Mental health services should be delivered in an integrated fashion. In addition, insurance companies should be required to treat mental illnesses similarly to physical illnesses (often referred to as "mental health parity"). For instance, insurance companies should reimburse providers adequately, and maintain reasonable co-payments and eligibility for mental health services for patients. Laws and policies mandating mental health parity are necessary. Similarly, uninsured adults and children must be provided with appropriate mental health care services.
Adequately train current and new health care providers. Most people who complete suicide saw a health care professional within a year of their death; and 40% saw a clinician within a month of their death. Screening for depression, suicidality, and substance abuse is not routine in primary care settings. Primary care clinicians should be trained to recognize and screen for signs of depression, suicide, alcohol and substance abuse. However, we shouldn't simply add this task onto the other activities that these doctors must accomplish in 15-20 minutes without compensating them accordingly and allowing extra time for patient visits. At the very least, if primary care doctors are unable and/or unwilling to take on this additional role, we should have mental health "screeners" working in primary care offices.
Most people receive medications intended to treat psychological conditions from primary care doctors. Many of these doctors have not received adequate training in prescribing and monitoring these types of medications. If we are going to continue to operate with this method of prescribing (i.e., obtaining psychiatric medications from primary care clincians rather than psychatrists), we need to require that primary care doctors are appropriately trained. Primary care offices should also establish linkages with nearby mental health clinicians who can offer assistance with complex cases, provide psychotherapy services, and allow more structured follow-up (symptom monitoring). Professional evidence-based guidelines for suicide risk screening, assessment, and referral need to be developed and used in primary health care settings.
- Educate and Collaborate with the Media. Media professionals should be educated about their role in imitation/copycat and cluster suicides. Mental health and media professionals should work together to find appropriate ways to provide coverage of suicides (particularly regarding celebrities) across all media venues. In addition, this partnership could be used to develop (and study the effectiveness of) long-term public education campaigns about suicide, risk factors, and treatment options.
- Limit Access to Methods. Access to guns should be reduced and more tightly regulated, especially for those who are mentally ill and at high risk of suicide. Family members of potentially suicidal young people often do not follow instructions about removing or securing firearms, or removing other means of suicide from the environment. Health care providers should be educated about how to better encourage families to cooperate with these guidelines.
Bolster Social Support Networks. Community-based groups and government programs need to work together to address the most prevalent needs for groups at risk of suicide, especially since the more natural supports of extended families, highly involved neighbors, and religious groups are either not intact or not equipped to do it all. Partnering mental health professionals with culturally relevant providers (including spiritual leaders) in easily accessible locations (and at convenient times) could increase access to and utilization of mental health services.
Certain populations face additional barriers to treatment that increase their vulnerability to suicide. For instance, older adults and young children often have difficulty with transportation to and from treatment sites. Individuals from minority groups may face discrimination and/or health care providers who are ignorant and/or insensitive to their needs and style of handling mental illness and suicidality. Again, tailoring services to the needs of particular communities is vital.
School-based programs can enhance social support, self-efficacy, and self-esteem, and may reduce depression, substance abuse, and suicidality in children. These programs should provide skills training for staff, teachers and administrators, include designated "gatekeepers" who are responsible for addressing these issues on a schoolwide basis, develop crisis response plans, and mechanisms for screening students. Longer-term approaches that include teaching, appropriate follow-through, and a coherent service plan are more effective than short-term educational seminars (i.e., having someone from the community come in and give a presentation).
- Enhance Research on Suicide Statistics and Prevention. Suicidal individuals have been largely excluded from tightly controlled research studies investigating the effectiveness of medications, psychotherapy, and a combination of both due to liability concerns (from funding agencies; Institutional Review Boards, the committees that govern research with human subjects; and from individual researchers). As a result, we don't have very much or very good information about what treatment strategies are effective in reducing suicide. Large, interconnected research centers are studying other psychological conditions (e.g., bipolar disorder) and should also be used to investigate suicidality with long-term studies. Adequate funding should be provided for centers and researchers focused on investigating this issue.