National Strategy for Suicide Prevention: Goals and Objectives for Action Retooling the Village

National Strategy for Suicide Prevention: Goals and Objectives for ActionRetooling the Village Colonel (Dr.) David LittsSpecial Advisor to the U.S. Surgeon General

Overview • The Problem • Public Health Strategy • Community Perspective • Air Force Suicide Prevention Program

Suicide Among Leading Causes of Deaths by Age Group-1998

Suicides and suicide rates by age group-- United States, 1998 Rate  Number Source: Natl. Center for Health Statistics

Suicide and Homicide Rates 1995-1998* *CDC, National Center for Injury Prevention and Control

Suicide and Homicide Rates 1995-1998* (7.07) *CDC, National Center for Injury Prevention and Control

Public Health Approach • Prevention based--no public health problem has ever been treated out of existence • Public Health Strategies: • Find the noxious agent and render it harmless • Prevent transmission of the noxious agent to the host • Strengthen the host to be resistant to the noxious agent

Society/ Culture Noxious Agent (Influence) for Suicide • Loneliness and isolation • Hopelessness • Beliefs and stigmas about help-seeking • Violence -- child abuse, sexual abuse • Harassment & bullying • Acceptance/tolerance of suicide • Low value on human life • Depression and other mental illnesses* * Also has a significant society/cultural component

Lethal Means • What role • Potential for Prevention • Impulsive/Agitation • Potential for Prevention

Suicide Rates by Method Source: Lois A. Fingerhut, MA, Centers for disease Control and Prevention, Unpublished

Suicide Rates United States, 1933-1998 Source: Natl. Center for Health StatisticsAge-adjusted to 1940 U.S. population

Community “...not just the sum of its citizens, but rather the web of relationship between people and institutions that hold communities together.” Wallack L and Dorfman L: Media advocacy: a strategy for advancing policy and promoting health. Health Education Quarterly; 1996, 23:293-317.

Community CapacitySocial Capital • Extent to which community members: • Demonstrate a sense of shared responsibility for the general welfare of the community and its members, and • Evidence collective competence in confronting situations that threaten the integrity of the community and the safety and well-being of its members.

Community Types Collective Competence Low High Anomic Communities LL Detached Communities LH Low Shared Responsibility Intentional Communities HL Empowered Communities HH High

Prevention goes beyond changing individuals--it changes cultural norms --Murray Levine (1998)

Cultural Directions • Interdependence -- interconnectedness • “My brother’s keeper” -- shared responsibility • Knowledge and skills • High view of human life • Positive attitudes toward help-seeking • Accurate understanding of mental illness

Think not only about: Changing children Changing students Changing workers Changing people with problems Think also about: Changing families Changing schools Changing work settings Changing societal attitudes about suicide prevention, mental health, stressful living patterns, violence Cultural Approaches

Expected Results Drops in • Suicide rate • Family violence • Truancy • Drug abuse • Alcohol Abuse • Crime

“We are on a treadmill to nowhere if all our efforts are directed at helping individual victims…..It is well-known public health doctrine that no mass disorder afflicting humankind has ever been eliminated or brought under control by treatment of affected individuals. Only successful efforts at primary prevention reduce the rate of distress in the future.” -- George Albee Albee, G. (1996). Editorial: Primary Prevention Means a Change in Business as Usual. J Nerv Ment Dis, 184(2).

U.S. Air Force Suicide Prevention: A Community Based Public Health Approach Colonel (Dr.) David LittsSpecial Advisor to the U.S. Surgeon General for Suicide Prevention

The Air Force Community • 350,000 Service Members • Educated, Employed, Housed, Health Care, One Language • Prescreened; Low Illicit Drug Use (1%); Discharge for Mental Illness • Clearly Identified Community Leaders • Formal Gatekeeper Network

Community Prevention Partners • Medics-Mental Health • Public Health • Personnel • Command • Law Enforcement • Legal • Family Advocacy • Child & Youth • Chaplains • Criminal Investigative Svc. • CDC • Walter-Reed Army Inst. Of Research

Air Force Community Unit Leaders Informal Networks Community Capacity Community Results Community Agencies

Assumptions / Approach • One is too many • Address entire iceberg • A community problem • Use CDC & WHO guidelines • All partners shared stake in outcome • Leverage sr. leaders for cultural change • Suicides are preventable • Tip of the iceberg • Not a medical problem • No proven approaches • Partnerships key to success • Cultural barriers to prevention

Explanation Prevention Action (Mood, Impulsiveness, Aggression, Substance Abuse Anxiety, Sexual Abuse, Sexual Orientation, Neuro-Chemistry) Vulnerability Case Find--Treat Anger Management, ConflictResolution, Negotiation Skills,Parenting Skills, Financial Mgmt Stress Event (In Trouble, Loss, Humiliation) Crisis Intervention,Protection/Support (Anxiety--Dread, Hopelessness, Anger) Mood Change Promote/ProtectHelp-Seeking--Treat Taboo,Support,Ventilation, Faith Inhibition Facilitation No Taboo,Method AvailRecent ExampleExcitation/Impulsivity,Solitude Public Affairs GuidanceMethod ControlAlcohol Control Social Support Survival Suicide Suicide Model* *David Shaffer, M.D., Columbia U.

Data-Driven Prevention Model* Assess Incidence/Prevalence, Risk/Protection & Demographics PrioritizePopulations &Risk/ProtectiveFactors PromoteReadinessforPrevention ComparePopulations,Risk/Protection, &Resources Assess Community ReadinessforPrevention Monitor Data toEvaluate Clear vision for Prevention ImplementProgramstoMitigate Risks,EnhanceProtection, Assess Resources * Richard Catalano, Univ of Washington (Adapted)

Leading Causes of Death ADAF 1990 -1995

Suicide Rates for USAFSuicides/100,000 - 1990-95

Suicide Rates for Enlisted Males1979-1995 (Per 100,000) White Enlisted Males Trend Lines Black Enlisted Males

Risk FactorsAF Suicides vs AF Population* Data from various sources, covering various timeframes between 1990 and 1995.

Mental Health ServicesUtilization Suicides 1990 - 1995 with Criminal Problems (n = 92)

Suicide Factors • Key Risk Factors* • Mental Health Problems • Substance Abuse • Relationship Problems • Poor Coping Skills • Legal Problems • Previous Attempts • Financial Problems • Job/Performance • Social Isolation Protective Factors* • Social Support • Belonging & caring • Leadership responsibilities • Effective Coping Skills • Policies & Culture that: • Approve/encourage help seeking behavior • Protect those who seek help * Most of these are modifiable

Actions • Community Leader Messages • Social Support • Help-seeking Behavior

“Since relationship problems are a factor in over half of our suicides, be vigilant for risk signs and respond with help to fellow airmen having problems. Encourage your troops to get whatever assistance they need…we need to continually communicate that we value peoplewho demonstrate good judgement by seeking help when they need it.” General Michael E. Ryan Air Force Chief of Staff, 19 Jul 99. “Please go the extra mile to foster a sense of belonging. Make sure your people feel they are a member of the team at unit functions and other small gatherings. It has been repeatedly demonstrated that social connections save lives…Let’s ensure we take care of our own--our Air Force family.” General Michael Ryan Air Force Chief of Staff, 1998

Actions • Community Leader Messages • Social Support • Help-seeking Behavior • Policy • Increased confidentiality in mental health • Handoff to commanders • Education • Career Development Courses • Annual Risk Awareness & Prevention Training

Annual Training Rates - 1998 82% 77% 42%

Actions • Mental Health Screening • Entry to USAF & Annually Thereafter • Unit Behavioral Health Surveys • Surveillance Database--All Self Injuries • Postvention • Re-engineering Human Services • Primary Prevention Roles for Mental Health Providers • Integrated Delivery of Community Services

Community Preventive ServicesPre-1996 Family Support Family Advocacy HAWC Mental Health Child and Youth Chaplains Unique Mission Prevention Mission Unique Mission Prevention Mission Unique Mission Prevention Mission Unique Mission Prevention Mission Unique Mission Prevention Mission Unique Mission Prevention Mission Customer

Seamless, Integrated Delivery System for Preventive Services Community Preventive ServicesPost-1996 Family Support Family Advocacy HAWC Mental Health Child and Youth Chaplains Unique Mission Unique Mission Unique Mission Unique Mission Unique Mission Unique Mission

Principles • Gatekeeper Training • Buddy Care, Supervisor, Community, Medical • Community Suicide Prevention Education • Screening Programs • Support and Protection for Responsible Help-seekers • Resiliency Building - Community Agencies • Access to Mental Health Care

Annual ADAF Count and Rate of Suicides: 1980-1999 *Significant negative linear trend in suicide rate from 1994 to 1998 (p < .002)

Necessary Conditions Prevention • Knowledge base • Political will • Social strategy

Where Do We Go From Here • Evaluate • Improve • Evaluate • Improve

Take Home • Leadership, Vision • Consolidate Political Will • Community as an organizing principle for Social Strategy • Limitations of single sector approach

“Still, the effort seems unhurried. Every seventeen minutes in America someone commits suicide. Where is the public concern and outrage?”Kay Redfield Jamison, Ph.D., Professor of Psychiatry, The Johns Hopkins School of Medicine

Comments? Questions?dlitts@osophs.dhhs.gov

National Strategy for Suicide Prevention: Goals and Objectives for Action Retooling the Village