Suicidality: Prevention

Clinical Interventions for at-Risk Individuals and Families

The ability of primary care and other health providers to recognize and treat depression, substance abuse, and other mental illnesses associated with suicide risk, often as comorbid conditions, and to make referrals to specialty care when appropriate, all constitute prevention. Reducing stigma associated with suicidal behaviors and supporting help seeking for mental illness, including substance abuse disorders, contribute to reducing suicidal risk. Accessibility to and acceptability of effective clinical care for mental, physical, and substance abuse disorders, and family and community support are protective, as are removing financial barriers and alleviating geographic distance as barriers to clinical interventions.

With the availability of many antidepressants, it is critical to work with a knowledgeable service provider to determine the best medication(s) and most [Page 703]appropriate levels if a drug regimen is indicated. Suicide prevention contracts are widely used. Their effectiveness may depend on the strength of the therapeutic relationship between clinician and patient. They are likely overvalued and should not be used as the sole treatment for patients with suicidal behaviors.

Means Restriction

Evidence suggests that means restriction has an immediate impact on suicidal behavior. Examples of lethal means (and restrictions) include firearms (not having them in the home, removing them from the home to prevent access for at-risk persons, locking them away, separating the firearm from ammunition); bridges (barriers, particularly on bridges that are symbolic, e.g., the Golden Gate bridge); and potentially deadly medications, for example, acetaminophen (bubble wrap, where only one tablet can be undone at a time). Evidence consistently indicates that firearms are the most common method for suicide completion for all demographic groups in the United States, and are particularly highly used in the 24 and younger age groups. Declines in suicides following means restrictions sometimes occur without means substitution, resulting in reduced suicides, especially in the short term. The impact of such restrictions over longer time periods is not clear. Evidence suggests legislation can be effective in promoting means restriction. Health care professionals should involve families in reducing access to means. Education of health care professionals about means restriction can increase their potential effectiveness in helping reduce suicidality among their patients.

School Prevention Programs

School suicide prevention programs that include longer-term education and clinical referral have shown success in reducing suicidal acts. Components include skills training, gatekeeper training, crisis response plan(s), and screening for youth at risk. Onetime assemblies teaching about suicide have not been determined effective; some evidence indicates they may be harmful. Concern has been raised that indiscriminate suicide awareness efforts and overly inclusive screening risk factor lists may promote suicide as a possible solution to ordinary distress or suggest that suicidal thoughts and behaviors are normal responses to stress. Recent evidence from a randomized control trial suggests, however, that no harm came from screening universally in school settings for suicidal risk. Given that youth suicides are often impulsive, screening should take place at regular intervals. Natural or peer helpers have been used in schools with some success since youth often confide in peers before adults. It is critical that peer or natural helpers are backed with knowledgeable adults and clinical support in the school setting.

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