Richard McKeon

The Garrett Lee Smith Memorial Suicide Prevention Program

In response to calls for greater efforts to reduce youth suicide, the Garrett Lee Smith (GLS) Memorial Act has provided funding for 68 state, territory, and tribal community grants, and 74 college campus grants for suicide prevention efforts. Suicide prevention activities supported by GLS grantees have included education, training programs (including gatekeeper training), screening activities, infrastructure for improved linkages to services, crisis hotlines, and community partnerships. Through participation in both local- and cross-site evaluations, GLS grantees are generating data regarding the local context, proximal outcomes, and implementation of programs, as well as opportunities for improvement of suicide prevention efforts.

Impact of the Garrett Lee Smith Youth Suicide Prevention Program on Suicide Mortality

OBJECTIVES We examined whether a reduction in youth suicide mortality occurred between 2007 and 2010 that could reasonably be attributed to Garrett Lee Smith (GLS) program efforts. METHODS We compared youth mortality rates across time between counties that implemented GLS-funded gatekeeper training sessions (the most frequently implemented suicide prevention strategy among grantees) and a set of matched counties in which no GLS-funded training occurred. A rich set of background characteristics, including preintervention mortality rates, was accounted for with a combination of propensity score-based techniques. We also analyzed closely related outcomes that we did not expect to be affected by GLS as control outcomes. RESULTS Counties implementing GLS training had significantly lower suicide rates among the population aged 10 to 24 years the year after GLS training than similar counties that did not implement GLS training (1.33 fewer deaths per 100 000; P = .02). Simultaneously, we found no significant difference in terms of adult suicide mortality rates or nonsuicide youth mortality the year after the implementation. CONCLUSIONS These results support the existence of an important reduction in youth suicide rates resulting from the implementation of GLS suicide prevention programming.

Effect of the Garrett Lee Smith Memorial Suicide Prevention Program on suicide attempts among youths

IMPORTANCE Youth suicide prevention is a major public health priority. Studies documenting the effectiveness of community-based suicide prevention programs in reducing the number of nonlethal suicide attempts have been sparse. OBJECTIVE To determine whether a reduction in suicide attempts among youths occurs following the implementation of the Garrett Lee Smith Memorial Suicide Prevention Program (hereafter referred to as the GLS program), consistent with the reduction in mortality documented previously. DESIGN, SETTING, AND PARTICIPANTS We conducted an observational study of community-based suicide prevention programs for youths across 46 states and 12 tribal communities. The study compared 466 counties implementing the GLS program between 2006 and 2009 with 1161 counties that shared key preintervention characteristics but were not exposed to the GLS program. The unweighted rounded numbers of respondents used in this analysis were 84 000 in the control group and 57 000 in the intervention group. We used propensity score-based techniques to increase comparability (on background characteristics) between counties that implemented the GLS program and counties that did not. We combined information on program activities collected by the GLS national evaluation with information on county characteristics from several secondary sources. The data analysis was performed between April and August 2014. P < .05 was considered statistically significant. EXPOSURES Comprehensive, multifaceted suicide prevention programs, including gatekeeper training, education and mental health awareness programs, screening activities, improved community partnerships and linkages to service, programs for suicide survivors, and crisis hotlines. MAIN OUTCOMES AND MEASURES Suicide attempt rates for each county following implementation of the GLS program for youths 16 to 23 years of age at the time the program activities were implemented. We obtained this information from the National Survey on Drug Use and Health administered to a large national probabilistic sample between 2008 and 2011. RESULTS Counties implementing GLS program activities had significantly lower suicide attempt rates among youths 16 to 23 years of age in the year following implementation of the GLS program than did similar counties that did not implement GLS program activities (4.9 fewer attempts per 1000 youths [95% CI, 1.8-8.0 fewer attempts per 1000 youths]; P = .003). More than 79 000 suicide attempts may have been averted during the period studied following implementation of the GLS program. There was no significant difference in suicide attempt rates among individuals older than 23 years during that same period. There was no evidence of longer-term differences in suicide attempt rates. CONCLUSIONS AND RELEVANCE Comprehensive GLS program activities were associated with a reduction in suicide attempt rates. Sustained suicide prevention programming efforts may be needed to maintain the reduction in suicide attempt rates.

Prevalence and correlates of past 12-month suicide attempt among adults with past-year suicidal ideation in the United States

OBJECTIVE To examine the prevalence and correlates of attempting suicide in the past 12 months among adults with past-year suicidal ideation in the United States. METHOD Data were from 229,600 persons aged 18 years or older who participated in the 2008-2012 National Survey on Drug Use and Health. Among them, 12,300 reported having past-year suicidal ideation, and over 2,000 of those reported attempting suicide within the past 12 months prior to survey interview. Descriptive analyses and pooled and stratified (by suicide plan and major depressive episode [MDE]) multivariate logistic regression models were applied. Major depressive episode was based on assessments of individual diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). RESULTS Among persons aged 18 years or older in the United States, 3.8% reported having suicidal ideation in the past 12 months. Among past-year suicidal ideators, 13.2% attempted suicide in the past 12 months. The prevalence of past 12-month suicide attempt among past-year ideators with MDE was higher than among those without MDE (14.1% vs 12.0%). Past 12-month suicide attempt was more common among ideators with a suicide plan than among ideators without a plan (37.0% vs 3.7%). However, the prevalence of suicide attempt was higher among ideators with a plan but without MDE than among ideators with a plan and MDE (42.1% vs 32.9%). Compared with ideators without a plan, ideators with a plan had a higher (adjusted odds ratio [AOR] = 2.2; 95% confidence interval [CI], 1.47-3.45) suicide attempt risk among those without MDE (AOR = 22.4; 95% CI,16.55-30.27) than among those with MDE (AOR = 10.7; 95% CI, 7.91-14.49). CONCLUSIONS Among adult suicidal ideators, factors associated with their progression from ideation to suicide attempt may vary by their suicide plan and major depression status. Focusing attention on high-risk subgroups may be warranted.

Identifying and referring youths at risk for suicide following participation in school-based gatekeeper training

Gatekeeper training is a core strategy of the Garrett Lee Smith Memorial Suicide Prevention Act of 2004. Using data gathered from school-based gatekeeper trainings implemented by GLS grantees, this analysis examines training and gatekeeper factors associated with (1) identification and referral patterns and (2) services at-risk youths receive. Time spent interacting with youths was positively correlated with the number of gatekeeper identifications and knowledge about service receipt. Gatekeepers who participated in longer trainings identified proportionately more at-risk youths than participants in shorter trainings. Most gatekeeper trainees referred the identified youths to services regardless of training type.

Suicidal ideation among community-dwelling adults in the United States.

OBJECTIVES We examined the prevalence and correlates of past-year suicidal ideation among US community-dwelling adults. METHODS We examined data from 183 100 persons aged 18 years or older (including 9800 sampled adults with past-year suicidal ideation) who participated in the 2008-2011 National Survey on Drug Use and Health. We applied descriptive analyses and pooled and stratified (by age and major depression) multivariate logistic regression models. RESULTS The prevalence of past-year suicidal ideation among younger adults (6.6% among those aged 18-25 years and 4.0% among those aged 26-49 years) was higher than was that among adults aged 50 years or older (2.5%). The prevalence of suicidal ideation was high among adults with major depression (26.3%), adults with both major depression and substance use disorder (37.7%), and adults who received mental health treatment but perceived unmet treatment need (33.5%). CONCLUSIONS Many risk and protective factors of suicidal ideation are dynamic and vary by age or major depression. These results have important implications for developing specific suicide prevention strategies that help screen, assess, and treat suicidal adults at the earliest possible time.

Mental Health Treatment Patterns Among Adults With Recent Suicide Attempts in the United States

OBJECTIVES We examined mental health treatment patterns among adults with suicide attempts in the past 12 months in the United States. METHODS We examined data from 2000 persons, aged 18 years or older, who participated in the 2008 to 2012 National Survey on Drug Use and Health and who reported attempting suicide in the past 12 months. We applied descriptive analyses and multivariable logistic regression models. RESULTS In adults who attempted suicide in the past year, 56.3% received mental health treatment, but half of those who received treatment perceived unmet treatment needs, and of the 43.0% who did not receive mental health treatment, one fourth perceived unmet treatment needs. From 2008 to 2012, the mental health treatment rate among suicide attempters remained unchanged. Factors associated with receipt of mental health treatment varied by perceived unmet treatment need and receipt of medical attention that resulted from a suicide attempt. CONCLUSIONS Suicide prevention strategies that focus on suicide attempters are needed to increase their access to mental health treatments that meet their needs. To be effective, these strategies need to account for language and cultural differences and barriers to financial and treatment delivery.

Referral Patterns for Youths Identified at Risk for Suicide by Trained Gatekeepers

BACKGROUND In order to better understand the posttraining suicide prevention behavior of gatekeeper trainees, the present article examines the referral and service receipt patterns among gatekeeper-identified youths. METHODS Data for this study were drawn from 26 Garrett Lee Smith grantees funded between October 2005 and October 2009 who submitted data about the number, characteristics, and service access of identified youths. RESULTS The demographic characteristics of identified youths are not related to referral type or receipt. Furthermore, referral setting does not seem to be predictive of the type of referral. Demographic as well as other (nonrisk) characteristics of the youths are not key variables in determining identification or service receipt. LIMITATIONS These data are not necessarily representative of all youths identified by gatekeepers represented in the dataset. The prevalence of risk among all members of the communities from which these data are drawn is unknown. Furthermore, these data likely disproportionately represent gatekeepers associated with systems that effectively track gatekeepers and youths. CONCLUSIONS Gatekeepers appear to be identifying youth across settings, and those youths are being referred for services without regard for race and gender or the settings in which they are identified. Furthermore, youths that may be at highest risk may be more likely to receive those services.

Preventing suicide is a national imperative

Preventing suicide is a national imperative (Goldsmith S, Pellmar T, Kleinman A, Bunney W. Reducing Suicide: A National Imperative. Washington, DC: National Acadamies Press; 2002.). Over 36 000 Americans die by suicide annually, another 1.1 million adults make suicide attempts, and over 8 million adults seriously consider suicide each year (Substance Abuse and Mental Health Services Administration [SAMHSA]. 2010 National Survey on Drug Utilization and Health. Rockville, MD: SAMHSA; 2010.). In the past dozen years, there have been increasing efforts to reduce suicide’s tragic toll, and suicide prevention has emerged as a national priority. There is a special obligation to prevent suicide among those who have served our nation in the military, as well as to support their families. It is particularly poignant when we lose to suicide those who have risked their lives for the rest of us. In the words of former Secretary of Defense Robert Gates, spoken when he and Secretary of Health and Human Services Kathleen Sebelius launched the National Action Alliance for Suicide Prevention, “It is always a horrible tragedy to see a service member safely off the battlefield, only to lose them to this scourge. We can, we must, we will do better.” This special issue of the American Journal of Public Health presents vibrant testimony to the many outstanding ways that we as a nation are working to do better. The articles represent different strands of a comprehensive public health approach to suicide prevention—our nation’s best hope for saving lives. These studies cover a broad array of settings and interventions, including key components of a comprehensive approach, ranging from surveillance to clinical services to mental health enhancement, from emergency departments to primary care settings to suicide hotlines, from promotion of community integration to the reduction of sleep disturbance. They demonstrate the intensive efforts of the Department of Veterans Affairs (VA) and Department of Defense (DoD), as well as public and private partners around the country. As one example of these efforts, the VA has placed a suicide prevention coordinator in each of its medical centers in the country. The Substance Abuse and Mental Health Services Administration (SAMHSA) has been privileged to work with our Federal partners on these extraordinarily important efforts. SAMHSA’s collaboration with VA to utilize the National Suicide Prevention Lifeline (1-800-273-TALK/8255) as the gateway to the Veteran’s Crisis Line has led to this service being accessed by hundreds of thousands of veterans and their families and friends since its inception in 2007. SAMHSA also works closely with the VA and DoD to support our nation’s military families, and through vehicles such as the Suicide Prevention Resource Center and the National Action Alliance for Suicide Prevention, helps ensure that the nation benefits from the knowledge gained through efforts such as those included in this special issue. The DoD recently released a suicide prevention task force report called “The Challenge and the Promise.” This title underscores the fact suicide is preventable, but that large-scale prevention requires sustained, focused effort. The authors of the studies in this special issue have met the challenge of providing important new information, and it is now up to the rest of us to meet the challenge, to put this knowledge into practice, and to fulfill the promise of preventing suicide among those who have risked everything to protect us. j

Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: The Importance of Active Engagement, Active Rescue, and Collaboration Between Crisis and Emergency Services

In 2012, the SAMHSA-funded National Suicide Prevention Lifeline (Lifeline) completed implementation of the first national Policy for Helping Callers at Imminent Risk of Suicide across its network of crisis centers. The policy sought to: (1) provide a clear definition of imminent risk; (2) reflect the state of evidence, field experience, and promising practices related to reducing imminent risk through hotline interventions; and (3) provide a uniform policy and approach that could be applied across crisis center settings. The resulting policy established three essential principles: active engagement, active rescue, and collaboration between crisis and emergency services. A sample of the research and rationale that underpinned the development of this policy is provided here. In addition, policy implementation, challenges and successes, and implications for interventions to help Lifeline callers at imminent risk of suicide are detailed.