Substance Abuse Prevention is Suicide Prevention

By Action Alliance Executive Secretary David Litts & Colleen Carr

When we prevent or successfully treat substance abuse, we prevent suicides. There is a powerful connection between the missions of the substance abuse prevention and treatment communities and the suicide prevention community – and much to be gained when these groups come together around their common goals.

Drug poisoning deaths have increased 120 percent in recent years – from 17,415 in 2000 to 38,329 in 2010. The majority (58 percent) of the drug deaths involved pharmaceuticals, and 75 percent of those deaths involved prescription pain relievers.[i] In 2010, U.S. emergency departments treated 202,000 suicide attempts in which prescription drugs were used as the means, 33,000 of which were narcotic pain relievers.[ii]

The suicide and substance abuse prevention fields need to align their efforts to promote healthy individuals and healthy communities.

Many of the factors that increase the risk for substance abuse, such as traumatic experiences, also increase the risk for suicidal thoughts and behaviors,[iii],[iv] and substance abuse, like mental health problems, is linked with a several-fold increase in suicide risk.[v],[vi]

There is hope, however: Prevention works, treatment is effective, and recovery is possible. Life skills that support effective problem-solving and emotional regulation, connections with positive friends and family members, and social support can protect individuals from both substance abuse and suicide. Treatment and support are important precursors for recovery from substance abuse as well as recovery from suicidal thoughts.[vii],[viii]

In September 2012, a newly revised National Strategy for Suicide Prevention (NSSP) was released by the National Action Alliance for Suicide Prevention (Action Alliance) in conjunction with the Office of the Surgeon General. The Action Alliance is a public-private partnership, jointly launched in 2010 by the Secretaries of Health and Human Services and Defense, envisioning a Nation free from the tragic experience of suicide. The connection between suicide prevention and the prevention and treatment of substance abuse is either implicit or explicit in each of the 13 goals of the NSSP, as it should be. Recognizing this, the NSSP calls for several actions, including:

• Train staff in substance abuse treatment settings to ask their clients and patients directly and in a non-judgmental way whether they are having thoughts of suicide or think things would be better if they were dead. Ask on intake and periodically throughout the course of treatment, and ask in a way that opens the door for a truthful response. 
• Work with individuals, families and other social groups, and communities to reduce access to drugs, especially access to lethal quantities of drugs among individuals at increased risk for suicide. This includes reducing stocks of medications kept in the home, locking up commonly abused medications, and encouraging the proper disposal of unused and unneeded prescription drugs, a key component of the 2013 National Drug Control Strategy.

Let us commit to stronger collaboration between substance abuse and suicide prevention efforts at all levels: community, state, tribal, and national. And let’s take action. The stakes are too high to do otherwise.

---

[i] Centers for Disease Control and Prevention. National Vital Statistics System. 2010 Multiple Cause of Death File. Hyattsville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2012.

[ii] www.samhsa.gov/data/2k13/DAWN2k10ED/DAWN2k10ED.htm#6.2

[iii] Dube, S, Felitti V et all. (2003). Childhood Abuse, Neglect, and Household Dysfunction and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study. Pediatrics, Vol. 111 No. 3.

[iv] Afifi T, Murray W, et al. (2008) Population Attributable Fractions of Psychiatric Disorders and Suicide Ideation and Attempts Associated With Adverse Childhood Experiences. American Journal of Public Health 2008, Voi 98, No. 5.

[v] Conwell Y, Duberstein PR, Cox C, Herrmann JH, Forbest NT, Caine ED (1996). Relationships of age and axis I diagnoses in victims of completed suicide: A psychological autopsy study. American Journal of Psychiatry, 153(8): 1001-1008.

[vi] Moscicki EK (2001). Epidemiology of completed and attempted suicide: Toward a framework for prevention.Clinical Neuroscience Research, 1, 310-323.

[vii] Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive Therapy for the Prevention of Suicide Attempts: A Randomized Controlled Trial. JAMA: Journal of the American Medical Association, 294(5), 563-570.

[viii] Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., et al. (2006). Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder. Archives of General Psychiatry, 63(7), 757-766.

This blog entry is cross-posted on the white house website.

The Enduring Legacy of My Son, Garrett

Today, September 9, brings to mind some of the most wonderful times in my life and also the saddest. You see, on this day 32 years ago, my precious son Garrett came into my wife Sharon’s and my life. He was a beautiful baby who soon grew into a kind and generous boy. However, this same day 10 years ago was the first time Sharon and I awoke with the knowledge that Garrett no longer was on this Earth. 

Gordon H. SmithPresident and CEO,
National Association of Broadcasters
Former U.S. Senator from the State of Oregon
Private Sector Co-Chair,
Action Alliance for Suicide Prevention

Sadly, the day before, we received the news that Garrett had taken his life in his college apartment in Utah. Even in his death, Garrett was a kind and considerate boy. He gave away some of his most precious possessions, ensured the safety of his beloved dog Oliver, and wrote a note absolving Sharon and me of any fault. 

Yet, in looking back over Garrett’s life, we realized we were ignorant of the signs of mental illness and because of that Garrett struggled for much of his life with an undiagnosed ailment.  While he began receiving care close to the time of his death, we knew it came too late and we wondered how different his life would have been had we known of his struggle and connected him to care much earlier in his young life.

However, in Garrett’s death came a call to action. I became and continue to be focused on helping other young people and adults who struggle with mental illness and who are at risk for suicide. In Garrett’s memory, an outstanding piece of legislation was enacted into law – the Garrett Lee Smith Memorial Act. It was passed by the U.S. Senate with support from all 100 Senators and passed the U.S. House of Representatives with significant bipartisan support.  President George W. Bush signed it into law on October 21, 2004. And to this day, the programs that bear Garrett’s name continue to receive full funding and wide bipartisan support.

It is through these programs that millions of Americans have been helped. The Garrett Lee Smith Memorial Act provides states, tribal nations and organizations, and colleges and universities with much needed funding to create and implement youth suicide prevention plans with a significant focus on early identification. To date, 49 states, DC and Guam, and 46 tribal organizations have received funding, as well as 135 institutions of higher learning. Further, through the Garrett Lee Smith Memorial Act, more than 600,000 people have been trained in suicide prevention, including teachers, coaches and other youth-serving individuals. The law also authorizes and funds the Suicide Prevention Resource Center (SPRC). The center’s key functions are to provide technical assistance, training and resources to federal grantees. The SPRC also works closely with the federally funded National Suicide Prevention Lifeline (Lifeline) (1-800-273-TALK) and its network of more than 160 crisis centers. Lifeline provides free and confidential support to people in suicidal or emotional distress, including veterans, active military, and their families and friends. This year, the Lifeline expects to answer more than 1.1 million calls.

While early identification efforts and training to recognize the signs of mental illness and suicidality are important to saving lives, access to evidence-based treatment is the most critical component – and often the most difficult to achieve. That is why I was so pleased to support the Paul Wellstone and Pete Dominici Mental Health Parity and Addiction Equity Act. Enacted at the end of 2008, this law, once fully implemented, will help ensure persons in need of treatment receive it. The law eliminates the differentiation in cost between physical and mental illnesses and will further reduce the stigma of mental illness. 

I was honored to accept the appointment by Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services (HHS), to serve as the private sector co-chair of the National Action Alliance for Suicide Prevention. Created in 2010, the Action Alliance has a mission of advancing the National Strategy for Suicide Prevention by championing suicide prevention as a national priority, catalyzing efforts to implement high priority objectives, and cultivating the resources needed to sustain progress in suicide prevention. I am privileged to be joined by the public sector co-chair, John M. McHugh, Secretary of the U.S. Army. Our aspirational goal is to save 20,000 lives over the next five years.

In Garrett’s memory, Sharon and I continue to try and find meaning in helping others. This past July, with support and funding from the members of the National Association of Broadcasters, I was able to launch the OK2TALK media campaign. As these public service announcements have hit the airwaves, public awareness about mental illness and assistance in connecting with care is growing exponentially. In just the first month, the PSAs have been aired on TV over 48,000 times and on radio 3,300 times. The total financial accounting of this free airtime totals $6.9 million. America’s broadcasters should be commended for their generosity and support. To ensure people receive needed care, HHS launched in conjunction with our effort a new website www.mentalhealth.gov, and we launched a Tumblr page. To date, the Tumblr page has had 198,000 page views; 100,000 total visits; 13,900 followers; 774 submissions; 22,000 engagements; and 17,000 have clicked “Get Help” to access mentalhealth.gov/suicide hotline resources.

While Sharon and I will never stop longing to see and hold our precious son just one more time, we do rejoice in the knowledge that in his death has come so much good. On this day, the day that Garrett would have turned 32, I invite all of you to join us in celebrating all of the outstanding accomplishments our nation has made in the past 10 years to expand access to mental health identification and treatment, and to reduce the tragic event of suicide. We also call on you to continue the fight, continue working to save lives one person at a time.

On Being Bold in Suicide Prevention: Innovative Approaches in Innovative Places

By Sally Spencer-Thomas, Co-Lead of the Action Alliance Workplace Task Force and CEO & Founder of the Carson J Spencer Foundation

I had been in the field of mental health 16 years before my brother Carson took his life in 2004, and I would

Sally Spencer-Thomas,
CEO & Founder,
Carson J Spencer Foundation

say that since then I have learned much about the “gaps” that need to be filled in the field of suicide prevention. In the aftermath of his death, our family and his friends came together in our grief, as many people do, with a strong sense to “do something” and formed the Carson J Spencer Foundation (CJSF). From CJSF’s inception, what quickly became obvious was the huge “gap” between the target population of most suicide prevention efforts and population that most represented by those who were dying. We were shocked to learn that most people who took their lives were just like Carson: white, working-aged men. We made the commitment to be bold and try to fill this “gap” with innovative approaches in innovative places.

Innovation is critical in the field of suicidology because it helps us engage untapped resources, explore new partnerships, and ultimately expand our capacity. Without innovation, we will just keep repackaging the same methods and will be limited in our ability to create the significant change we all envision. Innovation begins with an idea to take a radically different approach – especially if it’s difficult.

In hindsight, we can usually see the benefits of innovation, but at first they are sometimes considered radical ideas. Where would we be if that first crisis call center had never emerged or if the Air Force had decided, like so many others had before, that there was nothing that could be done to prevent suicides? Often, because innovation challenges convention of how things get done, initial backlash and doubt ensue. Inevitably, trial and error cycle as the innovative idea evolves. Sustained change comes as the context of discovery moves into the context of justification, and rigorous evaluation helps us better understand the cause and effect cycle of change.

Since my brother Carson was a gifted entrepreneur and not afraid of risk-taking, the founders of CJSF not only dedicated our mission to preventing what happened to him from happening to others, but also to celebrating his gifts as a dynamic and bold visionary.  

When taking an inventory of existing suicide prevention efforts, we noted that very few people were addressing suicide prevention in the workplace, and this gap became ours to fill. In 2007 CJSF launched the Working Minds program (www.WorkingMinds.org) and in 2009 we published the Working Minds Toolkit, which was accepted to the National Best Practice Registry in 2010. The goal of these efforts is to build capacity in workplaces, so that they are better able to implement comprehensive and sustained suicide prevention programs.

Today, with the help of the National Action Alliance for Suicide Prevention’s Workplace Task Force, workplace suicide prevention efforts are better able to leverage the influence of leaders from across the country and create a “tipping point” of change. We are bringing together executives and industry leaders to be spokespeople for the cause; we are pulling together resources to outline a blueprint for change; and we are partnering with the Public Education and Awareness Task Force to “Change the Conversation.”

The Workplace Task Force, in partnership with CJSF and others, has launched three new innovative resources for workplaces:

•  A Manager’s Guide to Suicide Postvention in the Workplace: 10 Action Steps for Dealing with the Aftermath of Suicide
• A Comprehensive Blueprint for Workplace Suicide Prevention
• VIDEO: Firefighters Coping with the Aftermath of Suicide

In addition, we need innovation to reach those at highest risk for suicide – men of working age with multiple risk factors, who are also least likely to seek care. For years, the same message – “if you are depressed, seek help” – was repackaged with little success in reaching this demographic.  What the effort needed was a brand that was compelling to high-risk men. In 2007, the Carson J Spencer Foundation, Cactus Marketing and Colorado’s Office of Suicide Prevention – a public-private-nonprofit partnership – came together to find a new way to reach high-risk men by using “manspeak” and humor.

On July 9, 2012, after four years of research, development, and planning, the partnership launched the one-of-a-kind Man Therapy™ campaign (www.ManTherapy.org) with an article in the New York Times. While the unconventional approach raised a few eyebrows, our initial results look promising so far – the campaign seems to be reaching the target audience and having the intended effect. In just nine short months, the website has experienced over 200,000 unique visitors averaging over 6 minutes per visit. More than 60,000 people have completed the 18-point head inspection (a self-screening tool) and 15,000-plus have accessed information on crisis services. The qualitative feedback we have received from men and therapists alike is that men’s thinking about mental health shifts during their interaction with www.ManTherapy.org  and they are more likely to do something different about their problems as a result.

While innovation is particularly unnerving in a profession where lives are at stake, we must “be visible, be vocal, be visionary. There is no shame in stepping forward, but there is great risk in holding back and just hoping for the best.” (Higher Education Center)

Law Enforcement Officer Suicide and Mental Health

By Yost Zakhary, Director, Woodway Public Safety Department, Woodway, TX, First Vice President, International Association of Chiefs of Police

Chief Yost Zakhary
Director, Woodway Public Safety Department
First Vice President, International Association of
Chiefs of Police

Law enforcement agencies are like families.  A special camaraderie forms in a department where men and women work side by side in service to their communities.  Not unlike more traditional family units, police departments are shaken to the core with the death of one of their own.  The response, organizational and individual, is even more complex when that death comes at the officer’s own hand.

In a profession where strength, bravery, and resilience are revered, mental health issues and the threat of officer suicide are “dirty little secrets”—topics no one wants to address or acknowledge.  The resulting stigma associated with asking for help leaves officers in need with nowhere to turn.  But in reality, mental health is an issue of officer safety, and departments should treat it as such.  From body armor and seat belt use policies, to self-defense and firearms training, any police chief can offer a litany of measures available to ensure an officer’s physical safety.  However, efforts to actively protect and promote officers’ mental and emotional health, in many cases, are sorely lacking.

The International Association of Chiefs of Police (IACP), the world’s leading professional association for law enforcement executives, recognizes this deficiency and is committed to action.  The Association, under the auspices of its broader officer safety and wellness initiative, is taking an active leadership role in erasing the stigma the profession associates with officer mental health issues and emphasizing the importance of suicide prevention and emotional wellness as integral parts of the officer safety continuum.  Several efforts are underway.

The IACP joined the National Action Alliance for Suicide Prevention in the summer of 2012, and I am honored to serve on its Executive Committee.  Through active involvement with the Workplace Task Force, we hope to advance suicide prevention in the first responder community.

Officer suicide was covered extensively at the 119^th Annual IACP Conference in October 2012, with several related workshops and a plenary session.  Attendance at all events exceeded expectations, offering a clear indication of the level of interest and need.  The new Center for Officer Safety and Wellness section of the IACP website also highlights existing suicide prevention resources with more to come.

Our next steps are to provide the field with meaningful leadership and guidance.  With assistance from the US Department of Justice’s Office of Community Oriented Policing Services, the IACP will host Breaking the Silence: a National Symposium on Law Enforcement Officer Suicide and Mental Health this summer.  Our goals for this symposium are to:

• Raise awareness regarding suicide and mental health issues in law enforcement and move toward a culture of support and understanding.
• Identify and evaluate existing resources, best practices, and training related to suicide prevention, intervention, and response programs.
• Create a strategic plan to guide police chiefs in taking proactive measures to mitigate the risk of suicide and openly address officer mental health as a core element of officer safety. 

The vision of the Action Alliance is “a nation free from the tragic experience of suicide.”  The IACP holds the same “zero–tolerance” approach regarding officer deaths, including suicides.  We are committed to raising awareness among our members of approaches to preventing suicide and providing resources to guide them in developing prevention, intervention, and response programs that will save lives.  We look forward to working with our partners at the Action Alliance and the Suicide Prevention Resource Center and leveraging their collective expertise to draft a strategy for suicide prevention in law enforcement.  And we look forward to contributing to the Action Alliance’s goal of saving 20,000 lives in five years.

Health Care Reform: The Opportunity for Suicide Prevention

By Michael Hogan, Ph.D., Independent Advisor and Consultant at Hogan Health Solutions LLC, Action Alliance Executive Committee member, and co-lead of the Clinical Care and Intervention Task Force

When the Action Alliance selected the integration of suicide prevention into health care reform as one of its four national priorities stemming from the National Strategy for Suicide Prevention, it was still unclear as to what the Supreme Court’s response would be to legal challenges involving the Affordable Care Act. Either way, the Action Alliance felt that major changes to the health care system were going to occur. Should we not strive to use the momentum of reform to better focus health care on people at risk for suicide?

Most mental health professionals and advocates agree that the health and behavioral health care system in the US does not currently meet the needs of patients struggling with suicidal behavior – in sum, “suicide care” is inadequate. Health care reform presents the most significant opportunity in a generation to make the health care system more responsive to individuals who are at risk for suicide or who are engaging in suicidal behavior. It’s an opportunity to save lives, contributing to the realization of the Action Alliance’s goal of saving 20,000 lives in five years.

The US Centers for Medicare and Medicaid Services (CMS) has the lead responsibility of interpreting and implementing the Affordable Care Act of 2010, and the Substance Abuse and Mental Health Services Administration (SAMHSA) has the lead on behavioral health issues. For this reason, the Action Alliance has been working with SAMHSA Administrator Pam Hyde to engage senior CMS leadership in a conversation about the integration of suicide prevention into health care reform over the last year and a half.

Health care reform aims to deliver what former CMS Administrator Don Berwick called the Triple Aim: better health for populations, better care for individuals, and reduced costs to society. Transforming health systems to prevent suicide and improve suicide care addresses all of these goals.

By identifying patients at risk for suicide early, risks can be reduced and effective treatment can be delivered. By providing early and effective treatment in a behavioral health setting or in a collaborative care setting where primary care and behavioral health care are integrated, we can save lives and prevent some suicide attempts that result in costly emergency medical expenses.

We know that people admitted to hospital or emergency department care with suicidal behavior remain at high risk when they leave. And we know that if we ensure a patient receives continuity of care through the discharge and out-patient care engagement process, we can reduce expensive re-hospitalizations and suicides.

We have also learned that when health systems focus on safety and suicide care, the results are far better than those achieved through piecemeal approaches. One of the keys must be leadership among health plans and systems. They can encourage better screening for depression and suicidality, delivery of effective, evidence-based treatment and continuous care to patients who are at risk. Health plans and payers must transition from paying for the quantity of episodic services to paying for better integrated care that will change the health outcomes of populations.

I have been privileged to meet with the Action Alliance Co-Chairs, SAMHSA Administrator Hyde, CMS Administrators (Acting Administrator Don Berwick in 2011, and current Acting Administrator Marilyn Tavenner in 2012), my fellow Action Alliance Executive Committee member Paul Schyve, and the Action Alliance Secretariat on several occasions to discuss areas of health care reform implementation that are relevant and critical to suicide prevention. The Action Alliance has also submitted public comments in response to CMS’s efforts to implement electronic health record technology. In all of our interactions, we have focused on three domains: promoting early identification of those at risk for suicide, the delivery of effective treatment for suicidal behavior, and the provision of the follow-up care for those at risk as they transition from one setting of care to another. Later this year, the Suicide Prevention Resource Center will partner with The National Council for Community Behavioral Healthcare to “go live” with a website providing tools for providers to take these steps. These improvements within an evolving health system are the key targets for getting us to that goal of saving 20,000 lives in five years.

What do you think? How would you like to see suicide prevention integrated into health care reform? Please comment and share your ideas below.