A Comprehensive Approach to Suicide Prevention within a Public Health Framework

  • Date: Oct 26 2021
  • Policy Number: 20213

Key Words: Mental Health, Violence, Injury Prevention Control

Age-adjusted suicide rates in the United States rose from 12.1 per 100,000 in 2010 to 13.9 per 100,000 in 2019. Efforts to implement evidence-based interventions have done little to curb this trend. Our most promising interventions have been fragmented in delivery, with most efforts concentrated in the clinical realm for individuals experiencing acute crisis. To effectively produce and sustain reductions in suicide in the United States, we must implement a comprehensive public health approach to suicide prevention. This approach recognizes and addresses the many intrapersonal, interpersonal, community, occupational, environmental, and societal factors that contribute to risk. Such an approach reduces fragmentation of efforts and mirrors the comprehensive preventive approaches used for conditions such as heart disease or diabetes. Targeting contextual factors that contribute to risk and increasing protection would likely have positive effects on other related injury prevention priorities, such as preventing family and workplace violence, bullying, homicide, and accidental death. Public health professionals must support an approach to suicide prevention that includes improving national, state, and local infrastructure for supporting suicide prevention efforts; increasing access to timely and accurate suicide-related data; increasing research and evaluation to better understand and address contextual factors that produce risk and support resilience, particularly for historically underserved populations; addressing lethal means safety and other policies that support suicide prevention; and supporting acute crisis interventions and other evidence-based strategies for those experiencing a suicide-related crisis.

Relationship to Existing APHA Policy Statements
This proposed policy addresses the lack of a comprehensive APHA policy statement on suicide prevention. It replaces archived policy 7524(PP) (Suicide Prevention), which recognized suicide as a major public health problem and requested that APHA support a multidisciplinary task force on suicide prevention. This archived statement serves as a historical document that no longer guides APHA efforts.

This proposed policy statement builds on the recognition in 15 current policy statements that suicide and suicidal ideation are socially determined and the recognition in six statements that there are specific groups at high risk for suicide. The current statement advocates for a comprehensive public health approach to suicide prevention. This type of approach recognizes and addresses the many interpersonal, intrapersonal, community, occupational, environmental, and societal factors that contribute to risk.

The following existing policy statements are relevant to the proposed policy statement:

Suicide Prevention in a Public Health Framework

  • APHA Policy Statement 20184: Reducing Suicide by Firearms
  • APHA Policy Statement 20185: Violence is a Public Health Issue: Public Health is Essential to Understanding and Treating Violence in the U.S. 
  • APHA Policy Statement 201912: Addressing Alcohol-Related Harms: A Population Level Response 
  • APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
  • APHA Policy Statement 20179: Reducing Income Inequality to Advance Health Suicide and Social Determinants of Health

Suicide and Social Determinants of Health

  • APHA Policy Statement 20196: Addressing the Impacts of Climate Change on Mental Health and Well-Being
  • APHA Policy Statement 201810: International Food Security and Public Health: Supporting Initiatives and Actions
  • APHA Policy Statement 20178: Housing and Homelessness as a Public Health Issue
  • APHA Policy Statement 20123: Cessation of Military Recruiting in Public Elementary and Secondary Schools
  • APHA Policy Statement 20101: Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities
  • APHA Policy Statement 20095: The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War
  • APHA Policy Statement ;200914: Building Public Health Infrastructure for Youth Violence Prevention
  • APHA Policy Statement 200712: Toward a Healthy Sustainable Food System

Suicide and Administrative Data and Language

  • APHA Policy Statement 201513: Improving Availability of and Access to Individual Worker Fatality Data
  • APHA Policy Statement 20086: Patients’ Rights to Self-Determination at the End of Life

Suicide and Vulnerable Populations

  • APHA Policy Statement 20142: Reduction of Bullying to Address Health Disparities Among LGBT Youth
  • APHA Policy Statement 20192: A Global Call to Action to Improve Health Through Investment in Maternal Mental Health
  • APHA Policy Statement LB-18-01: APHA Opposes Separation of Immigrant and Refugee Children and Families at U.S. Borders
  • APHA Policy Statement 20169: Promoting Transgender and Gender Minority Health through Inclusive Policies and Practice
  • APHA Policy Statement 201411: Removing Barriers to Mental Health Services for Veterans

Problem Statement
Extent of the problem: In the United States, the age-adjusted suicide rate has increased over 32% over the past two decades, from 10.5 per 100,000 people in 1999 to 13.9 per 100,000 people in 2019. Over 47,500 people died by suicide in 2019, averaging about 130 suicide deaths per day. In 2019, suicide was the 10th leading cause of death in the overall U.S. population and the second leading cause of death among individuals between the ages of 10 and 34 years. Suicide mortality rates are consistently highest among those in the “middle years” (45 to 64 years).[1]

In 2019, firearms were the most common means of suicide (50.4%), followed by suffocation (28.5%) and intentional poisoning (12.9%).[2] Patterns of means differ between males and females. While firearms were used in over half of male suicides in 2019 (55.6%), they were used in less than a third of suicides among women (31.4%), who were also likely to die by suffocation (29.0%) or poisoning (30.0%).[1] In part because of the lethality of firearms, males are more than three times as likely as females to die by suicide.[1]

In 2019, the age-adjusted suicide death rate was highest among non-Hispanic American Indians/Alaska Natives (22.3 per 100,000), followed by non-Hispanic Whites (17.5 per 100,000), non-Hispanic Blacks (7.4 per 100,000), Hispanics (7.2 per 100,000), and non-Hispanic Asian/Pacific Islanders (7.1 per 100,000).[1] Of concern is the increasing suicide rate among Black youth. As discussed in Ring the Alarm: The Crisis of Black Youth Suicide in America, the suicide mortality rate among Black youth 5 to 12 years of age is roughly two times higher than that of White youth. While the Centers for Disease Control and Prevention (CDC) cautions that challenges in determining suicidal intent among children younger than 10 years make using rates for this group unadvisable, there remains growing concern regarding the pervasive structural inequalities that contribute to suicide risk for Black youth.

While suicide rates among military members are similar to those in the civilian populations, rates among veteran populations are higher than civilian rates after adjustment for age and sex.[3] Youth who identify as lesbian, gay, bisexual or transgender, or queer or questioning (LGBTQ) are also at particularly high risk of suicide. In fact, LGB youth seriously contemplate suicide at a rate that is nearly three times that of their heterosexual counterparts.[4] Trends in suicide risk for LGB youth have generally remained stable since 2015.[4]

In 2019, age-adjusted suicide mortality rates were generally highest in western states where there is more widespread access to firearms, including Wyoming (29.3 per 100,000), Alaska (28.5 per 100,000), Montana (26.2 per 100,000), and New Mexico (24.0 per 100,000). Rates were lowest in northeastern states such as New Jersey (8.0 per 100,000), New York (8.3 per 100,000), and Massachusetts (8.7 per 100,000).[1] At the local level, rural counties generally have higher rates of suicide mortality than urban counties.[5]

Many more people attempt suicide than die by suicide. According to the National Survey of Drug Use and Health, 1,379,000 adults (18 years or older) reported attempting suicide in 2019, 732,000 reported receiving medical attention for a suicide attempt, and 526,000 reported being hospitalized overnight or longer in response to a suicide attempt.[6] Among adults, suicide thoughts, plans, and attempts are highest among women and among young adults between the ages of 18 and 25 years.[6] In 2019, American Indian/Alaska Native adults were at a higher risk of past-year suicide-related thoughts than members of other races/ethnicities.[6]  Youth Risk Behavior Surveillance Survey data from 2019 indicate that high school youth are more likely than the general adult population to report suicide-related thoughts or attempts in the past year.[7] Early evidence suggests that risk of suicide attempts, particularly among adolescent girls, may have worsened during the COVID-19 pandemic, as suspected suicide attempt visits were up 50.6% for girls during early 2021 relative to the same period in 2019.[8] 

Risk and protective factors: While the mental health challenges that people suffer—including anxiety disorders, mood disorders, and schizophrenia—have long been associated with increased suicide risk,[9] mental illness is only one of many factors that can correlate with suicide risk. Data for 36 states from the CDC’s National Violent Death Reporting System indicate that among those who died by suicide in 2017, four out of five (80%) had no prior history of a suicide attempt.[1] Many suicide decedents had a social, economic, or physical stressor that immediately preceded the suicide death, including intimate partner conflicts (26.5%), physical health problems (22.2%), or a recent or impending crisis (31.0%).[1] Access to care is also an important correlate of risk. Among the 20% of adults in a national household survey who reported having a mental health condition in 2019, almost three quarters (73%) were unable to access behavioral health outpatient services, primarily as a result of cost/lack of insurance or because they did not know where to get services.[10]

Suicide can be understood by looking through a socioecological lens and recognizing the many intrapersonal, interpersonal, community, occupational, environmental, and societal factors that can correlate with risk or provide protection.[11] Individual-level correlates can include a person’s genetic background, a family history of suicide, early life adversity, social isolation, level of physical activity, and immediate access to lethal means.[12,13] At the relationship level, youth bullying and a family history of suicide and intimate partner conflict are correlated with risk, while relationships with care providers can offer support.[14] At the community level, policies influencing access to lethal means, social isolation, stigma related to help seeking, and lack of access to mental and physical health care can correlate with risk, while community connections and policies limiting access to lethal means for those at risk can provide support.[14] Geographically, risk may be correlated with stressors related to climate change events such as hurricanes, fires, or extreme cold, which produce changes in human well-being and life satisfaction (see APHA Policy Statement 20196). At the societal level, public health crises including the COVID-19 pandemic, economic turmoil, historical trauma, and lack of access to culturally competent care; siloed approaches to public health, mental health, substance misuse, and suicide prevention; and systemic forces of oppression can also confer risk.[12,15,16] Suicide contagion, whether through imitation, affiliation, or contextual influence, can be exacerbated by media reports on suicide that do not adhere to safer suicide reporting guidelines.[17] Risk and protective factors intersect with various aspects of identity and shift over the course of the life span. Furthermore, risk and protective factors intersect with one another and with other public health problems, including alcohol and drug misuse and overdose. Between 2015 and 2018, there was a three-year loss of life expectancy in the United States due to the combined impact of suicide, drug overdose, and alcohol misuse.[18] Often referred to as “deaths of despair,” these public health issues share risk factors at all levels of the socioecological model. Escalating health care costs, which have had a negative impact on employment, wages, pensions, access to education, housing, and other quality of life factors, have been a major driver of these issues.[19] Application of a socioecological lens shows that causes of suicide risk in the United States include those described below. 

An underfunded, inconsistent national, state, and local infrastructure to support suicide prevention efforts: Lack of a consistent suicide prevention infrastructure nationwide challenges our ability to address suicide in a systematic and equitable fashion. In 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA) stated that “the absence of [a strong state] infrastructure almost certainly compromises suicide reduction efforts to a significant degree.”[20] Suicide prevention in the United States is woefully underfunded,[21] and thus many state and local prevention programs have to braid funding from a variety of sources, often short-term state or national grant programs. This piecemeal approach to funding poses a significant challenge to sustaining interventions.[22]

A lack of accurate suicide-related data and an overreliance on morbidity and mortality data that are often more than a year old: Public health professionals and policymakers face challenges in making data-driven decisions on where to focus limited resources because suicide death and attempt data are challenging to collect and slow to be released at the national level. Accurate data on minority populations are particularly lacking due to underreporting and poor capture of detailed demographics including gender identity, sexual orientation, veteran status, race, and ethnicity.[23] Medical examiners and coroners find it difficult to ascertain the intent behind overdose deaths, which can lead to inaccurate death data that conflate accidental overdose with intentional suicide. State, territorial, and local health data systems frequently are not connected to each other, and staff face hurdles in obtaining the data-sharing agreements necessary to access additional data sources. Data-driven decision making is critically affected by these hurdles and others such as a lack of public competency in data literacy, poorly supported data platforms and outdated analytic support tools, and a lack of state or local staff with analytic competencies in qualitative and quantitative methods.[24] Syndromic surveillance efforts are currently being funded by the CDC to support closer-to-real-time suicide morbidity data, and these efforts show promise in increasing the timeliness of suicide-related data.[25]

A lack of research on and evaluation of contextual factors that produce risk and confer resilience: When the field focuses mainly on individual-level psychosocial risk factors, it misses opportunities to explore how novel contextual risk and protective factors for suicide coincide for different populations.[26] Stand-alone, single-intervention, one-size-fits-all approaches are unlikely to bend consistently high population-level suicide rates,[27] but little is known about the synergistic impact of contextual risk factors, particularly for those who have historically experienced marginalization.

A lack of policies that support suicide prevention: Suicide prevention lacks consistent, comprehensive policies that meaningfully reduce known risk factors for suicide, such as access to lethal means among those at risk. Furthermore, suicide prevention requires, but is short on, policy approaches that support parity, a term that refers to equity among mental health, substance misuse, and physical health.[28]

Need for widespread implementation of evidence-based acute crisis care and treatment: While progress has been made in efforts to implement widespread suicide prevention training for key professionals, such as behavioral health providers and school personnel who may encounter clients and students experiencing suicidal ideation, there are still widespread shortages of behavioral health clinicians who are trained in evidence-based, culturally sensitive suicide treatment. Suicide treatment differs from standard mental health treatment, as it requires the additional management of suicide-related thoughts as part of the treatment of overall behavioral health symptoms. In addition, many states have insufficient trauma-informed and culturally sensitive crisis care services, leading to more suicidal individuals seeking care in emergency departments or avoiding care altogether.[29] Lack of trauma-informed, evidence-based care may cause those experiencing behavioral health emergencies to receive limited or inappropriate care, resulting in symptom escalation or other poor clinical outcomes.[30]

Evidence-Based Strategies to Address the Problem
Suicide prevention in the United States has long reflected a clinical or at-risk approach to prevention, with efforts directed toward those identified as “vulnerable” or “at risk.”[11,12] Such terms can obscure the root causes of health disparities including historical trauma, discrimination, and structural racism. Rather than marginalize a group by calling its members vulnerable or at risk, the field should explore how the environment has put them at greater risk in the first place. If the public health field can broaden its identification of contextual contributions to risk and protection, it can implement improved solutions that change the risk trajectory for entire populations. Suicide prevention will always have a fragmented approach until context is put first.

A comprehensive public health approach to suicide prevention: To effectively reduce suicide morbidity and mortality—and to sustain such reductions—suicide prevention must invoke a public health approach in which prevention, intervention, treatment, and postvention efforts are woven together into a comprehensive strategy that capitalizes on synergies to create systemic change. There are many benefits of a public health approach to suicide prevention. First, a public health approach explores the context surrounding suicide risk to reduce fragmentation of efforts.[12] Second, a public health approach to suicide prevention (as exemplified by the National Strategy for Suicide Prevention) simultaneously espouses both early prevention activities to address contextual factors and intervention activities that address the needs of those who are already struggling with suicidal thoughts and behaviors.[31] Third, the use of a socioecological lens allows preventionists to target contextual forces of oppression as part of prevention efforts.[11,32] Finally, a focus on shared risk and protective factors through a public health approach creates benefits for other injury prevention efforts, including family violence, homicide, and accidental death.[33]

What does a public health approach entail? The National Strategy for Suicide Prevention provides strategic guidance for comprehensive suicide prevention across the nation. A recent study by the Suicide Prevention Resource Center used a series of key informant interviews and expert panels to produce a list of 27 state infrastructure elements needed to support suicide prevention; these elements are organized around resources needed to authorize, lead, examine, build, and guide suicide prevention efforts.[22] At the same time, infrastructure extends beyond the concrete, practical foundations or frameworks that support suicide prevention at the national, state, or local level. It encompasses the infrastructure of all systems that affect the contextual determinants of health, including schools, places of worship, and workplaces. In workplaces, guidelines from the World Health Organization for suicide prevention emphasize the role of working conditions and the need to prioritize reducing job stressors.[34] Such strategies can include promoting help seeking, integrating wellness into the overall culture, producing resources, facilitating referrals to mental health care and supportive services for workers at risk, training leadership to detect and respond appropriately to suicide risk, and creating crisis response plans that address the needs of the full workplace community.[34,35]

Appropriate infrastructure, defined as a combination of elements that “serves as a solid foundation for effective, comprehensive, and sustained suicide prevention,”[22] across a variety of systems is required to support effective delivery of education and training, such as that provided through Question, Persuade, Refer[36]; Mental Health First Aid[37]; Teen Mental Health First Aid[38]; and other gatekeeper training programs designed to improve mental health literacy and awareness. In addition to supporting both education and training for the general public as well as direct service providers (including physicians, nurses, social workers, and community health workers), appropriate infrastructure is needed to ensure that resources are available for trauma-informed social policy advocacy efforts[39] and implementation of trauma-informed care from a population health perspective[40] and that service delivery systems can adequately engage in prevention efforts across the continuum of care. Appropriate infrastructure is also a prerequisite to enacting CDC recommendations specific to suicide prevention and the recommendations of the National Action Alliance for Suicide Prevention, which include supporting strategic, culturally informed public health campaigns.[41] When used in combination with other public health efforts, such campaigns can contribute to improvements in public awareness of and attitudes toward depression and suicide.[42]

A data-driven approach to suicide prevention requires access to timely and accurate suicide prevention data. Machine learning approaches, which can both learn from and model large data sets using statistical and algorithmic approaches to identifying complex patterns of risk predictive of outcomes, hold promise for suicide prevention efforts and have been applied to electronic health record (EHR) data sets[43]; however, the predictive modeling outcomes generated are only as good as the data used as inputs. Moreover, EHRs are often inaccessible due to confidentiality and privacy protections imbued in the Health Insurance Portability and Accountability Act. To facilitate use of machine learning techniques beyond individual health system data sets, state, territorial, and local health data systems must be updated and made available regularly, and their interfaces must be interoperable. 

Federal legislation has potential to address these and other barriers to accessing data that can critically inform public health approaches to suicide prevention. For example, initially passed into law in 2009, the Health Information Technology for Economic and Clinical Growth (HITECH) Act provision of the American Recovery and Reinvestment Act, which was designed to facilitate meaningful use of EHRs, has shifted in focus to prioritize EHR interoperability and data access for patients.[44,45] Furthermore, Congress’s 2018 clarification to the Dickey Amendment permitting CDC research on gun violence and the accompanying fiscal year 2020 omnibus spending bill earmarking funding for this purpose provide an opportunity to undertake new research in this arena. 

Approaches that include simultaneous components at the system, community, and individual levels are needed to effectively reduce suicide risk.[33,46,47] For example, the United States Air Force Suicide Prevention Program (AFSPP) has employed a multicomponent approach across seven prevention domains: (1) leadership involvement, (2) continuous professional military training, (3) development of guidelines for commanders, (4) ongoing community education, (5) development of integrated delivery system and community action information boards, (6) enhancement of community mental health services, and (7) institution of policies.[48] In addition to reductions in reported suicides, the AFSPP demonstrated reductions in family violence and accidental death, suggesting that programs targeting early and shared risk factors are likely to produce positive outcomes in addition to reducing suicide.[48] While multicomponent approaches that show promise include the European Alliance Against Depression[46] and the Lifespan Suicide Prevention Model in New South Wales,[49] both of which comprise multilevel evidence-based suicide prevention strategies, effectiveness data on these specific programs are not yet available to report. 

To effectively address contextual factors of risk and resilience, researchers and practitioners must work in partnership with local communities to cooperatively develop and implement interventions appropriate to local contexts. Qualitative and community-based participatory research projects are urgently needed to contextualize interventions and understand nuanced suicide prevention needs. For example, the Western Athabaskan Tribal Nation’s Adolescent Suicide Prevention Project developed culturally embedded, trauma-informed, community-wide systems strategies for suicide prevention in cooperation with the Indian Health Service. This resulted in a multipronged approach to collect high-quality suicide data, train tribal youth as natural helpers, integrate drug and suicide education, screen for suicide risk across settings (including traditional dance events), increase suicide prevention emphasis in social and cultural events, reorient and expand mental health services, and conduct culturally appropriate family outreach postsuicide. After 15 years of successful implementation, the project has been shown to markedly decrease suicide attempts.[50]

While place-based, institutional, and systems-level approaches to suicide prevention are gaining traction, these approaches may yield greater gains when undertaken in conjunction with larger-scale policy interventions that limit lethal means restriction and address the social determinants of health. Lethal means safety is the practice of removing highly lethal means of suicide, such as firearms and medications, during times of increased suicide risk. In particular, reducing firearm access among at-risk individuals has had demonstrable impacts on reducing suicide outcomes. Reducing firearm access includes safer storage practices (e.g., storing firearms and ammunition separately), lethal means safety counseling, Gun Shop Project initiatives to promote firearm safety and suicide risk recognition, and policies including extreme risk protection orders (colloquially known as “red flag laws” that temporarily restrict access to guns for individuals identified as at elevated risk of harming themselves or others),[51] mandatory waiting periods, and permit-to-purchase laws.[52] Evidence-based training, such as the Counseling on Access to Lethal Means (CALM) training program, can effectively prepare behavioral health providers and mental health advocates to promote and use lethal means prevention activities to reduce client risk[53]; means safety should also extend beyond firearms to include reduction of access to lethal quantities of medication and proper prescription medication storage.[54] 

Although reducing access to lethal means is most frequently conceptualized as a component of individual safety planning,[55] it has also been implemented through structural modifications (including bridge barriers) that can prevent deaths at specific locations but have little effect on regional suicide rates.[56] However, there is evidence to suggest that large-scale lethal means reduction strategies enacted through policy interventions represent an effective approach to reducing population-level rates. For example, when Yip and colleagues examined the effects of charcoal shelving practices in Hong Kong, they found that moving charcoal from self-service access to locked storage yielded a significant decline in reported suicides (relative to a district similar in geography, population size, and socioeconomic status).[57] Similarly, policies that have limited lethal pesticide use in Sri Lanka,[58] barbiturate access in Australia,[59] and carbon monoxide in the United Kingdom[60] have yielded population-level reductions in suicide risk. 

In addition to lethal means safety, suicide prevention needs policies that address social determinants of health. For example, homelessness, discrimination, income inequality, access to quality health care, and the environmental climate all influence suicide risk but have historically been considered beyond the scope of suicide prevention work. There is already empirical support for the association between socially inclusive policies and reduced suicide rates; states that have adopted marriage equality have shown a lower prevalence of adolescent suicide attempts than states that have not.[61] In the case of employment policies, a 10% minimum wage increase has been shown to reduce nondrug suicides among adults with lower levels of educational attainment by 2.7%, and a 10% increase in the Earned Income Tax Credit reduces such suicides by 3.0%.[62]

The National Action Alliance for Suicide Prevention has provided recommendations for safer suicide care by health and behavioral health care systems through its publication Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe. Recently, health care organizations in the United States have begun to adopt a multifaceted approach to suicide prevention, known as the Zero Suicide (ZS) initiative, that simultaneously spans multiple settings within a given health care system (including primary care, emergency department, outpatient, inpatient).[63] ZS is designed to assist health care systems in reaching the goal of zero suicides by harnessing organizational infrastructure to improve clinical care through implementation of seven core elements: lead, train, identify, engage, treat, transition, and improve.[64] The ZS approach helps to identify and mitigate barriers to help seeking, including stigma and lack of access to culturally responsive suicide care. Furthermore, the ZS model strengthens coordination of patient care to ensure that at-risk clients are contacted after discharge for seamless transitions to care. 

To support quick access to suicide care, the Federal Communications Commission in 2020 established 988 as the new designated national number for suicide prevention and mental health. It will require all service providers to direct 988 calls to the National Suicide Prevention Lifeline, a national network of approximately 170 crisis centers, by 2022. Currently, the National Suicide Prevention Lifeline is supported by local, state, public, and private sources and (as the access point for the for the Veterans Crisis Line) by congressional appropriations through SAMHSA. States are under no requirement to support the use of 988, although its implementation is hypothesized to reduce police interventions for mental health issues and increase efficient referrals to treatment.

Opposing Arguments/Evidence
In the United States, the suicide prevention field faces insufficient prevention dollars and a limited workforce with adequate knowledge of suicide prevention strategies.[21] Opponents of a public health approach to suicide prevention will be concerned that its multipronged comprehensive nature diverts scarce resources away from those experiencing acute crises. In fact, public health approaches to suicide have reflected substantial cost savings by averting suicide deaths and by decreasing disability due to short and/or long episodes of depression.[65] Opponents would question the feasibility of such a model—particularly at the state or local level, where funding and delivery services may have a long history of fragmentation. In response, proponents of the approach would point to recent significant investments by the CDC and SAMHSA in public health approaches to suicide prevention. A notable example of the model’s application can be found in Colorado, where the Colorado National Collaborative is engaging six high-risk counties in comprehensive suicide prevention efforts that span the prevention continuum with the goal of a 20% reduction in suicide by 2025.[12]

Opponents of a public health approach to suicide prevention would also have concerns about lethal means safety strategies related to promotion of gun safety. Opponents of this approach would be concerned about infringement of Second Amendment rights. Firearm suicide has the highest case fatality rate (90%), far outpacing other methods such as hanging (61%), carbon monoxide poisoning (42%), and drug poisoning (2%).[66] Firearm attempts usually result in death after a single attempt,[67] which is particularly problematic given that a meta-analysis of over 100 studies indicated that 90% of individuals who attempted suicide and survived did not go on to die by suicide.[68] Gun safety strategies are an important component of effective suicide prevention and can be implemented in partnership with firing ranges, gun shops, firearm owners, and advocates (e.g., the Gun Shop Project) to ensure that they meet the needs of the firearm community without infringing on Second Amendment concerns. Furthermore, when access to firearms has a delay factor, such as comprehensive background checks and laws promoting safer gun storage, this results in a reduction of unintentional shootings by children.[69] Policy implementation across all sectors at the local, state, and federal levels would reduce gun violence and suicide.

Opponents of a public health approach to suicide prevention would also be concerned that increased prevention resources may heighten awareness of suicide as a public health problem and increase community discussions about suicide, which may accelerate an increase in attempts. However, this type of risk has long been debunked.[70] A recent meta-analytic review revealed that the appropriateness of universal screening for suicidality was helpful and provided critical mitigation of harm reduction.[70] Public awareness campaigns that follow effective messaging guidelines can prove beneficial to both the general public and specific populations (e.g., veterans).[71] 

As mental health and wellness have received more attention during the COVID-19 pandemic, increases in stress and substance misuse among the general population have been demonstrated.[72] Although preliminary data point to a drop in overall suicide rates in 2020, some communities are reporting that populations disproportionately impacted by the pandemic have seen a rise in suicides, including concerning increases in mental health–related and suicide-related emergency department visits among children and adolescents.[8] The parceling out of prevention dollars to high-risk populations and communities, some would argue, will further lead to scarcity in funds for the general population. Opponents of a public health approach to prevention would further argue that the funding should go specifically to those in acute crisis. While it is true that a public health approach to suicide prevention is data driven, meaning that resources and efforts are allocated to those populations and places that are disproportionately affected by the problem, a true public health approach embraces activities at all levels of the socioecological model and at all spaces on the prevention to treatment continuum. A public health approach can simultaneously reach those at highest risk and those who are further back on the risk continuum. As such, it is a cost-efficient way to allocate scarce funding. Furthermore, public health approaches, by definition, ensure that crises are circumvented by strategies that connect with a person before the crisis hits.

Action Steps
APHA urges:

Expansion of infrastructure for a coordinated, comprehensive national, state, and local public health response to suicide prevention through:

  1. Congressional, state, territorial, and tribal appropriation of funding to the CDC, state and tribal public health agencies, and local public health departments to support the strengthening and expansion of existing surveillance data systems that track suicide deaths, attempts, and drug overdoses, such as the CDC’s National Violent Death Reporting System, the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE), and the Drug Overdose Surveillance and Epidemiology System (DOSE).
  2. Congressional, state, territorial, tribal, and local appropriation of funding to support the increased implementation of comprehensive, collaborative public health approaches to suicide prevention, including expansion of federal grant programs such as the CDC Comprehensive Suicide Prevention and SAMHSA Garrett Lee Smith Youth Suicide Prevention programs; adoption of the Suicide Prevention Resource Center’s State Suicide Prevention Infrastructure recommendations; and advancement of the National Strategy for Suicide Prevention (including the surgeon general’s 2021 Call to Action, which highlights specific implementation actions to advance the national strategy). Approaches should aim to increase the adoption of evidence-based strategies while also being culturally responsive and trauma informed.

Expansion of infrastructure to support public education and training in suicide prevention, including efforts by national, state, territorial, tribal, and local public health entities to:

  1. Educate the general public to recognize and respond to warning signs for suicide through evidence-based gatekeeper training programs and rigorously evaluate widely used gatekeeper training programs to ensure their efficacy.
  2. Develop and implement strategic, culturally relevant public health messaging campaigns that promote hope and healing.
  3. Educate and collaborate with local news media to ensure that news coverage about suicide adheres to best practices regarding reporting on suicides.
  4. Engage employers, labor unions, and community-based worker organizations to implement and develop training programs and model policies for workplace suicide prevention programs.
  5. Engage community partners in a comprehensive public health approach to suicide. Community partners include, but are not limited to, faith leaders, schools and community organizations that serve indigenous populations, active and retired military populations, firearm retailers and firing range owners, individuals with lived experience, youth who identify as LGBTQ, and Black youth.

National, state, territorial, tribal, and local public health agencies; health and behavioral health care systems; and educational institutions to contribute to improved data quality for suicide prevention by:

  1. Taking steps to improve the quality of suicide attempt and death data by strengthening data sharing across systems.
  2. Taking steps to train medical examiners and coroners in consistent death coding.
  3. Working closely with tribal communities to strengthen data collection, acknowledging additional ways of knowing that are consistent with indigenous knowledge systems.
  4. Taking steps to increase evaluations of suicide prevention strategies to build a stronger base around what works, particularly among underserved populations including, but not limited to, communities of color, LGBTQ communities, and military/veteran populations.

Expansion of funding to explore and address contextual risk factors for suicide and to develop strategies that promote resilience through:

  1. Congressional, state, territorial, tribal, and local funding allocated to the development, implementation, and evaluation of suicide prevention interventions that reflect diverse communities. In addition, Congress, state and local policymakers, state and local public health agencies, health care systems, and educational institutions should take steps to implement the recommendations set forth in Ring the Alarm: The Crisis of Black Youth Suicide in America to better address risk and protective factors specific to Black youth.
  2. Congressional, state, territorial, tribal, and local funding for research that explores the interrelationship among structural racism, historical trauma, discrimination, and suicide to provide information on how to address these issues at a policy and programmatic level. This should include qualitative research that centers the voices of individuals who have survived suicide attempts as well as people who have lost a loved one to suicide.

Congressional, state, territorial, tribal, and local adoption of policies that support strategies to reduce access to lethal means among those at risk for suicide and promote firearm safety, including:

  1. Allocation of funding to support research on firearm safety for those in suicidal crisis.
  2. Collaboration between public health agencies and firearm retailers, firing range owners, and firearm owners to adopt interventions, conduct training, and implement communication campaigns that reflect best-practice evidence and resonate with the firearm-owning community to support effective prevention strategies such as safe firearm storage and identification of firearm owners/purchasers at risk for suicide.
  3. Monitoring for patterns in suicide death and attempt data to identify commonalities in means used (e.g., firearms, suffocation) or locations of attempts (e.g., bridges, parking garages).
  4. Promotion of evidence-based safety planning interventions by behavioral health providers, pharmacies, and mental health advocates.
  5. Collaboration among public health agencies, law enforcement, pharmacies, primary care physicians, and mental health advocates to support opportunities to educate the public on safe medication storage, improve medication prescription practices, and increase opportunities for safe disposal of medications.

Adoption of evidence-based suicide care and policies that support those in crisis, including:

  1. Identification and mitigation of barriers to help seeking, including stigma and access to culturally responsive and trauma-informed suicide care, by national, state, territorial, tribal, and local public health agencies; health and behavioral health care systems; and advocates.
  2. Support from state, territorial, tribal, and local public health agencies; crisis centers; health and behavioral health care systems; and advocates to recruit and retain a diverse body of clinicians and other staff, including community health workers and peer support specialists trained in evidence-based, culturally sensitive, and trauma-informed suicide care.
  3. Adoption by health and behavioral health care systems of the National Action Alliance for Suicide Prevention’s Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe.
  4. Creation of a strategic plan for implementing the 988 mental health crisis line through a collaboration of public health agencies, health and behavioral health care systems, and advocates.
  5. Strengthening of coordination of patient care to ensure client contact postdischarge by health and behavioral health care systems through strategies outlined in the National Action Alliance for Suicide Prevention’s Best Practices for Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care, as well as through opportunities brought forth as a result of the Affordable Care Act.

1. Centers for Disease Control and Prevention. WISQARS: Web-based Injury Statistics Query and Reporting System. Available at: https://www.cdc.gov/injury/wisqars/index.html. Accessed August 8, 2021.
2. Centers for Disease Control and Prevention. CDC WONDER. Available at: https://wonder.cdc.gov/. Accessed August 8, 2021.
3. U.S. States Department of Defense. Annual suicide report: calendar year 2019. Available at: https://www.dspo.mil/Portals/113/Documents/CY20%20Suicide%20Report/CY%202020%20Annual%20Suicide%20Report.pdf?ver=0OwlvDd-PJuA-igow5fBFA%3d%3d. Accessed 19 October, 2021.
4. Johns MM, Lowry R, Haderxhanaj LT, et al. Trends in violence victimization and suicide risk by sexual identity among high school students: Youth Risk Behavior Survey, United States, 2015–2019. MMWR Morb Mortal Wkly Rep Suppl. 2020;69(1):19–27.
5. Rossen LM, Hedegaard H, Khan D, Warner M. County-level trends in suicide rates in the US, 2005–2015. Am J Prev Med. 2018;55(1):72–79.
6. Substance Abuse and Mental Health Services Administration. 2019 NSDUH detailed tables. Available at: https://www.samhsa.gov/data/report/2019-nsduh-detailed-tables. Accessed August 8, 2021.
7. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance System. www.cdc.gov/yrbs. Accessed Decemeber 1, 2020.
8. Yard E, Radhakrishnan L, Ballesteros MF, et al. Emergency department visits for suspected suicide attempts among persons aged 12–25 years before and during the COVID-19 pandemic—United States, January 2019–May 2021. MMWR Morb Mortal Wkly Rep. 2021;70(24):888–894.
9. Bachmann S. Epidemiology of suicide and the psychiatric perspective. Int J Environ Res Public Health. 2018;15(7):1425.
10. Substance Abuse and Mental Health Services Administration. Data from the Substance Abuse and Mental Health Data Archive. Available at: http://datafiles.samhsa.gov/. Accessed August 8, 2021.
11. Caine ED. Forging an agenda for suicide prevention in the United States. Am J Public Health. 2013;103(5):822–829.
12. Reed J, Quinlan K, Labre M, Brummett S, Caine E. The Colorado National Collaborative: a public health approach to suicide prevention. Am J Prev Med. 2021;152(1):106501.
13. Vancampfort D, Hallgren M, Firth J, et al. Physical activity and suicidal ideation: a systematic review and meta-analysis. J Affect Disord. 2018;225:438–448.
14. Centers for Disease Control and Prevention. Risk and protective factors. Available at: https://www.cdc.gov/suicide/factors/index.html. Accessed August 1, 2021.
15. Suicide Prevention Resource Center. The links between public health crises and suicide. Available at: https://sprc.org/sites/default/files/LinksBetweenPublicHealthCrisesSuicide.pdf. Accessed January 15, 2021.
16. Sher  L. The impact of the COVID-19 pandemic on suicide rates. QJM. 2020;113(10):707–712.
17. Cheng Q, Li H, Silenzio V, Caine ED. Suicide contagion: a systematic review of definitions and research utility. PloS One. 2014;9:9.
18. Levi J, Segal LM, Martin A. The facts hurt: a state-by-state injury prevention policy report, 2015. Available at: https://www.healthyamericans.org/assets/files/TFAH-2015-InjuryRpt-FINAL.pdf. Accessed January 25, 2021.
19. Case A, Deaton A. Deaths of Despair and the Future of Capitalism. Princeton, NJ: Princeton University Press; 2020.
20. Substance Abuse and Mental Health Services Administraiton. National strategy for suicide prevention implementation assessment report. Available at: https://store.samhsa.gov/product/National-Strategy-for-Suicide-Prevention-Implementation-Assessment-Report/sma17-5051. Accessed January 25, 2021.
21. Kennedy K, Carmichael A, Brown M, Trudeau A, Martinez P, Stone D. The state of state, territorial, and tribal suicide prevention: findings from a Web-based survey. Available at: https://www.cdc.gov/suicide/pdf/State-of-the-States-Report-Final-508.pdf. Accessed August 1, 2021.
22. Suicide Prevention Resource Center. Recommendations for state suicide prevention infrastructure. https://www.sprc.org/state-infrastructure. Accessed January 15, 2021.
23. Rockett IR. Counting suicides and making suicide count as a public health problem. Crisis. 2010;31(5):227–230.
24. Quinlan K, Nickerson K, Ebin J, Wadsworth T, Stout E, Frankini E. Supporting a public health approach to suicide prevention: recommendations for state infrastructure. Suicide Life Threat Behav. 2021;51(2):352–357.
25. Centers for Disease Control and Prevention. Emergency department surveillance of nonfatal suicide-related outcomes. Available at: https://www.cdc.gov/suicide/programs/ed-snsro/index.html. Accessed August 1, 2021.
26. Franklin JC, Ribeiro JD, Fox KR, et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol Bull. 2017;143(2):187.
27. Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3(7):646–659.
28. Krupnick A. Parity Enforcement Act of 2021. Available at: https://norcross.house.gov/sites/norcross.house.gov/files/Parity%20Enforcement%20Act%20of%202021%20-one-pager.pdf. Accessed October 5, 2021.
29. National Action Alliance for Suicide Prevention. Crisis now: transforming services is within our reach. Available at: https://theactionalliance.org/resource/crisis-now-transforming-services-within-our-reach. Accessed October 5, 2021.
30. Parker CB, Calhoun A, Wong M, Ambrose H, Davidson L, Dike C. A call for behavioral emergency response teams in inpatient hospital settings. AMA J Ethics. 2020;22(11):956.
31. Centers for Disease Control and Prevention. Suicide prevention strategic plan: FY2020–2022. Available at: https://www.cdc.gov/suicide/strategy/index.html. Accessed October 4, 2021.
32. Mueller AS, Abrutyn S, Pescosolido B, Diefendorf S. The social roots of suicide: theorizing how the external social world matters to suicide and suicide prevention. Front Psychol. 2021;12:763.
33. Knox KL, Litts DA, Talcott GW, Feig JC, Caine ED. Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study. BMJ. 2003;327(7428):1376.
34. World Health Organization. Preventing suicide: a resource at work. Available at: https://apps.who.int/iris/bitstream/handle/10665/43502/9241594381_eng.pdf?sequence=1. Accessed January 25, 2021.
35. World Health Organization. Preventing suicide: a global imperative. Available at: https://www.who.int/publications/i/item/9789241564779. Accessed August 8, 2021.
36. Burnette C, Ramchand R, Ayer L. Gatekeeper training for suicide prevention: a theoretical model and review of the empirical literature. RAND Health Q. 2015;5(1):16. 
37. Wong EC, Collins RL, Cerully JL. Reviewing the evidence base for mental health first aid: is there support for its use with key target populations in California? RAND Health Q. 2015;5:1.
38. Hart LM, Cropper P, Morgan AJ, Kelly CM, Jorm AF. Teen Mental Health First Aid as a school-based intervention for improving peer support of adolescents at risk of suicide: outcomes from a cluster randomised crossover trial. Aust N Z J Psychiatry. 2020;54(4):382–392. 
39. Bowen EA, Murshid NS. Trauma-informed social policy: a conceptual framework for policy analysis and advocacy. Am J Public Health. 2016;106(2):223–229. 
40. Magruder KM, Kassam-Adams N, Thoresen S, Olff M. Prevention and public health approaches to trauma and traumatic stress: a rationale and a call to action. Eur J Psychotraumatol. 2016;7(1):29715. 
41. National Action Alliance for Suicide Prevention. Transforming communities: key elements for the implementation of comprehensive community-based suicide prevention. Available at: https://theactionalliance.org/resource/transforming-communities-key-elements-implementation-comprehensive-community-based-suicide. Accessed December 8, 2020.
42. Dumesnil H, Verger P. Public awareness campaigns about depression and suicide: a review. Psychiatr Serv. 2009;60(9):1203–1213. 
43. Velupillai S, Hadlaczky G, Baca-Garcia E, et al. Risk assessment tools and data-driven approaches for predicting and preventing suicidal behavior. Front Psychiatry. 2019;10:36. 
44. Murphy J. HITECH programs supporting the journey to meaningful use of EHRs. Comput Inform Nurs. 2011;29(2):130–131. 
45. Centers for Medicare & Medicaid Services. Promoting interoperability programs. Available at: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms. Accessed August 1, 2021.
46. Hegerl U, Wittmann M, Arensman E, et al. The ‘European Alliance Against Depression (EAAD)’: a multifaceted, community-based action programme against depression and suicidality. World J Biol Psychiatry. 2008;9(1):51–58. 
47. While D, Bickley H, Roscoe A, et al. Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study. Lancet. 2012;379(9820):1005–1012.
48. Knox KL, Pflanz S, Talcott GW, et al. The US Air Force suicide prevention program: implications for public health policy. Am J Public Health. 2010;100(12):2457–2463.
49. Shand F, Torok M, Cockayne N, et al. Protocol for a stepped-wedge, cluster randomized controlled trial of the LifeSpan suicide prevention trial in four communities in New South Wales, Australia. Trials. 2020;21(1):332.
50. May PA, Serna P, Hurt L, Debruyn LM. Outcome evaluation of a public health approach to suicide prevention in an American Indian tribal nation. Am J Public Health. 2005;95(7):1238–1244.
51. Alliance for Gun Responsibility. Extreme risk protective orders. Available at: https://gunresponsibility.org/solution/erpo/. Accessed August 6, 2021.
52. American Public Health Association. APHA Policy Statement 20184: reducing suicides by firearms. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2019/01/28/reducing-suicides-by-firearms. Accessed January 26, 2021.
53. Sale E, Hendricks M, Weil V, Miller C, Perkins S, McCudden S. Counseling on Access to Lethal Means (CALM): an evaluation of a suicide prevention means restriction training program for mental health providers. Community Ment Health J. 2018;54(3):293–301.
54. American Psychiatric Association. Reducing patient access to lethal quantities of medication. Available at: https://www.psychiatry.org/File%20Library/Psychiatrists/Advocacy/Federal/Talking-Points/90-Day-Prescribing-Factsheet.pdf. Accessed August 6, 2021.
55. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cognitive Behav Pract. 2012;19(2):256–264.
56. Glasgow G. Do local landmark bridges increase the suicide rate? An alternative test of the likely effect of means restriction at suicide-jumping sites. Soc Sci Med. 2011;72(6):884–889.
57. Yip PS, Law C-K, Fu K-W, Law Y, Wong PW, Xu Y. Restricting the means of suicide by charcoal burning. Br J Psychiatry. 2010;196(3):241–242. 
58. Gunnell D, Fernando R, Hewagama M, Priyangika W, Konradsen F, Eddleston M. The impact of pesticide regulations on suicide in Sri Lanka. Int J Epidemiol. 2007;36(6):1235–1242.
59. Large MM, Nielssen OB. Suicide in Australia: meta‐analysis of rates and methods of suicide between 1988 and 2007. Med J Aust. 2010;192(8):432–437. 
60. Kreitman N. The coal gas story. United Kingdom suicide rates, 1960–71. J Epidemiol Community Health. 1976;30(2):86–93. 
61. Raifman J, Moscoe E, Austin SB, McConnell M. Difference-in-differences analysis of the association between state same-sex marriage policies and adolescent suicide attempts. JAMA Pediatr. 2017;171(4):350–356.
62. Dow W, Godøy A, Lowenstein CA, Reich M. Can economic policies reduce deaths of despair? Available at: https://www.nber.org/system/files/working_papers/w25787/w25787.pdf. Accessed August 5, 2021.
63. Brodsky BS, Spruch-Feiner A, Stanley B. The Zero Suicide model: applying evidence-based suicide prevention practices to clinical care. Front Psychiatry. 2018;9:33.
64. Education Development Center. Zero Suicide. Available at: http://zerosuicide.edc.org. Accessed December 20, 2020.
65. Vasiliadis HM, Lesage A, Latimer E, Seguin M. Implementing suicide prevention programs: costs and potential life years saved in Canada. J Ment Health Policy Econ. 2015;18(3):147–155.
66. Spicer RS, Miller TR. Suicide acts in 8 states: incidence and case fatality rates by demographics and method. Am J Public Health. 2000;90(12):1885–1891.
67. Boggs JM, Simon GE, Ahmedani BK, Peterson E, Hubley S, Beck A. The association of firearm suicide with mental illness, substance use conditions, and previous suicide attempts. Ann Intern Med. 2017;167(4):287–288.
68. Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm. Systematic review. Br J Psychiatry. 2002;181:193–199.
69. Rajan S, Branas CC, Hargarten S, Allegrante JP. Funding for gun violence research is key to the health and safety of the nation. Am J Public Health. 2018;108(2):194–195.
70. DeCou CR, Schumann ME. On the iatrogenic risk of assessing suicidality: a meta-analysis. Suicide Life Threat Behav. 2018;48(5):531–543. 
71. Langford L, Litts D, Pearson JL. Using science to improve communications about suicide among military and veteran populations: looking for a few good messages. Am J Public Health. 2013;103(1):31–38.
72. McKnight-Eily LR, Okoro CA, Strine TW, et al. Racial and ethnic disparities in the prevalence of stress and worry, mental health conditions, and increased substance use among adults during the COVID-19 pandemic—United States, April and May 2020. MMWR Morb Mortal Wkly Rep. 2021;70(5):162.