wisconsin suicide prevention strategy · wisconsin suicide prevention strategy, may 2002 - 5 -...

Wisconsin Department ofHealth and Family Services

The Wisconsin Suicide Prevention Strategy

Wisconsin Division of Public Health

Wisconsin Division of Supportive Living

May 14, 2002

Wisconsin Suicide Prevention Strategy, May 2002 - 1 -

Developed By:

The Wisconsin Department of Health and Family ServicesDivision of Public Health and Division of Supportive Living

Principal Editors:

Joanne Berman, RN, BSNBureau of Community Mental Health

Linda J. Hale, RN, BSN, EMTBureau of Emergency Medical Services & Injury Prevention

Susan Conlin OpheimHelping Others Prevent and Educate about Suicide, HOPES

Suicide Prevention Advocates Network, SPAN

Contributing Editor:

Susan Connors, CICSWBureau of Community Mental Health

Contributing DHFS Participants:

Sinikka McCabe, Division of Supportive LivingJohn Chapin, Division of Public Health

Linda Huffer, Division of Supportive LivingSharon L. Lidberg, Bureau of Family and Community Health

Gail Chapman, Office of Strategic FinanceVinod Daniel, Epidemiologist, Bureau of Emergency Medical Services & Injury

Prevention

For More Information, Please Contact:

Susan Conlin Opheim, HOPES,Phone: (608) 274-9686, Email: [email protected]

Joanne Berman, Bureau of Community Mental Health,Phone: (608) 261-6750, Email: [email protected]

Linda Hale, Bureau of Emergency Medical Services & Injury Prevention,Phone: (608) 267-7174, Email: [email protected]

Information about this document is available on the following web pages:www. hopes-wi.org and

www.dhfs.state.wi.us/dph_emsip/index.htm


Acknowledgements

We wish to acknowledge the work of the following people, including those whoserved on the Prevention Initiative Workgroup, who provided input into theWisconsin Suicide Prevention Strategy:

Eloiza Altoro-Acevedo, C.P.P., Director of Community Outreach, Mental Health Association ofMilwaukee

Michael Calvert, Student Intern, Bureau of Community Mental Health, University of Wisconsin,School of Social Work

Gail Chapman, Assistant Area Administrator, Northern Region, Office of Strategic Finance, WIDHFS

Jessica Davis, Needs Development Specialist, Division of Children and Family Services, WIDHFS

Nic Dibble, MSW, Health and Wellness Team, Wisconsin Department of Public Instruction

Mary Jean Erschen, RN EMT, Emergency Medical Services for Children, Bureau of EMS &Injury Prevention, Division of Public Health, WI DHFS, and NAMI of Wisconsin Board Member

The Goltz Seering Agency, Inc., Green Bay

Shel Gross, Director of Public Policy, Mental Health Association of Milwaukee

Oren Hammes, ACSW, CICSW, Criminal Justice and Clinical Coordinator, Bureau of SubstanceAbuse Services, WI DHFS

Chris Hanna, MPH, Director, National Children’s Center for Rural and Agricultural Health &Safety, Marshfield

George Hulick, MSW, Clinical Consultant, Bureau of Community Mental Health, WI DHFS

Sharon L. Lidberg, School Age and Adolescent Coordinator, Bureau of Family and CommunityHealth, Division of Public Health, WI DHFS

David Mays, MD, Director of Forensic Services, Mendota Mental Health Institute, Division ofCare Treatment Facilities, WI DHFS

National Strategy for Suicide Prevention, US Surgeon General David Satcher, MD, PhD

Carrie Nie, MPH, Firearm Injury Center, Medical College of Wisconsin, Milwaukee

Marty Ordinans, Director, Office of Detention Facilities, WI Department of Corrections

Lisa Ott, EMT-P, Education and Training, American Medical Response (AMR), Ft. Atkinson

Jerry and Elsie Weyrauch, SPAN USA, Georgia Plan for Suicide Prevention

Laurie Woods, MS, Violent Injury Reporting System, Medical College of Wisconsin, Milwaukee


The Wisconsin Suicide Prevention StrategyTable of Contents

Foreword .......................................................................................................................................4

Executive Summary....................................................................................................................5

Part 1: IntroductionOverview of the Wisconsin Suicide Prevention Strategy ........................................................................6The Problem of Suicide in Wisconsin ...................................................................................................7The Public Health Approach for Suicide Prevention ..............................................................................8Using the Public Health Approach to Suicide Prevention........................................................................9

Part 2: Goals, Objectives and Ideas for Action ................................................................. 10Goal 1. Promote Awareness That Suicide Is a Public Health Problem Th at Is Preventable ................. 10Goal 2. Develop Broad-Based Support for Suicide Prevention .......................................................... 11Goal 3. Develop and Implement Strategies to Reduce the Stigma Associated with Being a

Consumer of Mental Health, Substance Abuse and Suicide Prevention Services ................... 12Goal 4. Develop and Implement Community-Based Suicide Prevention Programs ............................. 12Goal 5. Promote Efforts to Reduce Access to Lethal Means and Methods of Self-Harm ..................... 13Goal 6. Implement Training for Recognition of At-Risk Behavior and Delivery of Effective

Treatment.......................................................................................................................... 14Goal 7. Develop and Promote Effective Clinical and Professional Practices....................................... 16Goal 8. Increase Community Linkages with and Access to Mental Health and Substance Abuse

Services .......................................................................................................................... 17Goal 9. Improve Reporting and Portrayals of Suicidal Behavior, Mental Illness, and Substance

Abuse in the Entertainment and News Media ...................................................................... 18Goal 10. Promote and Support Research and Evaluation on Suicide Prevention.................................. 19Goal 11. Improve and Expand Systems for Data Collection, Underscoring the Public Health

Emphasis on Surveillance of Suicide and Suicidal Behavior.................................................. 20

Part 3: Looking Ahead .............................................................................................................21

Web Resources on Suicide and Suicide Prevention.......................................................22

References..................................................................................................................................25

AppendicesA. Risk and Protective Factors for Suicide ........................................................................................ 27B. Development of the Wisconsin Suicide Prevention Strategy........................................................... 28C. Glossary of Terms....................................................................................................................... 29


The Wisconsin Suicide Prevention Strategy

Foreword

Suicide is a major public health problem in Wisconsin. It is the second leading cause ofdeath for Wisconsin young people and the tenth leading cause of death for all ages. Ourstate suicide rate is three times greater than the state homicide rate. In 2000, 588 peopledied of suicide in Wisconsin.

The problem of suicide is so extensive that someone in the United States commitssuicide every 17 minutes. Half a million Americans are taken to hospitals every yearbecause of suicide attempts. One in five people with major depression in the UnitedStates attempts suicide, and, even more striking, one in two people with manicdepressive illness attempts suicide.

The Department of Health and Family Services, Divisions of Public Health andSupportive Living are committed to addressing the problem of suicide in Wisconsin. Thecost of suicide in Wisconsin is significant, both in dollar and human terms. The majorityof suicides are of people in the prime of their working lives. Suicide and suicide attemptsexact an incalculable toll on family, friends and loved ones. In response to the SurgeonGeneral’s Call to Action to Prevent Suicide, we are participating in the National Strategyfor Suicide Prevention by developing a guide for suicide prevention that addresses theneeds of Wisconsin residents. Research and science of the past decade provide us withstrategies to save lives by applying new knowledge in rational ways. Suicide can beprevented.

The Wisconsin Suicide Prevention Strategy (the Wisconsin Strategy) provides aframework for getting every interested person in Wisconsin involved in preventingsuicide. The Wisconsin Strategy is designed to guide individuals, agencies andorganizations in local communities and at regional and state levels in suicide preventionefforts. The Strategy seeks to change knowledge and attitudes about suicide. It seeks topromote suicide prevention in many of the environments in Wisconsin that touch ourlives, including education, health care, media, the workplace, faith communities, andcriminal justice.

The Strategy is not a mandate for services or a state directive. Rather, it is offered as aguide for developing public/private partnerships that consist of multiple organizations,agencies, and interested others. It promotes the coordination of culturally appropriateresources and services that link science and practice for the prevention of suicide.

Promoting suicide prevention for all citizens of Wisconsin requires science and knowledgebut, more importantly, a community resolve to make the needed investment. Theinvestment does not call for massive budgets, which are not available, but rather thewillingness to educate others about suicide and mental illness and to implement evidence-based approaches in ways that best fit each community.

Sinikka McCabe, Administrator John Chapin, AdministratorDivision of Supportive Living Division of Public Health


Executive Summary

Suicide is a major public health problemin Wisconsin

Almost 600 people die by suicide each year inWisconsin. Suicide is the second leading causeof death for Wisconsin young people and thetenth leading cause of death for all ages. Ourstate suicide rate is more than three timesgreater than the state homicide rate and nearlyeight times greater than the number of deathsrelated to HIV.

These data show the need for a response byindividuals and communities that have not yetrecognized suicide as one of Wisconsin’sleading causes of death. The Department ofHealth and Family Services, as part of itsmission to help Wisconsin’s citizens becomeindependent, healthy and safe, has respondedto the Surgeon General’s Call to Action bydeveloping this guide for suicide prevention thataddresses the needs of Wisconsin residents.The Wisconsin Suicide Prevention Strategyprovides a framework to guide individuals,agencies, and organizations in localcommunities and at regional and state levels insuicide prevention efforts.

Suicide is preventable

This document seeks to raise awareness andhelp make suicide prevention a statewidepriority. Recognition of suicide as a public healthproblem, as well as the fact that the majority ofpersons who commit suicide have mental healthor substance abuse diagnoses, is needed.Supporting use of local data on suicide andsuicide attempts will be needed to develop andevaluate suicide prevention efforts. Bestpractices in assessment, crisis services andtreatment must be available in practice toaddress the incidence of suicide as well as itsimpact on others.

Partners in the development of this documentview suicide as a public health problem and thepublic health approach is used as a model ofaction. The approach emphasizes the use offactual data about suicide in Wisconsin and theuse of present research and best practice forwidespread education and improvement of andaccess to treatment services.

The Wisconsin Suicide Prevention Strategydocument lists 11 goals with related objectivesand activities that interested persons and

organizations can select from to implementsuicide prevention in their communities.

The 11 Goalsv Promote Awareness That Suicide Is A

Public Health Problem That is Preventablev Develop Broad-based Support For Suicide

Preventionv Develop And Implement Strategies To

Reduce The Stigma Associated With Beinga Consumer of Mental Health, SubstanceAbuse, and Suicide Prevention Services

v Develop and Implement Community-basedSuicide Prevention Programs

v Promote Efforts To Reduce Access ToLethal Means and Methods of Self-harm

v Implement Training For Recognition Of At-Risk Behavior And Delivery Of EffectiveTreatment

v Develop and Promote Effective Clinical andProfessional Practices

v Increase Community Linkages With AndAccess To Mental Health and SubstanceAbuse Services

v Improve Reporting and Portrayals ofSuicidal Behavior, Mental Illness, andSubstance Abuse in the Entertainment andNew Media

v Promote and Support Research andEvaluation on Suicide Prevention

v Improve and Expand Systems for DataCollection, Underscoring the Public HealthEmphasis on Surveillance of Suicide andSuicidal Behavior

Like its National model, the Wisconsin SuicidePrevention Strategy emphasizes that for anyprevention activity to go forward, three thingsare necessary: a knowledge base, publicsupport for change, and a strategy toaccomplish change. Approaches must becommunity focused with leadership at thecommunity level. Implementing the WisconsinSuicide Prevention Strategy requires broadparticipation and collaboration from each of us inour own communities.

Our challenge is to create communities whereresidents believe that suicide is preventable andthat suicide prevention is everyone’s business!


The Wisconsin SuicidePrevention Strategy

Part 1: Introduction

Overview of the Wisconsin SuicidePrevention Strategy

Suicide claims thousands of lives in theUnited States every year. Nationwide, thereis one suicide every 17 minutes.1 In 2000,there were 588 suicides in Wisconsin, threetimes more than the number of homicides.Only recently has the issue of suicide beenrecognized as a public health problem andbecome the focus of a national agendaaimed at its prevention. In 1999, the U. S.Surgeon General, David Satcher, MD, PhD,issued a "Call to Action to Prevent Suicide,"which identifies suicide as a major publichealth problem and recommends steps toreduce suicide. A comprehensive NationalStrategy for Suicide Prevention wasdeveloped and released in May 2001. In it,Dr. Satcher emphasizes that more suicidescould be prevented if our country wouldbetter focus its resources and its attentionon this problem.

The Wisconsin Department of Health andFamily Services (DHFS) Bureaus ofCommunity Mental Health and EmergencyMedical Services and Injury Prevention arecommitted to addressing the problem ofsuicide in Wisconsin. The DHFS along withother public and private partners hasresponded to the Surgeon General’s Call toAction by developing this guide for suicideprevention that addresses the needs ofWisconsin residents. The Wisconsin SuicidePrevention Strategy2 (referred to throughout

1 One economic analysis has estimated the totaleconomic burden of suicide in the U.S. in 1995 to be$111.3 billion; this includes medical expenses of $3.7billion, work-related losses of $27.4 billion, and qualityof life costs of $80.2 billion (Miller et al., 1999).2 The Wisconsin Strategy is based onrecommendations and information from The 1999Surgeon General’s Call to Action to Prevent Suicide;Mental Health: A Report of the Surgeon General; TheNational Strategy for Suicide Prevention: Goals and

this document as the Wisconsin Strategy)provides a framework to guide individuals,agencies and organizations in localcommunities and at regional and statelevels in suicide prevention efforts.

The Wisconsin Suicide Strategy seeks toincrease knowledge and change attitudesabout suicide and to promote suicideprevention in all sectors of society, includingeducation, health care, media, theworkplace, faith communities, and criminaljustice.The overall aims of the Wisconsin Strategyare:1. to prevent deaths due to suicide across

the life span,2. to reduce the occurrence of other self-

harmful acts,3. to reduce the suffering associated with

suicidal behaviors and the traumaticimpact of suicide on loved ones, and

4. to provide opportunities and settings toenhance resilience, resourcefulness,respect, nonviolent conflict resolution,and interconnectedness for individuals,families, and communities.

This Wisconsin Strategy document lists 11goals with related objectives and activitiesthat interested persons and organizationscan select from to implement suicideprevention in their communities.

The Wisconsin Strategy calls upon peoplein local communities all over the state totake action to prevent suicide. Effectivesuicide prevention efforts have to take place

Objectives for Action; Center for Disease Control’sSuicide Prevention: Prevention Effectiveness andEvaluation; Wisconsin Deaths, 2000; Division ofSupportive Living Annual Death Report; WisconsinInjury Report, 2000; as well as input from manyconcerned individuals and groups in Wisconsin. TheNational Strategy for Suicide Prevention isrecommended reading for all persons engaged insuicide prevention activities as it providescomprehensive documentation for the goals andobjectives of the goals and objectives for action. Amore complete history of the Wisconsin Strategyis available in Appendix B: Development of theWisconsin Suicide Prevention Strategy.)


at the local level, where local needs andresources are best understood. State andregional organizations can provide guidanceand support, but it is up to localcommunities to take action. The WisconsinSuicide Prevention Strategy is a guide forcommunities to engage partners, develop astructure and implement and evaluatesuicide prevention activities. This documentis not a manual on suicide preventiontechniques, a source of knowledge onevidence-based interventions for suicideprevention or a one-size-fits all formula forimplementing suicide prevention activities ina community. Rather, it is the framework onwhich local partnerships can build to definethe most appropriate strategies for theircommunities.

According to the National Strategy forSuicide Prevention, suicide is an outcome ofcomplex interactions among neuro-biological, genetic, psychological, social,cultural, and environmental factors. Multiplerisk and protective factors interact in suicideprevention. Development of a state suicideprevention strategy can bring togethermultiple disciplines and perspectives tocreate an integrated system of interventionsacross multiple levels, such as theindividual, the family, schools, thecommunity, and the health care system.Collaborating in a comprehensive suicideprevention strategy can help communitiesidentify and develop priorities. Resourcesare always finite and priorities directresources to projects that are likely toaddress the greatest needs and achieve thegreatest benefits. Collaborative efforts suchas public and private partnerships increasethe likelihood of success in generatingsupport for and improving suicideprevention efforts. It is important for publichealth agencies to play a key role incoordinated suicide prevention effortsbecause public health agencies haveexperience in organizing efforts andresources in such a way that they reachlarge groups of people systematically andeffectively. In addition, because mentalhealth and substance abuse problems

represent some of the greatest risks forsuicide, it is especially important that localmental health and substance abuse serviceproviders be part of integrated suicideprevention efforts.

There are many benefits of a state suicideprevention strategy. They include raisingawareness and helping make suicideprevention a statewide priority, providingopportunities to use public-privatepartnerships as well as the energy ofsurvivors and others to engage people whomay not consider suicide prevention part oftheir mission, linking information fromdifferent prevention programs to avoidduplication and to share information abouteffective prevention activities, and directingattention to efforts that benefit all people inWisconsin. By that means, the likelihood ofsuicide can be reduced before vulnerableindividuals reach the point of being at riskfor suicide.

All it takes to start mobilizing a localcommunity for suicide prevention is oneperson, any person, from any walk of life.The Suicide Prevention Advocacy Network(SPAN USA), a national non-profit advocacyorganization, was started by one family thatlost a daughter to suicide. It grew to becomea nationwide organization that mobilizedefforts resulting in the National Strategy forSuicide Prevention. A similar process couldbe used in any community. The startingpoint doesn't matter; getting started does. Itmatters that the persons or groups aredetermined to address the problem ofsuicide where they live and that they build acoalition of interested community andprofessional partners for action.

The Problem of Suicide in Wisconsin

Suicide is one of the leading causes ofdeath among Wisconsin residents of allages. The following facts about suicidetaken from Wisconsin Deaths, 2000, andfrom the Department of Public Instruction’s2000 Youth Behavioral Risk Survey show


that suicide is indeed a serious public healthproblem in Wisconsin:

Suicide: Cost To The Statev In 2000, Wisconsin lost 588 lives to suicide.v Ten suicides were young people under the age

of 15.v Suicide is the second leading cause of death

among young people aged 15 to 34.v One in five Wisconsin high school students

reported seriously considering suicide.v Suicide attempts are much more common than

death by suicide. Attempts are estimated to be20 times the number of deaths.

v Of the total number of Wisconsin suicides, 390are men and women in the prime of life, aged25 to 64.

v Each suicide death is estimated to affect atleast six others in the person’s family, school,workplace or community. This meansapproximately 3600 Wisconsin people areaffected by a loved one’s suicide each year.

v Suicide is three times more prevalent thanhomicide in our state.

v Elderly Wisconsin males (age 75 and older) arethree times more likely to commit suicide thanthe general population in the state.

v Firearms are the most common and lethalmeans of suicide, accounting for 52% of allsuicide deaths in Wisconsin.

v Suicide accounts for 24, 194 years of potentiallife lost before age 85.

These numbers do not include informationon those who attempt suicide, unreportedsuicides, or deaths that may have beenmisclassified as accidental or undetermined.In addition, there may be pressure to notreport a death as suicide because manypeople wrongly see suicide as a mark ofdisgrace or shame, a stigma on themselvesand their families.

Many suicides are preventable. Suicide victimsusually give some clue or warning of theirintentions. Persons having suicidal thoughtsoften have had recent contact with lovedones, medical professionals, mental healthprofessionals, and sometimes lawenforcement. These are all potential points ofintervention. The good news is that we all canplay a role in preventing these tragic deaths.

The Public Health Approachfor Suicide Prevention

The foundation for developing andimplementing the Wisconsin SuicidePrevention Strategy is the five-step publichealth approach presented in the NationalStrategy for Suicide Prevention: Goals andObjectives for Action. The public healthapproach is designed to organizeprevention efforts and resources in such away that they reach large groups orpopulations of people systematically andeffectively. The steps can and often dooccur at the same time and depend on oneanother. They can be used by groups ofinterested people, single agencies, regionalcollaborations and in state-level activities aswell. The five-step public health approach isoutlined below.

Clearly Defining the Problem• Needs assessments help clearly define

the existing conditions that affect theproblem.

Identifying Causes through Risk andProtective Factors Research• Information about risk and protective

factors contributes to selecting usefulinterventions for suicide prevention.3

Risk factors and protective factors forsuicide identified in the NationalStrategy for Suicide Prevention areincluded in Appendix A.

3 For example, research shows that persons with mentalhealth or substance abuse disorders are at high risk forsuicide. Studies have shown that 90% of persons whohave committed suicide had one or more psychiatricdiagnoses (including substance abuse disorder) at thetime of suicide. As a protective factor, effective clinicalcare for mental health and substance abuse disordershas been shown to be significant in preventing suicide.One example is that the success rate for the treatmentof depression has been shown to be higher than thesuccess rate for the treatment of heart disease. Yetresearch shows that 40% of Americans who have asevere mental illness do not seek treatment from eithergeneral medical or mental health specialty providers.Much remains to be learned, especially about how theserisk and protective factors interact across the life spanand how community suicide prevention programs canbest integrate this information.


Developing and Testing Interventions• This step involves developing

interventions, which are preventionactions or programs that can reduce theimpact of risk factors or that can supportprotective factors. Rigorous scientifictesting of interventions before they areput in place on a large scale is importantto ensure that the interventions are safe,ethical, and practical. Efficacy studieslead to the understanding of factorscritical in implementing the intervention.Research of this type can be promotedin research settings and then reliedupon in local efforts to develop up-to-date prevention plans already proven tobe effective.

Implementing Interventions According toSound Prevention Principles• Prevention science in other areas such

as substance abuse prevention andviolence prevention utilizes principles foreffective action that apply to suicideprevention initiatives as well. Inimplementing the goals and objectives ofthe Wisconsin Strategy, efforts should bebased on these prevention principles:

Principles of Suicide PreventionEffectiveness

v Prevention programs should be designed toenhance protective factors. They should alsowork toward reversing or reducing known riskfactors. Risk for negative health outcomescan be reduced or eliminated for some or allof a population.

v Prevention programs should be long-term,with repeat interventions to reinforce theoriginal prevention goals.

v Family-focused prevention efforts may havea greater impact than strategies that focussolely on individuals.

v Community programs that include mediacampaigns and policy changes are moreeffective when individual and familyinterventions accompany them.

v Community programs need to strengthennorms that support help-seeking behavior inall settings, including family, work, schooland community.

Principles of Suicide PreventionEffectiveness continued

v Prevention programming should be adaptedto address the specific nature of the problemin the local community or population group.

v The higher the level of risk of the targetpopulation, the more intensive the preventioneffort must be and the earlier it must begin.

v Prevention programs should be age-specific,developmentally appropriate and culturallysensitive.

v Prevention programs should be implementedwith no or minimal differences from how theywere designed and tested.

Evaluating Effectiveness• Evaluations need to occur when

implementing interventions in thecommunity. Ideally, program plannerswill choose programs that have beenfully evaluated and shown to beeffective. A community should build inan evaluation process to determinewhether any intervention selected worksunder local conditions. Communitysuicide prevention programs mustbudget the time and money to build inevaluation right from the start.

• Determining the costs associated withsustaining programs and comparingthose costs to the benefits of theprograms is another important aspect ofevaluation. This cost evaluation mayhelp justify continuing funding to sustaina program. Web resources listed at theend of the Wisconsin Strategy provideuseful sources of information aboutdesigning and carrying out evaluations.

Using the Public Health Approach toSuicide Prevention

There are broad public health themesinterwoven throughout the Strategy thatneed to be considered as groups andindividuals across Wisconsin move forwardin designing and strengthening their suicideprevention activities. These themes are asfollows:


Applying the Public Health Approachto Suicide Prevention

v Draw attention to a wide range of possibleactions so that specific activities to promotesuicide prevention can be developed to fitthe resources and areas of interest of peoplein everyday community life as well asprofessionals, groups, and public agencies.

v Seek to integrate suicide prevention intoexisting health, mental health, substanceabuse, education, and human servicesactivities. Settings that provide relatedservices, such as schools, workplaces,clinics, medical offices, correctional anddetention centers, care facilities for olderadults, faith communities, and communitycenters are all important areas for integratedsuicide prevention activities.

v Guide the development of activities that willbe tailored to the cultural contexts in whichthey are offered. While population-basedinterventions are applicable without regardto risk status, it does not mean that one sizefits all. The cultural and developmentalappropriateness of suicide preventionactivities is a vital consideration.

v Seek to eliminate disparities that erodesuicide prevention activities. Health caredisparities can be attributable to suchdifferences as race or ethnicity, gender,education or income, mental illness or otherdisability, age, stigma, sexual orientation,geographic location, or inadequate coveragefor treatment of mental illness and substanceabuse.

v Emphasize early interventions to promoteprotective factors and reduce risk factors forsuicide. As important as it is to recognizeand help suicidal individuals, progressdepends on measures that addressproblems early and promote strengths sothat fewer people become suicidal.

v Seek to build statewide capacity to conductintegrated activities to reduce suicidalbehaviors and prevent suicide. Capacitybuilding will ensure the availability of theresources, experience, skills, training,collaboration, evaluation, and monitoringnecessary for success.

Part 2:Goals, Objectives and Ideas for Action

The building blocks of the Wisconsin Strategyare eleven goals with related objectivesbased on the National Strategy for SuicidePrevention: Goals and Objectives for Action.The following section of the Wisconsin

Strategy lists the goals, along with ideas foractivities that individuals and communitiescan use. Activities that are proposed heremay not necessarily be adopted by allcommunities. The information offered is not tobe considered a "prescription" for what mustbe done. Rather, the ideas below areproposed as those from which suitableinterventions within a particular communitycan be selected. Comprehensive suicideprevention programs are believed to have agreater likelihood of reducing the suicide ratethan are suicide programs that address onlyone risk/protective factor or action step. Byacting on combinations of the ideas listed inthis section, individuals and groups can havea direct impact on suicide prevention efforts intheir community.

GOAL 1:PROMOTE AWARENESS THAT SUICIDEIS A PUBLIC HEALTH PROBLEM THATIS PREVENTABLE

The stronger and broader the support for apublic health initiative, the greater itschances for success. If the general publicunderstands that suicide and suicidalbehaviors can be prevented and if peopleare made aware of the roles individuals andgroups can play in prevention, the suiciderate can be reduced. The objectives for thisgoal focus on increasing cooperation andcollaboration within and between publicand private entities committed to publicawareness of suicide and suicideprevention.

Objectives1. Develop and implement public

information campaigns designed toincrease the knowledge of all personsand communities regarding suicideprevention and to increase anunderstanding of the role of risk andprotective factors in prevention.

2. Establish regular suicide preventionactivities such as conferences, regionalmeetings and public forums designed to


foster collaboration with stakeholders onprevention strategies.

Sample Implementation Activitiesv Access existing materials or develop information

materials that community members can distributeto neighbors, friends, and co-workers. Materialsshould describe suicide risk and protectivefactors, present available community resources,explain how to join in the effort to prevent suicidein Wisconsin, and discuss how to increase help-seeking behaviors.

v Work with local media to develop anddisseminate media guides and public serviceannouncements describing a safe and effectivemessage about suicide and its prevention.Material is available from the AmericanFoundation for Suicide Prevention and from thefederal Centers for Disease Control.

v Incorporate suicide awareness and preventionmessages into employee assistance programactivities.

v Hold public forums across the state at theregional level and in local communities. Theseforums should present the Wisconsin Strategyand encourage regions and communities to acton implementing the Wisconsin Strategy.

v Identify foundations and other stakeholders tocontribute to the support of conferences andforums on suicide prevention.

GOAL 2:DEVELOP BROAD-BASED SUPPORTFOR SUICIDE PREVENTION

Because there are many paths to suicide,prevention must address psychological,biological, and social factors if it is to beeffective. Taking action to prevent suicide ismore than just the job of mental health andsubstance abuse professionals. EveryWisconsin resident has a part to play insaving lives. Collaboration is a way toensure that prevention efforts arecomprehensive and it generates moreattention to suicide prevention than doesworking alone. Objectives for this goal workto ensure that suicide prevention is betterunderstood and that organizational supportexists for implementing key activities.

Objectives1. Increase the number of people in

Wisconsin actively involved in someaspect of suicide prevention.

2. Increase the number of localcommunities actively working toimplement the Wisconsin Strategy.

3. Include suicide prevention education inongoing programs and activities carriedout by prevention organizations alongwith professional, volunteer, and othergroups across Wisconsin.

4. Increase the number of faithcommunities that adopt policies andprograms promoting suicide prevention.

Sample Implementation Activitiesv At the community level, put in place outreach

activities that build on community education andpublic information campaigns.

v Actively recruit people from all parts of thecommunity to participate in suicide preventionefforts.

v Encourage organizations to consider ways theycould integrate suicide prevention into theirongoing work.

v Recruit and train at least one member of eachinterested community to be a community organizerfor suicide prevention.

v Visit leaders of these community groups toengage their participation and support inintegrating suicide prevention into ongoingprograms. Types of groups include neighborhoodcenters, youth groups, senior centers, child abuse,substance abuse, domestic violence, tobacco, andgambling prevention organizations.

v Identify faith communities at both the state andcommunity level. Visit their leaders to ask for theircooperation and support. Provide suggestedpolicies and programs promoting suicideprevention, and ask the faith leadership toimplement them in their organizations.

v Coordinate with existing prevention programs inrelated areas such as substance abuse, childabuse, aging services, gambling prevention, faithcommunities, Cooperative Extension Service,Human Service Associations and others.


GOAL 3: DEVELOP AND IMPLEMENTSTRATEGIES TO REDUCE THE STIGMAASSOCIATED WITH BEING ACONSUMER OF MENTAL HEALTH,SUBSTANCE ABUSE, AND SUICIDEPREVENTION SERVICES

Suicide is closely linked to mental illness andsubstance abuse, and both can be effectivelytreated. However, the stigma of mentalillness and substance abuse prevents manypeople from getting the treatment they need.Stigma has been identified as a strongbarrier to progress in the area of suicideprevention. The view that suicide is shamefuland/or sinful is a barrier to treatment forpersons who have suicidal thoughts or whohave attempted suicide. In addition, familymembers of persons who attempt suicideoften try to hide what is happening.

The stigma associated with mental illness,substance abuse, and suicide has contributedto inadequate resources for preventiveservices and to low insurance coverage forreimbursements for treatments, thuspromoting the continuing separation ofphysical health care and mental health care.As a result, preventive services and treatmentfor mental illness and substance abuse aremuch less available than for other healthproblems. Barriers between the two systemscan complicate provision of the services andfurther impede access to care. Destigmatizingmental illness and substance abuse disorderscould increase access to treatment byreducing financial barriers, integrating care,and increasing the willingness of individualsto seek treatment.

Objectives1. Increase the proportion of the people in

Wisconsin that views mental andphysical health as equal andinseparable components of overallhealth.

2. Increase the proportion of people inWisconsin that view mental disorders andaddictions as medical illnesses that can

be diagnosed and respond to specifictreatments.

3. Increase the proportion of the people inWisconsin who view consumers ofmental health, substance abuse, andsuicide prevention services as pursuingfundamental care and treatment foroverall health.

4. Increase the proportion of those suicidalpersons in Wisconsin with underlyingdepression and other mental disorderswho receive appropriate mental healthtreatment.

Sample Implementation Activitiesv Train community volunteers to give educational

presentations at local civic groups. Include aspresenters, consumers of mental health andsubstance abuse services and family members ofconsumers.v Review and modify (where indicated) school health

curricula to ensure that mental health andsubstance abuse is appropriately addressed.v Develop a public awareness campaign that shows

mental illnesses and addictions as treatabledisorders and not character failings.v Encourage an educational campaign designed to

help the community understand the implications ofthe brain research conducted over the past decade,with special emphasis on mental illness andaddiction.v Develop a speaker’s bureau that can make

community presentations. Include consumers ofmental health and substance abuse services andfamily members of consumers.v Develop public service announcements with

positive depictions of consumers of mental healthand substance abuse services.v Work to ensure that mental health services are

culturally sensitive.

GOAL 4: DEVELOP AND IMPLEMENTCOMMUNITY-BASED SUICIDEPREVENTION PROGRAMS

Research has shown that many suicides arepreventable, however, effective suicideprevention programs require commitmentand resources. Programs may be specific toone particular organization, such as auniversity or a community heath center, orthey may encompass the entire state. Aspecial emphasis of this goal is that of


ensuring a range of interventions thattogether represent a comprehensive andcoordinated program.

Objectives1. Improve collaboration and coordination

across government agencies andinvolve the public/private partners indeveloping and implementing theWisconsin Strategy at the state,regional, and local levels.

2. Establish agency policies andprocedures for crisis response andreferral of persons at risk.

3. Increase the number of school districts,colleges and universities with evidence-based programs that are designed toaddress childhood, adolescent andyoung adult distress and preventsuicide. Evidence-based programs areprograms that have some researchshowing that the programs wereassociated with the intended beneficialoutcome(s).

4. Increase the number of employers thatmake evidence-based preventionprograms for suicide available to theiremployees.

5. Improve suicide prevention programs forboth adult and juvenile offenders inWisconsin’s correctional institutions,jails, and detention centers.

6. Increase the number of services forolder people that include evidence-based suicide prevention programsdesigned to identify older people at riskfor suicidal behavior and refer them fortreatment.

7. Increase the number of family, youthand community service organizationsand providers in Wisconsin withevidence-based suicide preventionprograms.

8. Improve and coordinate crisis services.

Sample Implementation Activitiesv Provide knowledgeable presenters to assist with

inservice education programs that will keep schoolsystem personnel updated about referral and crisisresponse procedures.v Support parent-teacher groups and schools in

working with agencies such as the Department ofPublic Instruction to implement district-wide suicideprevention strategies.v Work with student counseling service directors at

colleges and universities to select and implementprograms.v Implement and evaluate a program that trains

college resident advisors in principles of suicide riskidentification, crisis intervention and referral.v Coordinate activities with employee assistance

professionals and human resources directors atlocal companies.v Work with business associations to provide financial

information about the costs and benefits of coveragefor mental health and substance abuse treatment ona par with other health care.v Foster cultural changes in organizations that

strengthen social support among workers andencourage help-seeking for emotional and healthconcerns.v Invite staff from correctional institutions to

conferences and meetings on mental health andsubstance abuse services and suicide prevention.v Develop monitoring protocols for alcohol and drug

detoxification programs in jail and detention facilities.v Work with directors of senior centers, area aging

agencies, and nursing homes in communities toconduct needs assessments for suicide preventionprograms for their residents.v Develop and implement a training program for

employees of local aging programs to assist thoseworkers and volunteers in identifying and referringpersons at risk of suicide.v Establish round table meetings for local youth-

serving organizations to exchange information andpromote incorporation of suicide prevention into theirongoing programs.v Develop resource kits for service organizations that

include suggestions for activities designed tostrengthen connectedness.v Evaluate existing public safety and crisis coverage

to identify areas for improvement.

GOAL 5: PROMOTE EFFORTS TO REDUCEACCESS TO LETHAL MEANS ANDMETHODS OF SELF-HARM

There is evidence that limiting access tolethal means of self-harm in many countriesand cultures is an effective strategy toprevent self-destructive behaviors. A small


but significant number of suicidal acts areimpulsive. These suicides result from acombination of psychological pain ordespair coupled with the easy availability ofthe means to inflict self-injury (medications,carbon monoxide, firearms, etc.) and oftenintoxication. Therefore, by limiting theindividual’s availability to the means of self-harm, a self-destructive act may beprevented. The objectives for this goal aredesigned to separate in time and space thesuicidal impulse from access to lethalmeans of self-harm.

Objectives1. Increase the proportion of primary care

clinicians, other health care providersand health and public safety officialswho routinely ask about the presence oflethal means of self-harm includingfirearms, drugs and poisons in thehome, and provide education aboutactions to reduce associated risks.

2. Develop and distribute materialsproviding education to identified high-risk populations about actions to reducethe accessibility of lethal means of self-harm.

Sample Implementation Activitiesv Collaborate with the Wisconsin Medical Society

and with other health-related providerorganizations to provide opportunities forphysicians and other health care providers tolearn about ways to decrease access to lethalmeans of self-harm in the home.

v Develop standard practices for law enforcementresponse to domestic emergencies that assess forthe presence of lethal means and advocate theirsafe removal or storage.

v Promote improved safety designs in firearms andautomobiles to prevent their use for self-destructive purposes.

v Engage community leaders and preventionspecialists in the development and distribution ofappropriate educational materials.

v Develop and disseminate educational materials tomake parents aware of safe methods for storingand dispensing common pediatric and othermedications.

v Provide educational material to parents of youngpersons with substance abuse or mental healthproblems regarding the heightened likelihood thatthese youth may use lethal firearms or othermeans of self-harm.

GOAL 6:IMPLEMENT TRAINING FORRECOGNITION OF AT-RISK BEHAVIORAND DELIVERY OF EFFECTIVETREATMENT

Many of the conditions associated withsuicidal behaviors, such as depression,have effective treatments. Unfortunately,many people are not trained to recognizepersons at risk for suicide who could benefitfrom treatment. Studies indicate that manyhealth professionals are not adequatelytrained to provide proper assessment,treatment and management of suicidalclients, nor do they know when and how torefer clients properly for specializedassessment and treatment. Despite theincreased awareness of suicide as a majorpublic health problem, gaps remain intraining programs for health professionalsand others in need of the specializedtechniques and treatment approaches,including those providing services inschools and in correctional settings andservices for older persons. In addition, manyhealth professionals lack training in therecognition of risk factors often found ingrieving family members of loved ones whodied by suicide (suicide survivors).

This goal also addresses the need toprovide training to key communitygatekeepers as well as professionals.Community gatekeepers are people whomay come into contact with persons whoare in distress. They can include lawenforcement and correctional personnel,primary health care providers, emergencyhealth care providers, mental health andsubstance abuse treatment providers,clergy, school personnel, lawyers, funeraldirectors, coroners and others who regularlycome into contact with people who may beat risk for suicide.

Objectives1. Provide continuing education for primary

health care providers that includes therecognition of persons at risk for suicide,information on screening programs,


assessment and management of suiciderisk, effective treatments, andappropriate conditions for referral tospecialty care.

2. Incorporate suicide prevention materialsin training programs for physicianassistants, physicians, medicalresidents, nursing care providers, andother health professionals.

3. Increase the number of clinical socialwork, counseling, and psychologygraduate programs that include suicideprevention training.

4. Increase the number of social workers,poison control center personnel,outreach workers, case managers, andhome visitation program providers whoreceive job-related suicide preventiontraining. This training should cover theassessment of and response to suiciderisk and behaviors.

5. Increase the number of clergy from allfaith communities in Wisconsin who aretrained in identification of and responseto suicide risk and behaviors, who aretrained to identify the differencebetween mental disorders and faithcrises and who are comfortable talkingto their congregations about suicideprevention.

6. Increase the number of educationalfaculty and staff as well as youthdevelopment staff working outsideschool settings who have receivedtraining on identifying and responding tochildren and adolescents at risk forsuicide.

7. Increase the number of juvenile justice,justice, correctional and public safetysystem personnel who have receivedtraining on identifying and responding topersons at risk for suicide. Includedivorce, family law and criminal defenseattorneys.

8. Increase effective education programsand support services available tosurvivors of suicide and to familymembers and others in closerelationships with people who are at riskfor suicide.

9. Increase the number of re-certificationor licensing programs in relevantprofessions that require or promotecompetencies in depression andaddiction assessment and managementof suicide prevention.

10. Increase the number of “natural”community helpers, such as mailcarriers or hairdressers, who are trainedto recognize, respond to, and refer forhelp elderly people who are at risk ofsuicide and associated mental andsubstance abuse disorders.

Sample Implementation Activitiesv Include workshops on suicide prevention at

annual meetings of professional associations.v Work with directors of education at professional

schools to include suicide prevention training inthe basic curriculum. This training should coverthe assessment and management of suicide riskand identification and promotion of protectivefactors.

v Work with the Department of Health and FamilyServices, Department of Public Instruction,Department of Corrections and other stateagencies to incorporate training on theassessment and response to suicide risk andbehaviors into contracts, standards and ongoingin-service education.

v Provide speakers to the local ministerial alliance toassist in suicide prevention training programs.

v Work with local school systems and youth-servingorganizations to provide “gatekeeper” training forall staff, e.g., teachers, school counselors, busdrivers, custodians, coaches, playgroundsupervisors, and after-school program staff.

v Work with youth detention centers to providegatekeeper training for all their staff.

v Work with community mental health agencies andpublic health agencies to incorporate educationand support programs for family members andothers in close relationships with people at risk forsuicide.

v Work with local Meals on Wheels and other agingprograms to provide gatekeeper training to staffand volunteers.


GOAL 7: DEVELOP AND PROMOTE EFFECTIVECLINICAL AND PROFESSIONALPRACTICES

One way to prevent suicide is to identifyindividuals at risk and to engage them intreatments that are effective in reducing thepersonal and situational factors associatedwith suicidal behaviors, e.g., depressedmood, hopelessness, helplessness, andalcohol and other drug abuse. Another wayto prevent suicide is to promote and supportthe presence of protective factors (see thelist in Appendix A). By improving clinicalskills in the assessment, management andtreatment for individuals at risk for suicide,the chances for preventing those individualsfrom acting on their despair and distress inself-destructive ways are greatly improved.

Mental health and substance abusedisorders present the greatest risk forsuicidal behavior, yet research shows thateach year eight million Americans withserious mental illness fail to receiveadequate treatment. In addition to theprovision of effective mental health services,an important approach to prevent suicideand injuries from suicidal behavior is toaddress the problems of undetected andunder-treated mental health disorders.Effective research-based treatments areavailable for treating a wide range ofdisorders. Yet these treatmentsunfortunately do not appear to be widelyused by clinicians in the field. The NationalStrategy for Suicide Prevention emphasizesthe importance of strategies to improveindividual clinical care. Such efforts wouldinclude the development of critical careprotocols for hospital emergencydepartments and for physicians’ offices, theestablishment of optimal treatment protocolsfor psychiatric disorders and for thetreatment of teenagers who attempt suicide,and the implementation of a public policy toincrease the access to mental health care.

Objectives1. Increase the proportion of patients

identified and treated for self-destructivebehavior by Wisconsin hospitalemergency departments who pursuetheir proposed mental health follow-upplans.

2. Promote the incorporation of guidelinesto use in assessing suicidal risk amongpeople receiving care in primary healthcare settings.

3. Increase the number of mental healthand substance abuse treatment agenciesthat have clear suicide preventionpolicies and procedures designed topromote assessment of suicide risk andto intervene to reduce suicidal behaviors.Include also the means of evaluatingthese programs and policies.

4. Enhance screening for depression,substance abuse and suicide risk as abasic standard of care in primary healthcare settings, hospices and skillednursing facilities.

5. Promote guidelines for dischargeplanning and aftercare treatment forindividuals exhibiting suicidal behavior,especially those discharged frominpatient hospital units and mentalhealth institutional settings.

6. Provide training that specificallyaddresses the impact of suicide onsuicide survivors as well as the impactof suicide on the first responder.(Certain people in Wisconsin providekey immediate services to suicidesurvivors as first responders, forinstance, emergency medicaltechnicians, public safety officers,funeral directors, and clergy.)

7. Promote mental health and substanceabuse disorder treatment services forpersons with mental disorders,especially mood disorders, substanceabuse disorders, or a history of traumaor abuse and for survivors of suicide.

8. Increase the number of persons whocomplete their course of mental healthor substance abuse treatment orcontinue indicated maintenancetreatment.


9. Increase the number of hospitalemergency departments that routinelyprovide immediate post-trauma supporteducation and/or mental health referralfor all victims of sexual assault and/orphysical abuse.

10. Develop guidelines for providingeducation to family members andsignificant others of people receivingcare for the treatment of mental healthand substance use disorders that are atrisk for suicide. Implement theguidelines in facilities such as hospitalsand mental health and substance abusetreatment agencies.

11. Extend and improve comprehensivesupport services for survivors of suicide.

Sample Implementation Activitiesv Work with hospitals and health care delivery

systems to develop guidelines for confirmation ofmental health follow-up appointments.

v Collaborate locally to establish processes thatincrease the proportion of patients who keepfollow-up mental health appointments afterdischarge from the emergency department.

v Sponsor the distribution of posters foremergency departments and doctors’ offices thatlist important steps in assessing suicide risk.

v Develop standardized suicide assessmentguidelines for primary health care physicianswhen assessing patients of all ages.

v Work with local mental health and substanceabuse agencies to offer community and staff in-service sessions in suicide prevention education.

v Sponsor depression and substance abusescreening days.

v Work with local mental health and substanceabuse agencies and offer communityparticipation in developing guidelines that includeeducation and psychological support to familiesand significant others of those who haveexhibited suicidal behavior.

v Organize suicide survivors in the community toprovide seminars on recognizing and managingthe personal impact of suicide on first respondersand all survivors.

v Promote follow-up calls or letters by localclinicians to encourage their clients withdepression who have discontinued treatment toresume it.

v Provide guidelines for specific educationalmessages to be provided to patients andcaregivers in order to increase treatmentadherence and relapse prevention.

v Encourage volunteer training in suicideprevention and victim support. Link volunteers tohospital emergency departments as a resource.

Sample Implementation Activities Cont.v A partnership made up of service providers in a

community can work together with some familymembers to develop education guidelines andimplement them in their respective facilities.

v Provide training and professional support forgroup facilitators and community meeting spacesfor survivor of suicide support groups.

GOAL 8: INCREASE COMMUNITY LINKAGESWITH AND ACCESS TO MENTALHEALTH AND SUBSTANCE ABUSESERVICES

Services to prevent suicide must beavailable when and where people needthem. That means providing services inmany different places. A variety of outreachactivities can address personal barriers,such as not knowing what to do or when toseek care, or concerns about confidentialityor discrimination.

Barriers to access to mental health andsubstance abuse services that must beaddressed include structural barriers suchas lack of health care professionals to meetthe need for services. Financial barrierssuch as not having health insurance mustalso be addressed. The National Strategyfor Suicide Prevention emphasizes theimportance of promoting health insuranceplans that cover mental health andsubstance abuse services on a par withcoverage for other health care.

Objectives1. Compile and update a guide to

Wisconsin suicide prevention resourcesand services (a Wisconsin SuicidePrevention Resource Directory).Provide linkages to national preventionresources.

2. Increase the number of Wisconsincounties with health and/or humanservices outreach programs for at-riskpopulations. These outreach programsshould include mental health and


substance abuse services and suicideprevention activities.

3. Support guidelines for mental health andsubstance abuse screening with referralprocedures for at-risk students inschools, colleges and universities.Expand the availability of site-basedprofessionals to provide assessmentand referral after screening.

4. Support consistent use of guidelines formental health screening and referral inother sites with at risk populations suchas correctional facilities, detentioncenters, crisis centers, family planningclinics, recreation centers, youth servingorganizations, homeless shelters,employee assistance offices, andalcohol and drug treatment programs.

5. Support quality care and usemanagement guidelines that detailappropriate responses to suicidal risk orbehavior. Implement these guidelines inmental health, substance abuse andprimary health care treatment settings.

6. Promote health insurance plans thatcover mental health and substanceabuse services on a par with coveragefor other health care services.

Sample Implementation Activitiesv Provide current suicide prevention information to

Wisconsin's existing help lines.v Work with county health, human service and

aging agencies to address the need for all staffwho make home visits and/or provide casemanagement services to the elderly to be trainedto make appropriate referrals to mental healthservices.

v Encourage parents to work with the local schoolboard to institute policies and procedures forassessment, referral, and follow-up to localservice providers that would offer same dayinitial appointments for high risk students.

v Support ongoing continuing education inscreening and referral for providers and theavailability of licensed professionals to providereferral services.

v Work with professional correctional organizationsto identify and promote model suicideassessment guidelines for jails during the initialhigh-risk 48-hour period of incarceration.

v Work with managed care organizations inWisconsin to develop and implement clinicalpractice guidelines for suicide risk assessmentand management.

Sample Implementation Activitiesv Work with key policymakers in order to build the

necessary support for substantial legislation forcoverage for mental health and substance abusetreatment on a par with other health care.

v Work with employee organizations and localemployers to provide benefits for mental healthand substance abuse coverage at the same levelas coverage for physical health care.

GOAL 9: IMPROVE REPORTING ANDPORTRAYALS OF SUICIDAL BEHAVIOR,MENTAL ILLNESS, AND SUBSTANCEABUSE IN THE ENTERTAINMENT ANDNEWS MEDIA

Research indicates that the way suicide,mental illness, and substance abuse arepresented in the media may increasesuicide rates, especially among youth.“Cluster suicides” and “suicide contagion”have been documented. Studies haveshown that both news reports and fictionalaccounts of suicide in movies and televisioncan lead to increases in suicide. In addition,negative views of mental health andsubstance abuse problems or inaccuratedepictions of treatment may lead individualsto be reluctant to seek treatment, anduntreated mental illness or substance abuseare strongly correlated with suicide.

Objectives1. Establish a coalition of public and

private organizations to influence mediapractices. This group can promote theaccurate and responsible representationof suicidal behaviors and mentalillnesses and informed media coverageof suicides and suicide prevention.Resources are available from theAmerican Foundation for SuicidePrevention and the federal Centers forDisease Control.

2. Increase the proportion of entertainmentand news programs and print coveragein Wisconsin that reflect accurate andresponsible portrayal of suicidal


behavior, mental illnesses, and relatedissues.

3. Encourage Wisconsin journalismschools to include guidance in theircourse of study on the portrayal andreporting of depression and othermental illnesses, substance usedisorders, suicide, and suicidalbehaviors.

4. Increase the number of news reports onsuicide that follow the recommended mediaguidelines developed by Center for DiseaseControl-American Association ofSuicidology. These guidelines entitled,“Reporting on Suicide: Recommendationsfor the Media” are available athttp://www.afsp.org.

Sample Implementation Activitiesv Identify survivors, community advocates and the

media who will be active participant members ofthe coalition.

v Offer regular seminars for editors and producersthat identify appropriate coverage andmisleading or dangerous depictions of suicide,mental illnesses, and treatments.

v Implement a media monitoring process toprovide entertainment media and sponsors oftelevision programming with information aboutappropriate coverage and with constructivecritiques of hurtful depictions of suicide, mentalillness, substance abuse disorders, or mentalhealth and substance abuse treatments.

v Bring survivors and prevention specialiststogether with journalism professors in developingcurriculum materials.

v Develop and provide press information kits thatprovide a resource for reporting on suicide andcontact information for local spokespersons thatmay provide additional information and providecopies of the 2001 Center for Disease Control-American Association of Suicidology MediaGuidelines.

GOAL 10:PROMOTE AND SUPPORT RESEARCHAND EVALUATION ON SUICIDEPREVENTION

All suicides are highly complex. Researchon suicide and suicide prevention hasincreased considerably in the past decadeand has generated new questions about

why individuals become suicidal or remainsuicidal. Important contributing factors ofunderlying mental illness, substance abuse,and biological factors, as well as potentialrisk that comes from certain environmentalinfluences is becoming clearer. Increasingthe understanding of how individual andenvironmental risk and protective factorsinteract with each other to affect anindividual’s risk for suicidal behavior is thenext challenge in building suicide preventionplans and strategies on solid scientificevidence.

Continued advancements in the preventionof suicidal behaviors can only come withsolid support of a wide range of basic,clinical, and applied research endeavorsdesigned to enhance understanding of theetiology, development, and expression ofsuicidal behaviors across the life span aswell as those factors which enhanceresiliency. Such enhanced understandingwill lead to better assessment tools,treatments, and preventive interventions. Itwill also lead to more effective and efficienttherapeutic interventions for survivors ofsuicide attempts.

Objectives1. Increase public and private funding for

suicide prevention research andevaluation, and for studies on how to putscientific knowledge into practice at thestate, regional, and community levels.

2. Support development of and access to aregistry of prevention activities aroundthe state and nation with demonstratedeffectiveness for preventing suicide andsuicidal behaviors.

3. Provide training and technicalassistance on the evaluation of suicideprevention programs that areimplemented.

4. Increase the number of jurisdictions,e.g., human service agencies, coroners’offices, etc., that will regularly collectand review information on suicides.


Sample Implementation Activitiesv Develop community-researcher-practitioner

networks for better suicide prevention researchand evaluation.

v Local suicide prevention program planners couldreview the registry to help guide their selection ofactivities.

v Develop and distribute user-friendly tool kits onprogram evaluation.

v Follow-up studies of suicide gather additionalinformation after a death that can be useful inprevention. Develop community support for thesereviews, such as a child-fatality review team, sothat local jurisdictions will be willing to participateand promote standardization for guidelines forthe reviews. These reviews are sometimes calledfollow-back studies (see Appendix C: Glossary).

GOAL 11. IMPROVE AND EXPAND SYSTEMS FORDATA COLLECTION, UNDERSCORINGTHE PUBLIC HEALTH EMPHASIS ONSURVEILLANCE OF SUICIDE ANDSUICIDAL BEHAVIOR

Surveillance is defined as the systematicand ongoing collection of data. Surveillancesystems are key to health planning. Theycan be used to track trends in rates, identifynew problems, provide evidence to supportactivities and initiatives, identify risk andprotective factors, target high riskpopulations for interventions and assess theimpact of prevention efforts. Data areneeded not only at the federal and statelevels but also at the local levels. Nationaldata assists us to identify the magnitude ofthe suicide problem and to look at the high-risk populations. State and local data canhelp establish local program priorities andare necessary for evaluating the impact ofsuicide prevention strategies. Theobjectives for this goal are designed toenhance the quality and quantity of data onsuicide and attempted suicide available atthe state and local levels and to ensure thatthe data are useful for prevention purposes.

Objectives1. Develop and refine standard procedures

for death scene investigations andimplement these procedures in allWisconsin counties.

2. Promote and work with hospitals incollecting uniform and reliable data onsuicidal behaviors by coding externalcauses of injury and determiningassociated costs.

3. Implement a system of reporting violentdeaths that includes suicides andcollects information not currentlyavailable from death certificates.

4. Produce regular reports on suicide andsuicide attempts in Wisconsin,integrating data from multiple state datamanagement systems.

5. Establish surveillance systems of riskbehaviors for suicide among youth,adults, and older persons in Wisconsin.

6. Increase the proportion of jurisdictionsthat regularly completes follow-backstudies (see Appendix C: Glossary) oncompleted suicides.

7. Develop a data base that links andanalyzes information on suicide andself-destructive behavior derived fromseparate data systems, including, forexample, law enforcement, emergencymedical services and hospitals.

Sample Implementation Activitiesv Provide scientific information about suicide to

coroners and medical examiners developingprocedures so the appropriate kinds ofinvestigation evidence can be sought toaccurately identify deaths that are suicide.

v Develop or use existing local fatality reviewcommittees to provide additional information.

v Support publication of regular Wisconsin suicidesurveillance reports from the Department ofHealth and Family Services Divisions ofSupportive Living and Public Health.

v Promote requests by local community membersfor their school boards and superintendents toadminister the Centers for Disease Control(CDC) Youth Risk Behavior Survey (YRBS)throughout the school system, includingquestions about suicidal thinking and behaviors.

v Determine whether a local jurisdiction regularlycompletes follow-back studies on completedsuicides and, if not, advocate for such studies.


Part 3: Looking Ahead

This Wisconsin Strategy is a livingdocument. That means it is expected tochange and to further develop over time, asnew opportunities, new community partners,new research, and new conditions arise.Whether you have been involved in theinitial development of the WisconsinStrategy or are just now joining, you canmake a difference by contributing to theWisconsin Strategy's continueddevelopment. Suicide Prevention inWisconsin is truly everyone's business.

The National Strategy for SuicidePrevention emphasizes that for anyprevention activity to go forward, threethings are necessary: a knowledge base,the public support for change, and a socialstrategy to accomplish change.

Plans are underway to launch the NationalStrategy for Suicide Prevention web sitehttp://www.mentalhealth.org/suicidepreventionso that available knowledge can be in thehands of those who will use it for effectivedecision-making in suicide prevention. Up-to-date information can help shape publicdetermination to prevent suicide.

Implementing the Wisconsin Strategyrequires broad participation andcollaboration from each of us in our owncommunities. The strategy is just thebeginning. Professionals and communityvolunteers must work side-by-side andpublic agencies and private organizationswill have to expand their partnerships sothat together the people of Wisconsin canmake a lasting difference in suicideprevention. Each member of a partnershipmust work to build the knowledge base, thepublic support for change, and the socialstrategy to accomplish change in his or hercommunity. For the Wisconsin Strategy towork, every one of us must be involved.


Web Resources on Suicide and Suicide Prevention

Evaluation Information

Georgia Suicide Prevention Planhttp://www.georgiasuicideplan.org

Evaluation Handbook from the W. K. Kellogg Foundation for Community-Based Projectshttp://www.wkkf.org/publications/evalhdbk

Primer on Evaluation from the U.S. Department of Justicehttp://www.bja.evaluationwebsite. org

The Public Health Approach to Evaluationhttp://www.cdc.gov/eval

University of Kansas Community Programs Evaluationhttp:/ /ctb.Isi.ukans.edu

National and International Organizations Working for Suicide Prevention

American Association of Suicidologyhttp://www.suicidology.org/

American Foundation for Suicide Preventionhttp://www.afsp.org

Faith in Action (the Robert Wood Johnson Foundation)http://www.faithinaction. org

Georgia Suicide Prevention Planhttp://www.georgiasuicidepreventionplan.org

The Link: National Resource Center for Suicide Prevention and Aftercarehttp://thelink.org/

National Organization of People of Color Against Suicidehttp://www.nopcas.com/

Suicide Awareness Voices of Educationhttp://www.save.org/

Suicide Prevention Advocacy Network USAhttp://www.spanusa.org/

Suicide Prevention Efforts in Canadahttp:/ /www.suicideinfo.ca/

Suicide Prevention Efforts in Norwayhttp://www.med.uio.no/ipsy/ssff/


Suicide Prevention Research Centerhttp://www. suicideprc.com/

World Health Organization Suicide Prevention Effortshttp://www.who.int/mental_health/Topic_Suicide/suicidel.html

Youth Suicide Prevention in Australia http://www.nhmrc.health.gov.au/publicat/pdf/mh12.pdf

National Strategy for Suicide Prevention

Comprehensive National Strategy for Suicide Prevention Web Sitehttp://www.mentalhealth.org/suicideprevention

Suicide Prevention Advocacy Network, USAhttp://www.spanusa.org

Surgeon General's Web site: Call to Actionhttp://dev.shs.net 8004/suicide/strategy/calltoaction.htm and www.spanusa.org

State Suicide Prevention Efforts

Wisconsin Suicide Prevention StrategyTo be established on state Department of Health and Family Services web sites

State Planning for Suicide Preventionhttp://www. wwu.edu/~hayden/spsp

State Resources for Child Injury and Violence Preventionhttp://www.edc.org/HHD/csn/StateResources/state.htm

Suicide Prevention Resources by Statehttp://www.edc.org/HHD/csn/Suicide0.pdf

Suicide Data

Centers for Disease Control and Prevention National Center for Injury Prevention and Control Datahttp://www.cdc.gov/ncipc/osp/data.htm

Costs of Completed and Medically Treated Suicidehttp://www.edc.org/HHD/csn/sucost.pdf

Maternal and Child Health Bureau Block Grant Datahttp://wvw.mchdata.net/

Web Based Injury Statistics Query and Reporting System (WISQARShttp://www.cdc.gov/ncipc/wisqars


Suicide and Suicide Prevention Information

Center for Mental Health Services Suicide the Five W's: Depression and Mood Disordershttp://dev.shs.net:8004/suicide/fivews/rates.htm

Crisis Management in Schools Following a Suicidehttp://www.ed.gov/databases/ERIC_Digests/ed315700.html

Evangelical Lutheran Church in America. A Message on Suicide Preventionwww/elca.org/dcs/suicide_prevention.html

National Institute Mental Health Frequently Asked Questions about Suicidehttp://www.nimh.nih.gov/research/suicidefaq.cf

National Institute of Mental Health Selected Bibliography on Suicide Research--1999http://www.nimh.nih.gov/research/suibib99.cfm

National Institute Mental Health Suicide Fact Sheetshttp://www.nimh.nih.gov/research/suifact.htm

Providing Immediate Support for Survivors of Suicidehttp://www.ed.gov/databases/ERIC_Digests/ed315708.html

Role of Maternal and Child Health Bureau in Youth Suicide Preventionhttp://www.edc.org/HHD/csn/Suicidef.pdf

World Health Organization, United Nations. (WHO/UN2000). Preventing Suicide in six groups.www.who.int/mental_health/suicide/resources.html


References

ADAMHA -Alcohol, Drug Abuse, and Mental Health Administration (1989). Report of It theSecretary's Task Force on Youth Suicide: Volumes 1-4. DHHS Pub. No. ADM 89-1624.Washington, DC: U.S. Government Printing Office.

Anderson, MA., Powell, K.E., Davidson, S.C. Suicide in Georgia: 2000. GeorgiaDepartment of Human Resources, Division of Public Health, Epidemiology Section, June 2000.Publication number DPH00 .34H.

Atwood, K., Colditz, G.A., Kawachi, I. (1997). From Public Health Science toPrevention Policy: Placing Science in its Social and Political Contexts. American Journal ofPublic Health 87:1603-1605.

CDC National Mortality Statistics. Available at www.cdc.gov/ncipc/osp/usmort.htm

Commonwealth Department of Health and Aged Care. Promotion, Prevention and EarlyIntervention for Mental Health--A Monograph. Mental Health and Special Programs Branch,Commonwealth Department of Health and Aged Care, Canberra, Australia, 2000.

Durkheim, E. Suicide: A Study in Sociology. Translated by J.A. Spaulding & G. Simpson. NewYork: Free Press, (1987/1951).

Goodman, R.M., Speers, M.A., McLeroy, K., Fawcett, S., Kegler, M., Parker, E., Smith, S.,Sterling, T. and Wallerstein, N. An Initial Attempt to Identify and Define the Dimensions ofCommunity Capacity to Provide a Basis for Measurement. Health Education and Behavior,vol.25 (3), 1998.

Jamison, K.R. Night Falls Fast--Understanding Suicide. Alfred A. Knopf, New York, 1999.

McCraig, L.F., Strussman, B.J. National Hospital Ambulatory Care Survey: 1996. In: CDC.Emergency Department Summary: Advance Data from Vital and Health Statistics, no. 293.Hyattsville, Maryland: National Center for Health Statistics, 1997.

MMWR-Morbidity and Mortality Weekly Report. Vol.43 No. RR-6, Apri1 22, 1994.

National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD: U.S.Dept. of Health and Human Services, Public Health Service, 2001.

Ramsey, R. United Nations Impact on the United States National Suicide Prevention Strategy.Paper presented at the 34th conference of the American Association of Suicidology, Atlanta,GA, 2001.

Raphael, B. Promoting the Mental Health and Wellbeing of Children and Young People.Discussion Paper: Key Principles and Directions. National Mental Health Working Group,Department of Health and Aged Care, Canberra, Australia, 2000.


Shneidman, E.S. and Farberow, N.L. The LA SPC: A Demonstration of Public HealthFeasibilities. American Journal of Public Health 55:21-26.

Silverman, M.M., Davidson L., Potter L., Eds. Background Papers from the National SuicidePrevention Conference October 1998 Reno, Nevada. Suicide and Life-Threatening Behavior, 31Supplement, Spring 2001.

Suicide in Georgia: 2000, Georgia Department of Human Resources, Division of Public Health.Atlanta, 2001.

United Nations World Health Organization. Prevention of Suicide: Guidelines for the formationand implementation of national strategies. ST /ESA/245 .Geneva: World Health Organization,1996.

U.S. Department of Health and Human Services. Healthy People 2010. 2nd ed. Washington,DC: U.S. Government Printing Office, November, 2000.

U.S. Department of Health and Human Services. Mental Health: A Report of the SurgeonGeneral. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse andMental Health Services Administration, Center for Mental Health Services, National Institutes ofHealth, National Institute of Mental Health, 1999.

U.S. Public Health Service, The Surgeon General's Call to Action to Prevent Suicide.Washington, DC, 1999.


Appendix A: Risk and Protective Factors for Suicide

The base for suicide prevention comes from identifying suicide risk factors, suicide protectivefactors, and their interactions. Suicide risk factors are things that increase the potential for aperson's suicide or suicidal behavior. A person's age, gender, or ethnicity can increase the impactof certain risk factors or combinations of risk factors for them. Understanding risk factors can helpcounteract the myth that suicide is a random act or results from stress alone. Suicide protectivefactors are things that reduce the potential for a person's suicide or suicidal behavior. Protectivefactors include attitudes and behaviors.

Some risk factors cannot be changed, such as a previous suicide attempt, but even these mayhave a purpose as reminders of the heightened risk of suicide when the individual is ill orencountering adversity. To prevent suicide, enhancing resilience and protective factors is asimportant as reducing risk. Unfortunately, resilience against suicide is not permanent. Thismeans that activities to support and maintain protection against suicide need to be repeated andongoing.

The following Risk Factors and Protective Factors for Suicide are identified in the NationalStrategy for Suicide Prevention: Goals and Objectives for Action.

Risk Factors for SuicideBiological, Psychological and Social Risk Factorsv Previous suicide attemptv Mental disorders, particularly mood disorders such as depression and bipolar disorder, anxiety

disorders, schizophrenia, and certain personality disorder diagnosesv Alcohol and substance abuse disordersv Family history of suicidev History of trauma or abusev Hopelessnessv Impulsive and/or aggressive tendenciesv Some major physical illnessesEnvironmental Risk Factorsv Job or financial lossv Relational or social lossv Easy access to lethal meansv Local clusters of suicide that have a contagious influenceSocio-cultural Risk Factorsv Lack of social support and sense of isolationv Stigma associated with help-seeking behaviorv Barriers to obtaining access to health care, especially mental health and substance abuse

treatmentv Certain cultural and religious beliefs, for instance the belief that suicide is a noble resolution of a

personal dilemmav Exposure to the influence of others who have died by suicide, including media exposure

Protective Factors in Preventing Suicidev Effective clinical care for mental, physical, and substance use disordersv Easy access to a variety of clinical interventions and support for help-seekingv Restricted access to highly lethal methods of suicidev Strong connections to family and community supportv Support through ongoing medical and mental health care relationshipsv Learned skills in problem solving, conflict resolution, and nonviolent handling of disputesv Cultural and religious beliefs that discourage suicide and support self-preservation


Appendix B:Development of the Wisconsin Suicide Prevention Strategy

Only recently has knowledge become available to help us approach suicide as a preventableproblem with realistic opportunities to save many lives. The Wisconsin Suicide PreventionStrategy is framed upon these advances in science and public health. It is connected withnational efforts to develop strategies for suicide prevention that can be carried out by public andprivate partners in communities across the country.

There has been international interest in suicide prevention for many years. In 1993, the UnitedNations/World Health Organization, in collaboration with a Canadian partnership led hosted aninternational conference in Calgary, Canada. The results of that meeting were documented in apublication called Prevention of Suicide: Guidelines for the Formulation and Implementation ofNational Strategies (United Nations 1996). The UN Guidelines were developed as a way tofacilitate the development of national strategies for the prevention of suicidal behaviors withinthe socio-economic and cultural context of any interested country (Ramsey 2001).

SPAN USA was founded by Elsie and Jerry Weyrauch in January, 1996, to create andimplement a national suicide prevention strategy based on the UN Guidelines. SPAN USAmembers include suicide survivors (persons close to someone who completed suicide), suicideattempters, persons providing support for survivors and advocates of suicide prevention. SPANUSA' s efforts to mobilize political action for suicide prevention generated United StatesCongressional resolutions recognizing suicide as a national problem and suicide prevention asa national priority. As part of a 1998 National Suicide Prevention Conference in Reno, Nevada,SPAN USA and the Centers for Disease Control and Prevention commissioned briefing papersto summarize the evidence base for suicide prevention strategies among at-risk populations andto make recommendations for public health action (Silverman, Davidson, and Potter, 2001).Conference participants included researchers, health, mental health and substance abuseclinicians, policy makers, suicide survivors, consumers of mental health services, andcommunity activists and leaders. Five delegates represented Wisconsin.

Following the work of the Reno Conference, Surgeon General David Satcher issued his Call toAction to Prevent Suicide in July, 1999, emphasizing suicide as a serious public health problem(USPHS, 1999). The Surgeon General's Call introduced a blueprint for addressing suicideprevention through Awareness, Intervention, and Methodology (AIM). AIM describes 15 broadrecommendations containing goal statements, general objectives and recommendations forimplementation that are consistent with a public health approach to suicide prevention. Therecommendations were selected according to their scientific evidence, feasibility and degree ofcommunity support.

The recommendations of the SPAN USA Reno meeting, the Call to Action and subsequent criticalexamination by scientific, clinical and government leaders, other professionals and the generalpublic resulted in a comprehensive plan outlining national goals and objectives that wouldstimulate the development of defined activities for local, state and federal partners. SPAN USAhas worked to build its own state plan, the Georgia Plan, in concert with the National Strategywhile incorporating specific state needs and interests.

In 2000, a Wisconsin work group was formed through an informal collaborative partnership toaddress the need for a Wisconsin state strategy. Following participation in a teleconference callwith the Surgeon General and ten other states that have suicide prevention plans, thisWisconsin work group adapted goals and objectives from the National Strategy and from theGeorgia Plan for the Wisconsin Strategy.


Appendix C: Glossary of Terms Used in the Wisconsin Strategy

Assessment - The ongoing process of information gathering, examination, and evaluation to a) determinerisk, b) identify contributing factors which may be modified, c) diagnose, if applicable, d) choose optimalinterventions or treatments, and e) track the impact of interventions or treatments.

Attempters - See suicide attempt.

Community capacity - The characteristics of communities that affect their ability to identify , mobilize, andaddress social and health problems and the cultivation and use of transferable knowledge, skills, systemsand resources that affect community and individual level changes consistent with population health-related goals and objectives. (Goodman et. al., 1998)

Connectedness - A person's sense of belonging with others. A sense of connectedness can be withfamily, school, workplace, and community.

Effectiveness - Effectiveness studies test the real world impact of interventions that have been shown tobe efficacious under controlled conditions. These studies are needed to determine whether results fromstudies carried out under very controlled situations may be generalized to other settings.

Efficacy - Efficacy studies are used to develop and refine interventions under experimental conditions.These settings are usually controlled to represent ideal conditions.

Epidemiology - The study of statistics and trends in health as applied to the whole community orpopulation.

Evidence-based programs - Those programs that have some research showing that the program wasassociated with the intended beneficial outcome(s).

Follow-back study - A study carried out after a death to provide information from persons or from existingrecords that will add to the information sources used by the coroner or medical examiner in determiningthe cause of death. Example: the collection of the same categories of information about persons who haddied by suicide and persons who had died from heart disease in order to compare the two groups andhelp understand their risk and protective factors.

Gatekeeper training - Training for community members who have face-to-face contact with many othersas part of their usual routine. Training usually includes recognition of persons at risk of suicide andinformation on how to refer for treatment or supporting services, as appropriate.

Interventions - Actions or programs that can reduce the effect of risk factors and/or increase protectivefactors. An example of an intervention would be providing effective treatment for depressive illness.

Mental Health Screening - Surveys done by health care professionals, schools, and others to identifypeople who have a mental illness and to refer them to mental health professionals.

Outcome - A measurable change that can be attributed to an intervention or a program.

Outreach programs - Programs with staff that go into communities to deliver services or recruitparticipants.

Population - based interventions -Interventions targeting populations or communities rather thanindividuals.

Primary care - The care system that provides the first point of contact for those in the community seekinggeneral assistance; for example, family practitioners or pediatric nurse clinicians.


Program evaluation - The process used to measure the outcomes of a program or service.

Providers - Professionals who offer health, mental health, treatment, or social services.

Protective factors - Those characteristics and circumstances that reduce the likelihood of suicide orsuicidal behaviors.

Resilience - Capacities within a person that promote positive outcomes, such as mental health and well-being, and provide protection from factors that might otherwise place that person at risk for adversehealth outcomes.

Risk factors - Those characteristics and circumstances that make it more likely for suicide or suicidalbehaviors to occur.

Stakeholders - The groups and individuals that care about or are affected by suicide prevention decisionsand policies.

Substance use disorders - Disorders in which drugs, including alcohol, are used to such an extent thatsocial and occupational functioning is impaired and control or abstinence becomes impossible.

Suicide attempt - (Also Attempters) Nonfatal behavior that is intended to end one's own life, and whichmay produce self-injury.

Suicidal behavior - Suicidal behavior includes a range of activities related to suicide and self-harm,including suicidal thinking, self-harming behaviors without thoughts of death, and suicide attempts.

Suicide - Intentional, self-inflicted death.

Suicide attempt survivors - Individuals who have previously attempted suicide.

Suicide survivors - Family members, significant others, or acquaintances who have experienced the lossof a loved one due to suicide. In other publications this term may be used to refer to suicide attemptsurvivors.

Surveillance - The regular monitoring of health conditions in the population through thesystematic collection, evaluation, and reporting of measurable information. Surveillance can be used tounderstand trends.

EDITOR'S NOTE: Many entries in this Glossary quote or adapt usage from National Strategyfor Suicide Prevention: Goals and Objectives for Action; Mental Health: The Surgeon General’s Report;and the Wisconsin Blue Ribbon Commission on Mental Health Final Report.

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