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The Surgeon General's
Call To Action
To Prevent Suicide
1999
![Public Health Service](https://webarchive.library.unt.edu/eot2008/20090114031445im_/http://www.surgeongeneral.gov/images/phsgold.gif)
Department of Health and Human Services
U.S. Public Health Service
Copyright Information:
Material contained in this report is in the public domain and may be used
and reprinted without special permission; citation as to source is however appreciated.
Suggested Citation:
U.S. Public Health Service, The Surgeon General's Call To Action To Prevent Suicide.
Washington, DC: 1999.
A Letter From The Surgeon General
U.S. Department of Health and Human Services
Suicide is a serious public health problem. In 1996, the year for which the most recent
statistics are available, suicide was the ninth leading cause of mortality in the United
States, responsible for nearly 31,000 deaths. This number is more than 50% higher than the
number of homicides in the United States in the same year (around 20,000 homicides in
1996).1 Many fail to realize that far more Americans die from suicide than from
homicide. Each year in the United States, approximately 500,000 people require emergency
room treatment as a result of attempted suicide.2 Suicidal behavior typically
occurs in the presence of mental or substance abuse disordersillnesses that impose
their own direct suffering.3-5 Suicide is an enormous trauma for millions of
Americans who experience the loss of someone close to them.6 The nation must
address suicide as a significant public health problem and put into place national
strategies to prevent the loss of life and the suffering suicide causes.
In 1996, the World Health Organization (WHO), recognizing the growing problem of
suicide worldwide, urged member nations to address suicide. Its document, Prevention of
Suicide: Guidelines for the Formulation and Implementation of National Strategies7,
motivated the creation of an innovative public/private partnership to seek a national
strategy for the United States. This public/private partnership included agencies in the
U.S. Department of Health and Human Services, encompassing the Centers for Disease Control
and Prevention (CDC), the Health Resources and Services Administration (HRSA), the Indian
Health Service (IHS), the National Institute of Mental Health (NIMH), the Office of the
Surgeon General, and the Substance Abuse and Mental Health Services Administration
(SAMHSA) and the Suicide Prevention Advocacy Network (SPAN), a public grassroots advocacy
organization made up of suicide survivors (persons close to someone who completed
suicide), attempters of suicide, community activists, and health and mental health
clinicians.
An outgrowth of this collaborative effort was a jointly sponsored national conference
on suicide prevention convened in Reno, Nevada, in October 1998. Conference participants
included researchers, health and mental health clinicians, policy makers, suicide
survivors, and community activists and leaders. They engaged in careful analysis of what
is known and unknown about suicide and its potential responsiveness to a public health
model emphasizing suicide prevention.
This Surgeon Generals Call To Action introduces a blueprint for
addressing suicideAwareness, Intervention, and Methodology, or AIMan
approach derived from the collaborative deliberations of the conference participants. As a
framework for suicide prevention, AIM includes 15 key recommendations that were
refined from consensus and evidence-based findings presented at the Reno conference.
Recognizing that mental and substance abuse disorders confer the greatest risk for
suicidal behavior, these recommendations suggest an important approach to preventing
suicide and injuries from suicidal behavior by addressing the problems of undetected and
undertreated mental and substance abuse disorders in conjunction with other public health
approaches.
These recommendations and their supporting conceptual framework are essential steps
toward a comprehensive National Strategy for Suicide Prevention. Other necessary
elements will include constructive public health policy, measurable overall objectives,
ways to monitor and evaluate progress toward these objectives, and provision of resources
for groups and agencies identified to carry out the recommendations. The nation needs to
move forward with these crucial recommendations and support continued efforts to improve
the scientific bases of suicide prevention.
Many people, from public health leaders and mental and substance abuse disorder health
experts to community advocates and suicide survivors, worked together in developing and
proposing AIM for the American public. AIM and its recommendations chart a
course for suicide prevention action now as well as serve as the foundation for a more
comprehensive National Strategy for Suicide Prevention in the future. Together,
they represent a critical component of a broader initiative to improve the mental health
of the nation. I endorse the ongoing work necessary to complete a National Strategy
because I believe that such a coordinated and evidence-based approach is the best way to
use our resources to prevent suicide in America.
But even the most well-considered plan accomplishes nothing if it is not implemented.
To translate AIM into action, each of us, whether we play a role at the federal,
state, or local level, must turn these recommendations into programs best suited for our
own communities. We must act now. We cannot change the past, but together we can shape a
different future.
David Satcher, M.D., Ph.D.
Assistant Secretary for Health
and Surgeon General
Suicide as a Public Health Problem
On average, 85 Americans die from suicide each day. Although more females attempt
suicide than males, males are at least four times more likely to die from suicide.1,8
Firearms are the most common means of suicide among men and women, accounting for 59% of
all suicide deaths.1
Over time, suicide rates for the general population have been fairly stable in the
United States.9 Over the last two decades, the suicide rate has declined from
12.1 per 100,000 in 1976 to 10.8 per 100,000 in 1996.10 However, the rates for
various age, gender and ethnic groups have changed substantially. Between 1952 and 1996,
the reported rates of suicide among adolescents and young adults nearly tripled.1,11
From 1980 to 1996, the rate of suicide among persons aged 15-19 years increased by 14% and
among persons aged 10-14 years by 100%. Among persons aged 15-19 years, firearms-related
suicides accounted for 96% of the increase in the rate of suicide since 1980. For young
people 15-24 years old, suicide is currently the third leading cause of death, exceeded
only by unintentional injury and homicide.12 More teenagers and young adults
die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia
and influenza, and chronic lung disease combined. During the past decade,
there have also been dramatic and disturbing increases in reports of suicide among
children. Suicide is currently the fourth leading cause of death among children between
the ages of 10 and 14 years.10
Suicide remains a serious public health problem at the other end of the age spectrum,
too. Suicide rates increase with age and are highest among white American males aged 65
years and older. Older adult suicide victims, when compared to younger suicide victims,
are more likely to have lived alone, have been widowed, and to have had a physical
illness.13,14 They are also more likely to have visited a health care
professional shortly before their suicide and thus represent a missed opportunity for
intervention.15
Other population groups in this country have specific suicide prevention needs as well.
Many communities of Native Americans and Alaskan Natives long have had elevated suicide
rates.16,17 Between 1980 and 1996, the rate of suicide among African American
males aged 15-19 years increased 105% and almost 100% of the increase in this group is
attributable to the use of firearms.18
It is generally agreed that not all deaths that are suicides are reported as such. For
example, deaths classified as homicide or accidents, where individuals may have
intentionally put themselves in harms way are not included in suicide rates.19-21
Compounding the tragedy of loss of life, suicide evokes complicated and uncomfortable
reactions in most of us. Too often, we blame the victim and stigmatize the surviving
family members and friends. These reactions add to the survivors burden of hurt,
intensify their isolation, and shroud suicide in secrecy. Unfortunately, secrecy and
silence diminish the accuracy and amount of information available about persons who have
completed suicide information that might help prevent other suicides.
Methodology
Developing Recommendations for a National Strategy for
Suicide Prevention
Developing and implementing a National Strategy for Suicide Prevention should
achieve a significant, measurable, and sustained reduction in suicidal behaviors. The
action steps presented in this document were prioritized from among a variety of
recommendations developed through a public-private collaboration of nongovernmental
organizations, federal and state governmental agencies, corporations and foundations, and
public health, health, mental health experts.
Before the Reno Conference, experts evaluated research studies, programs, policies, and
best interventions to prevent suicide among five U.S. population groups known to be at
high risk of suicide. Those identified as being at increased risk were youth, the
medically ill, specific population groups, persons with mental and substance abuse
disorders, and the elderly. Following review of the evidence by a second expert, the lead
expert extracted recommendations for suicide prevention. In extracting recommendations,
experts were instructed to consider the robustness of the available data; an
interventions likelihood of reducing suicide; its perceived suitability for
implementation in the real world; and estimates of the lead-time to put the recommendation
into practice and produce its intended effect. They were also asked to consider the
ethical implications and cultural appropriateness of each recommendation.
Those experts draft recommendations were brought to the Reno conference. A broad
cross section of conference participants and a highly varied expert panel were identified
to work with the recommendations and evaluate each one. The panel and the invited
conference participants represented diverse areas of expertise and included researchers,
suicide survivors, persons who had attempted suicide, public health leaders, community
volunteers, clinicians, educators, consumers of mental health services, and
corporate/nonprofit advocates. Financial support was made available so that socioeconomic
status would not exclude panelists and participants who wanted to contribute from
attending the conference. The Regional Health Administrators of the U.S. Public Health
Service served as facilitators in working with over 400 participants to refine
recommendations during the conference. The expert panel received over 700 written comments
from participants during the course of their deliberations.
The expert panels recommendations were derived from a rigorous review of suicide
and suicide prevention research. Existing suicide research is strongest in the
identification of risk factors, particularly mental and substance abuse disorders, less
developed in categorizing protective factors, and only beginning to analyze the mutual
interactions among risk and protective factors. Some treatments for mental and substance
abuse disorders have been associated with a reduction in suicidal behaviors.22-30
Further research is needed to determine whether these benefits will occur if treatments
are offered to groups outside the small populations that were studied.
The recommendations the panel developed include past and current initiatives, programs,
and interventions. Other recommendations pragmatically extend findings from existing
suicide and suicide prevention research into proposed applications. Suicide prevention
experts from multiple disciplines endorsed these proposed recommendations as having the
greatest potential for effectiveness.
By the end of the conference, the expert panel had advanced 81 recommendations for
consideration for inclusion in a National Strategy for Suicide Prevention. These
recommendations were posted on the SPAN Web site to allow a period of further reflection
and public comment. The CDC developed a tool for priority ranking the 81 recommendations.
Respondents from all interested sectors prioritized the recommendations using criteria of
feasibility, necessity, clarity, and likelihood of being funded. Recommendations with the
highest priority scores and broadest support were combined and edited to serve as the
essential first steps of an action agenda for suicide prevention.
Results
AIM to Prevent Suicide
This Surgeon Generals Call to Action introduces an initial
blueprint for reducing suicide and the associated toll that mental and substance abuse
disorders take in the United States. As both evidence-based and highly prioritized by
leading experts, these 15 key recommendations listed below should serve as a framework for
immediate action. These recommended first steps are categorized as Awareness,
Intervention, and Methodology, or AIM.
Awareness: Appropriately broaden the publics awareness of suicide and its
risk factors
Intervention: Enhance services and programs, both population-based and clinical
care
Methodology: Advance the science of suicide prevention
Awareness: Appropriately broaden the publics
awareness of suicide and its risk factors
- Promote public awareness that suicide is a public health problem and, as such, many
suicides are preventable. Use information technology appropriately to make facts about
suicide and its risk factors and prevention approaches available to the public and to
health care providers.
- Expand awareness of and enhance resources in communities for suicide prevention programs
and mental and substance abuse disorder assessment and treatment.
- Develop and implement strategies to reduce the stigma associated with mental illness,
substance abuse, and suicidal behavior and with seeking help for such problems.
Intervention: Enhance services and programs, both
population-based and clinical care
- Extend collaboration with and among public and private sectors to complete a National
Strategy for Suicide Prevention.
- Improve the ability of primary care providers to recognize and treat depression,
substance abuse, and other major mental illnesses associated with suicide risk. Increase
the referral to specialty care when appropriate.
- Eliminate barriers in public and private insurance programs for provision of quality
mental and substance abuse disorder treatments and create incentives to treat patients
with coexisting mental and substance abuse disorders.
- Institute training for all health, mental health, substance abuse and human service
professionals (including clergy, teachers, correctional workers, and social workers)
concerning suicide risk assessment and recognition, treatment, management, and aftercare
interventions.
- Develop and implement effective training programs for family members of those at risk
and for natural community helpers on how to recognize, respond to, and refer people
showing signs of suicide risk and associated mental and substance abuse disorders. Natural
community helpers are people such as educators, coaches, hairdressers, and faith leaders,
among others.
- Develop and implement safe and effective programs in educational settings for youth that
address adolescent distress, provide crisis intervention and incorporate peer support for
seeking help.
- Enhance community care resources by increasing the use of schools and workplaces as
access and referral points for mental and physical health services and substance abuse
treatment programs and provide support for persons who survive the suicide of someone
close to them.
- Promote a public/private collaboration with the media to assure that entertainment and
news coverage represent balanced and informed portrayals of suicide and its associated
risk factors including mental illness and substance abuse disorders and approaches to
prevention and treatment.
Methodology: Advance the science of suicide prevention
- Enhance research to understand risk and protective factors related to suicide, their
interaction, and their effects on suicide and suicidal behaviors. Additionally, increase
research on effective suicide prevention programs, clinical treatments for suicidal
individuals, and culture-specific interventions.
- Develop additional scientific strategies for evaluating suicide prevention interventions
and ensure that evaluation components are included in all suicide prevention programs.
- Establish mechanisms for federal, regional, and state interagency public health
collaboration toward improving monitoring systems for suicide and suicidal behaviors and
develop and promote standard terminology in these systems.
- Encourage the development and evaluation of new prevention technologies, including
firearm safety measures, to reduce easy access to lethal means of suicide.
Discussion
Risk and Protective Factors
Suicide risk and protective factors and their interactions form the empirical base for
suicide prevention. Risk factors are associated with a greater potential for suicide and
suicidal behavior while protective factors are associated with reduced potential for
suicide.31-33
Substantial age, gender, ethnic, and cultural variations in suicide rates provide
opportunities to understand the different roles of risk and protective factors among these
groups. Risk and protective factors encompass genetic, neurobiological, psychological,
social, and cultural characteristics of individuals and groups and environmental factors
such as easy access to firearms.34-38 This expanding base of empirical evidence
generates promising ideas about what can be changed or modified to prevent suicide.
Clear progress has been made in the scientific understanding of suicide, mental and
substance abuse disorders, and in developing interventions to treat these disorders. For
example, increased understanding of brain systems regulated by chemicals called
neurotransmitters holds promise for understanding the biological underpinnings of
depression, anxiety disorders, impulsiveness, aggression, and violent behaviors.39
Much remains to be learned, however, about the common risk factors for mental disorders
and substance abuse, suicide and other forms of intentional violence including homicide,
domestic violence, and child abuse. Expanding the base of scientific evidence will help in
the development of more effective interventions for these harmful behaviors.
Advances in neurobiology and the behavioral sciences and their application in
developing effective treatments for mental and substance abuse disorders have generated
much hope. Wider public understanding of the science of the brain and behavior can reduce
the stigma associated with seeking help for mental and substance abuse disorders and
consequently may contribute to reducing the risk for suicidal behavior.
Risk Factors
Understanding risk factors can help dispel the myths that suicide is a random act
or results from stress alone. Some persons are particularly vulnerable to suicide and
suicidal self-injury because they have more than one mental disorder present40,
such as depression with alcohol abuse41. They may also be very impulsive and/or
aggressive42, and use highly lethal methods to attempt suicide. As noted above,
the importance of certain risk factors and their combination vary by age, gender, and
ethnicity.
The impact of some risk factors can be reduced by interventions (such as providing
effective treatments for depressive illness).31,43 Those risk factors that
cannot be changed (such as a previous suicide attempt) can alert others to the heightened
risk of suicide during periods of the recurrence of a mental or substance abuse disorder,
or following a significant stressful life event.31,44
Risk factors include:
- Previous suicide attempt
- Mental disordersparticularly mood disorders such as
depression and bipolar disorder
- Co-occurring mental and alcohol and substance abuse disorders
- Family history of suicide
- Hopelessness
- Impulsive and/or aggressive tendencies
- Barriers to accessing mental health treatment
- Relational, social, work, or financial loss
- Physical illness
- Easy access to lethal methods, especially guns
- Unwillingness to seek help because of stigma attached to mental and substance abuse
disorders and/or suicidal thoughts
- Influence of significant peoplefamily members, celebrities, peers who have died by
suicideboth through direct personal contact or inappropriate media representations
- Cultural and religious beliefsfor instance, the belief that suicide is a noble
resolution of a personal dilemma
- Local epidemics of suicide that have a contagious influence
- Isolation, a feeling of being cut off from other people
Some lists of warning signs for suicide have been created in an effort to identify and
increase the referral of persons at risk. However, the warning signs given are not
necessarily risk factors for suicide and may include common behaviors among distressed
persons, behaviors that are not specific for suicide. If such lists are applied broadly,
for instance in the general classroom setting, they may be counterproductive. In effect,
indiscriminate suicide awareness efforts and overly inclusive screening lists may promote
suicide as a possible solution to ordinary distress or suggest that suicidal thoughts and
behaviors are normal responses to stress.45 Efforts must be made to avoid
normalizing, glorifying, or dramatizing suicidal behavior, reporting how-to methods, or
describing suicide as an understandable solution to a traumatic or stressful life event.
Inappropriate approaches could potentially increase the risk for suicidal behavior in
vulnerable individuals, particularly youth.46,47
Protective Factors
Protective factors can include an individuals genetic or neurobiological
makeup, attitudinal and behavioral characteristics, and environmental attributes.31
Measures that enhance resilience or protective factors are as essential as risk reduction
in preventing suicide. Positive resistance to suicide is not permanent, so programs that
support and maintain protection against suicide should be ongoing.
Protective factors include:
- Effective and appropriate clinical care for mental, physical, and substance abuse
disorders
- Easy access to a variety of clinical interventions and support for help seeking
- Restricted access to highly lethal methods of suicide
- Family and community support
- Support from ongoing medical and mental health care relationships
- Learned skills in problem solving, conflict resolution, and nonviolent handling of
disputes
- Cultural and religious beliefs that discourage suicide and support self-preservation
instincts
The risk factors that lead to suicide (especially mental and substance abuse disorders)
and the protective factors that safeguard against it form the conceptual framework for the
prevention recommendations developed and presented in this document and in the evolving National
Strategy for Suicide Prevention.
Identifying and Addressing Risk
Unfortunately, it is difficult to identify particular individuals at greatest risk for
suicidal behaviors or completed suicide. Measures to screen the general population for
suicide risk lack the precision needed to identify in advance only those people who
eventually would die by suicide. Because suicide screening in the general population
currently is not feasible, it is especially important for suicide prevention programs to
include broader approaches that benefit the whole population as well as efforts focused on
smaller, high-risk subgroups that can be identified. Within those subgroups, a different
approach to screeningscreening programs for specific disorders, like depression,
that are associated with suicidecan be used to identify and direct people to highly
effective treatments that may lower their risk of suicide.
Often, the suicide prevention efforts in place are directed primarily at improving
clinical care for the individual already struggling with suicidal ideas or the individual
requiring medical attention for a suicide attempt. Suicide prevention also demands
approaches that reduce the likelihood of suicide before vulnerable individuals reach the
point of danger. Applying the public health approach to the problem of suicide in the
United States will maximize the benefits of efforts and resources for suicide prevention.
The Public Health Approach
Suicide is a public health problem that requires an evidence-based approach to
prevention. In concert with the clinical medical approach, which explores the history and
health conditions that could lead to suicide in a single individual, the public health
approach focuses on identifying and understanding patterns of suicide and suicidal
behavior throughout a group or population. The public health approach defines the problem,
identifies risk factors and causes of the problem, develops interventions evaluated for
effectiveness, and implements such interventions widely in a variety of communities.48,49
Although this description suggests a linear progression from the first step to the
last, in reality the steps occur simultaneously and depend on each other. For example,
systems for gathering information to define the exact nature of the suicide problem may
also be useful in evaluating programs. Similarly, information gained from program
evaluation and implementation may lead to new and promising interventions. Public health
has traditionally used this model to respond to epidemics of infectious disease. During
the past few decades, the model has also been used to address other problems that are
likewise complicated and challenging to prevent, such as chronic disease and injury.
The Public Health Approach Applied to Suicide Prevention
Defining the Problem
The first step includes collecting information about incidents of suicide and
suicidal behavior. It goes beyond simple counting. Information is gathered on
characteristics of the persons involved, the circumstances of the incidents, events that
may have precipitated the act, the adequacy of support and health services received, and
the severity and cost of the injuries. This step covers the who, what, when, where, how,
and how many of the identified problem.
Identifying Causes and Protective Factors
The second step focuses on why. It addresses risk factors such as depression, alcohol and
other drug use, bereavement, or job loss. This step may be used to define groups of people
at higher risk for suicide. Many questions remain, however, about the interactive matrix
of risk and protective factors in suicide and suicidal behavior and, more importantly, how
this interaction can be modified.
Developing and Testing Interventions
The next step involves developing approaches to address the causes and risk factors that
have been identified. Testing the effectiveness of each approach is a critical part of
this step to ensure that strategies are safe, ethical, and feasible. Pilot testing, which
may reveal differences among particular age, gender, ethnic and cultural groups, can help
determine for whom a suicide prevention strategy is best fitted.
Implementing Interventions
The final step is to implement interventions that have demonstrated effectiveness in
preventing suicide and suicidal behavior. Implementation requires data collection as a
means to continue evaluating effectiveness of an intervention. This is essential because
an intervention that has been found effective in a clinical trial or academic study may
have different outcomes in other settings. Ongoing evaluation builds the evidence base for
refining and extending effective suicide prevention programs. Determination of an
interventions cost-effectiveness is another important component of this step. This
ensures that limited resources can be used to achieve the greatest benefit.
As interventions for preventing suicide are developed and implemented, communities must
consider several key factors. Interventions have a much greater likelihood of success if
they involve a variety of services and providers. This requires community leaders to build
effective coalitions across traditionally separate sectors, such as the health care
delivery system, the mental health system, faith communities, schools, social services,
civic groups, and the public health system. Interventions must be adapted to support and
reflect the experience of survivors and specific community values, cultures, and
standards. They must also be designed to benefit from multi-ethnic and culturally diverse
participation from all segments of the community.
As it evolves, Americas National Strategy for Suicide Prevention must
recognize and affirm the value, dignity, and importance of each person. Everyone concerned
with suicide prevention shares the responsibility to help change and eliminate the
societal conditions and attitudes that often contribute to suicide. Individuals,
communities, organizations, and leaders at all levels should collaborate in promoting
suicide prevention. Final development of a National Strategy for Suicide Prevention
and the success of these essential action steps ultimately rest with individuals and
communities and institutions and policy makers across the United States.
Implementing AIM as an Action Agenda in Communities
As states and local communities apply the public health approach to AIM
recommendations, they must consider both population-based and clinical care initiatives.
Their first step is to define and to describe the problem of suicide and its associated
risk factors locally and measure their magnitude. Next, causes of the conditions found
must be identified. Then, community interventions must be designed to address the
identified needs through attention to the causes revealed. Evaluating project
effectiveness provides guidance for refining the intervention and expanding benefits to
other settings. The following hypothetical descriptions of community suicide prevention
activities have been created to illustrate applied public health and clinical management
prevention models.
Youth
Recognizing the states increasing rates of substance abuse and suicide among youth,
the state public health director in consultation with the Regional Health Administrator
brought together concerned representatives to form a state youth suicide, substance abuse
and depression prevention coalition. The coalition members reflected many sectors in the
community including suicide survivors, educators, social service agencies, the faith
community, businesses, the state cooperative extension programs (4-H), school
psychologists, child psychiatrists, the PTA, substance abuse treatment counselors, public
officials, and the juvenile justice system. The coalition also established a youth
advisory board.
After collecting detailed information on the dimensions of youth substance abuse,
depression and suicide in the state and identifying how few school systems had screening,
referral, and crisis plans, the coalition formed a multidisciplinary study committee to
develop a model suicide prevention plan. A broad array of public and professional
organizations in the state studied and endorsed the model plan. A corporate partner from
the business community provided a grant to distribute the model plan along with a
curriculum guide for natural helpers to identify high-risk youth. As school districts
adapted the plan and implemented it locally, followup surveys were conducted to determine
patterns of use, satisfaction with the model plan and guide, and impact on substance
abuse, depression and suicidal behaviors in communities statewide. Based on evidence
collected from the evaluations, the model plan was revised to include more guidance on
working with the media to de-sensationalize coverage of suicide, and promote abstinence
from substance use as well as encourage youth to seek treatment for both substance abuse
and depression.
The Elderly
The public health approach has revealed that suicide rates are highest among the elderly
and that most elderly suicide victims are seen by their primary care provider within a few
weeks of their suicide and are experiencing a first episode of mild to moderate
depression. Recognizing that clinical depression is a highly treatable illness, but
treatment has not yet been adequately provided in primary care settings, a state with a
large elderly population brought together a group of health professionals and community
advocates. Together they devised and supported a pilot program to follow depression
screening in the primary care setting with the addition of an on-site nurse or social
worker specializing in depression services. These on-site specialists ensured that those
elderly patients who screened positive for depression received depression treatment and
follow up from the physician and assessed patient progress so that ongoing treatments
could be adjusted to increase their effectiveness. Outcomes for patients in the pilot
project were compared to those patients receiving usual treatment in comparable primary
care settings. This evaluation provided information to fine tune the program and extend
its benefits to other primary care settings in the state.
Advancing a National Suicide Prevention Strategy
The 15 recommendations (AIM) presented in this Surgeon Generals Call to
Action propose a nationwide, collaborative effort to reduce suicidal behaviors,
and to prevent premature death due to suicide across the life span. The conceptual
framework for AIM incorporates analysis of suicide risk and protective factors and
emphasizes the benefits of effectively treating mental and substance abuse disorders. A
comprehensive National Strategy for Suicide Prevention should include these
elements along with supportive government policy, measurable objectives for the Strategy,
means of monitoring and evaluating progress, and provision of authority and resources to
carry out the Strategys recommendations.
To realize success in preventing suicide and suicidal behaviors, collaboration must be
fostered on this public health priority across a broad spectrum of agencies, institutions,
groups, and representative individuals throughout the country. As additional elements of a
comprehensive Strategy evolve, the public and prospective implementation partners
must also sustain awareness that improved detection and treatment of mental and substance
abuse disorders represent a primary approach to suicide prevention. These partners must
ensure the availability of evidence-based guidance for communities to develop and refine
effective suicide prevention approaches. Likewise, as communities implement approaches to
recognize and reduce risk factors to prevent suicide, they must be aware of the dangers of
inadvertently glamorizing suicide, and remain vigilant to avoid doing so. Ongoing review
of research, policy, and program advances in suicide prevention may expand the number of
effective initiatives and interventions for incorporation into the Strategy. Work
should continue that outlines measurable objectives for an overall Strategy,
provides mechanisms for tracking these objectives, and develops means of communicating
significant progress in preventing suicide and suicidal self-injury.
Conclusion
Americans in communities nationwide can make a significant difference in preventing
suicide and suicidal behaviors. The recommendations presented in AIM provide a
blueprint and call for action now. Programs and activities that are carried out and
evaluated today will generate additional recommendations for effective suicide prevention
initiatives in the future. Working together locally, in states, and at the federal level
to complete and implement a National Strategy for Suicide Prevention is an
important step in responding to the major public health problem of suicide in the United
States.
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Acknowledgements
Technical assistance and scientific consultation in the preparation of this document
was provided by the CDC, NIMH, Office of the Surgeon General and SAMHSA. Support for its
publication has been provided by the CDC, National Center for Injury Prevention and
Control. Support for the National Conference on Suicide Prevention in Reno, Nevada, 1998,
was provided in part by the Centers for Disease Control and Prevention (National Center
for Injury Prevention and Control), the Health Resources and Services Administration, the
National Institute of Mental Health, and the Substance Abuse and Mental Health Services
Administration (Center for Mental Health Services).
Written by Lucy Davidson, MD, EdS; Lloyd Potter, PhD, MPH; and Virginia Ross, PhD.
In collaboration with Virginia Trotter Betts, MSN, JD, RN, FAAN; Alex Crosby, MD, MPH;
CDR Robert DeMartino, MD; Rodney Hammond, PhD; Kay Jamison, PhD; Jane Pearson, PhD; RADM
Darrel Regier, MD, Elsie Weyrauch, RN; and Gerald Weyrauch, MBA.
Office of the Surgeon General scientific review and editing of this document was
provided by: RADM Susan J. Blumenthal, MD, MPA.
Members of the Conference Expert Panel: Morton M. Silverman, MD (Chairperson); Alex
Crosby, MD, MPH; Laurie Flynn; Dequincy A. Lezine; Jim Moore; Jane Pearson, PhD; Leslie
Scallet, JD; David Shaffer, MD; Scot Simpson; Susan Soule, MA; Karl F. Weyrauch, MD, MPH.
Last revised: January 4, 2007
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