Third-party callers to the national suicide prevention lifeline: Seeking assistance on behalf of people at imminent risk of suicide

OBJECTIVE

To assist suicidal individuals, people in their social network are often directed to the National Suicide Prevention Lifeline (Lifeline). The study's objective was to provide information on third-party calls made out of concern for another person.

METHOD

Reports on 172 third-party calls concerning individuals deemed to be at imminent suicide risk were completed by 30 crisis counselors at six Lifeline crisis centers.

RESULTS

Third-party callers were most likely to be calling about a family member or friend and were significantly more likely than persons at risk to be female and middle-aged or older. Counselors were able to collect information about suicide risk, and counselors and third-parties were nearly always able to identify at least one intervention to aid the person at risk. Emergency services were contacted on 58.1 percent of the calls, which represents a somewhat higher rate of emergency services involvement than previously reported on imminent risk calls placed by the person at risk. Characteristics of third-parties and persons-at-risk each predicted emergency service involvement, but counselor characteristics did not. Non-emergency interventions were implemented on 68.6 percent of calls.

CONCLUSIONS

Individuals calling the Lifeline when they are worried about someone are provided a range of interventions which can supplement, and at times replace, calling 911.

National Suicide Prevention Lifeline crisis chat interventions: Evaluation of chatters' perceptions of effectiveness

OBJECTIVE

As part of the National Suicide Prevention Lifeline's crisis response system, the Lifeline Crisis Chat Network (LCC) answers chats from hundreds of thousands of at-risk individuals yearly. The study's objective was to assess the effectiveness of these online crisis interventions.

METHOD

Data from 39,911 pre-chat surveys and 13,130 linked pre- and post-chat surveys completed by LCC chatters from October 2017-June 2018 were analyzed. The relationship of several effectiveness measures with chatter demographics, pre-chat distress, suicidal ideation, and chatters' perceptions of engagement with their counselors was examined using a series of logistic regression analyses.

RESULTS

Chatters were significantly and substantially less distressed at the end of the chat intervention than at the beginning. By the end of the chat, two-thirds of suicidal chatters reported that the chat had been helpful, while just under half reported being less suicidal.

CONCLUSIONS

Our study offers empirical evidence for the Lifeline's online crisis chat services' effectiveness, but also highlights areas for improvement. This is of critical import in light of the recent designation of 988 as the nationwide number for the Lifeline beginning in 2022, which will increase the Lifeline's prominence in providing suicide prevention and mental health crisis interventions in the United States.

Suicide mortality and related behavior following calls to the Veterans Crisis Line by Veterans Health Administration patients

OBJECTIVES

To assess outcomes for Veterans Health Administration (VHA) patients following calls to the Veterans Crisis Line (VCL).

METHODS

158,927 VHA patients had an initial VCL call in 2010-2015 with documented identifiers. Multivariable proportional hazards regressions assessed risks of suicide and suicide-related behavior through 12 months. Covariates included age, sex, region, mental health encounters in the prior year, time of day, weekday/weekend status, call outcome, and responder determination of caller risk.

RESULTS

Annualized suicide rates per 100,000 within 1, 3, 6, and 12 months were 797, 520, 387, and 298, respectively. Average age was 49.9 (SD = 15.2), 86.5% were male, 68.6% received mental health encounters in the prior year, and 5.9% had calls categorized as at high risk. Adjusting for covariates, suicide risk was greater among male callers and those with calls categorized as at high or moderate risk.

CONCLUSIONS

Veterans Crisis Line serves a high-risk population at a critical time. Rates were particularly high within one month and remained substantially elevated through 12 months. Findings have directly informed ongoing efforts to enhance coordination between VCL and VHA to support suicide prevention.

Physical activity, sedentary, and dietary behaviors associated with indicators of mental health and suicide risk

We used data from the 2017 national Youth Risk Behavior Survey to examine associations between physical activity, sedentary, and healthy dietary behaviors and indicators of mental health, suicidal thoughts, and suicidal attempts among a representative sample of US high school students. Sex-stratified logistic regression was used to separately model each mental health-related outcome on the health-related behaviors, while controlling for race/ethnicity, grade, and body weight status. Significant associations were found between insufficient physical activity, sedentary, and less healthy dietary behaviors and the mental health-related outcomes. Feeling sad and hopeless was associated with not eating breakfast on all 7 days (past week), drinking soda or pop (female only), not meeting the aerobic physical activity guideline (male only), not playing on at least one sports team, and playing video/computer games or using a computer more than two hours (per day). Suicidal thoughts were associated with not eating breakfast on all 7 days, drinking soda or pop, not meeting the aerobic physical activity guideline, and playing video/computer games or using a computer more than two hours per day. Attempted suicide was associated with not eating breakfast on all 7 days, drinking soda or pop, drinking sports drinks, watching television more than two hours per day, and playing video or computer games or using a computer more than two hours per day (male only). While limiting sedentary behaviors and increasing physical activity and healthy dietary behaviors is not a sole solution for improving mental health among adolescents, it could be another possible strategy used in schools to benefit all students.

Long-term impact of the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide mortality, 2006-2015

BACKGROUND

Comprehensive suicide prevention programs funded through the Garrett Lee Smith Memorial Youth Suicide Prevention Program (GLS) have previously been shown to be associated with lower youth suicide mortality rates 1 year following program implementation. However, longer term effects of GLS have yet to be examined.

METHODS

The impact of GLS implementation on youth suicide mortality through 2015 was estimated for U.S. counties initially exposed to state and tribal GLS activities between 2006 and 2009. The analytic approach combined propensity score-based techniques to address potential confounding arising from differences between counties exposed and not exposed to the program along an extensive set of characteristics, including historical suicide rates.

RESULTS

Counties exposed to GLS during a single year had youth suicide mortality rates lower than expected and for longer than previously reported following implementation of GLS activities. Youth suicide mortality rates in counties implementing GLS were estimated to be 0.9 per 100,000 youths lower than control counties (p = .029) 1 year after the implementation, and 1.1 per 100,000 youths lower than control counties (p = .010) 2 years after the implementation. Further, persistent implementation during multiple years was associated with larger effects during longer periods. Additionally, among rural counties, the youth suicide rates 2 years after exposure were estimated to be 2.4 per 100,000 youths lower than in the absence of the program (p = .003). There was no significant evidence of a decrease in youth suicide rates three or more years after the GLS activities were discontinued.

CONCLUSIONS

The effects of GLS comprehensive suicide prevention program were found to be stronger and longer lasting than previously reported, particularly in rural counties. In the face of well-documented increases in national suicide prevention rates, these results support the widespread and persistent implementation of comprehensive, community-based youth suicide prevention programs.

Examining the Unanticipated Adverse Consequences of Youth Suicide Prevention Strategies: A Literature Review with Recommendations for Prevention Programs

OBJECTIVE

Youth suicide is a public health problem in the United States. Suicide prevention programs have been shown to be beneficial; however, knowledge of unanticipated adverse consequences of programs is limited. The objective of this review is to present what is known about these consequences so informed decisions and appropriate planning can be made prior to implementation of suicide prevention interventions.

METHOD

A narrative but systematic review was conducted assessing what is known about adverse consequences utilizing a comprehensive keyword search of EBSCO and PubMed databases. Study populations beyond youth were included.

RESULTS

Unanticipated adverse consequences of suicide prevention interventions were included in 22 publications. Consequences occur at three levels: at the level of the youth, those who identify or intervene with at-risk youth, and at the system level. While rare, unanticipated adverse consequences include an increase in maladaptive coping and a decrease in help-seeking among program targets, overburden or increased suicide ideation among program implementers, and inadequate systemic preparedness.

CONCLUSIONS

Overall, the benefits of youth suicide prevention outweigh the unanticipated adverse consequences. Nevertheless, these results may be utilized for informed decision-making regarding suicide prevention programming, and to ensure appropriate infrastructure is in place prior to prevention efforts.

The Relationship Between Perceived Unmet Mental Health Care Needs and Suicidal Ideation and Attempt

This study utilizes data from the National Survey of Drug Use and Health (NSDUH) to analyze the relationship between perceived unmet mental health care needs and suicidal ideation and attempt. Estimates from multivariable logistic regression models suggest that individuals who report perceived unmet mental health care needs have higher probability of experiencing suicidal ideation and attempt. Perceived unmet mental health care need has an important association with suicidal ideation and attempt, and efforts aimed at improving access to care are needed to address this issue.

RISING SUN: Prioritized Outcomes for Suicide Prevention in the Arctic

The Arctic Council, a collaborative forum among governments and Arctic communities, has highlighted the problem of suicide and potential solutions. The mental health initiative during the United States chairmanship, Reducing the Incidence of Suicide in Indigenous Groups: Strengths United Through Networks (RISING SUN), used a Delphi methodology complemented by face-to-face stakeholder discussions to identify outcomes to evaluate suicide prevention interventions. RISING SUN underscored that multilevel suicide prevention initiatives require mobilizing resources and enacting policies that promote the capacity for wellness, for example, by reducing adverse childhood experiences, increasing social equity, and mitigating the effects of colonization and poverty.

Predictive utility of an emergency department decision support tool in patients with active suicidal ideation

Emergency department (ED) clinicians routinely decide the disposition of patients with suicidal ideation, with potential consequences for patient safety, liability, and system costs and resources. An expert consensus panel recently created a 6-item decision support tool for patients with passive or active suicidal ideation. Individuals scoring a 0 (exhibiting none of the tool's 6 items) are considered "lower risk" and suitable for discharge, while those with non-0 scores are considered "elevated risk" and should receive further evaluation. The current study tested the predictive utility of this tool using existing data from the Emergency Department Safety Assessment and Follow-up Evaluation. ED patients with active suicide ideation (n = 1368) were followed for 12 months after an index visit using telephone assessment and medical chart review. About 1 in 5 patients had attempted suicide during follow-up. Because of the frequency of serious warning signs and risk factors in this population, only three patients met tool criteria for "lower risk" at baseline. The tool had perfect sensitivity, but exceptionally low specificity, in predicting suicidal behavior within 6 weeks and 12 months. In logistic regression analyses, several tool items were significantly associated with suicidal behavior within 6 weeks (suicide plan, past attempt) and 12 months (suicide plan, past attempt, suicide intent, significant mental health condition, irritability/agitation/aggression). Although the tool did not perform well as a binary instrument among those with active suicidal ideation, having a suicide plan identified almost all attempters while suicide plan and past attempt identified over four-fifths of near-term attempts. (PsycINFO Database Record

Comparing the Effectiveness of Brief Versus In-Depth Gatekeeper Training on Behavioral Outcomes for Trainees

BACKGROUND

A common suicide prevention strategy is training gatekeepers to identify at-risk individuals and refer them to services.

AIMS

The study aimed to examine whether differences in training outcomes were observed for brief versus in-depth gatekeeper trainings for trainees from varied professional settings while controlling for differences in trainee characteristics and community context.

METHOD

Trainees' identification and referral behavior 3 months after gatekeeper training was compared with a sample of respondents matched on individual- and community-level variables using propensity score-based techniques. The value was estimated, in terms of additional identification and associated costs, of adopting in-depth training.

RESULTS

A higher proportion of trainees who participated in in-depth trainings from K-12 and community settings identified at-risk youth, and a higher proportion of in-depth trainees from mental health settings referred youth to services compared with participants of brief trainings from the same setting and with similar characteristics. The effect of training type on outcomes varied by professional role and community context.

LIMITATIONS

Self-report measures were used to assess outcomes. Similar measures are used in other studies; their validity has not been conclusively established.

CONCLUSION

Findings suggest certain individuals may benefit from in-depth training more than others, which favors targeting this intervention to particular gatekeepers.

An Economic Evaluation of the Garrett Lee Smith Memorial Suicide Prevention Program

For more than a decade, the Garrett Lee Smith Youth Suicide Prevention Program has provided funding for community-based suicide prevention programs to states, tribes, and colleges across the United States. Recent studies provided evidence of the program's effectiveness in reducing suicide mortality and suicide attempts among youth. This study compares the cost of implementing the program with the estimated savings resulting from avoided hospitalization and emergency department visits associated with the averted suicide attempts. The findings suggest that the cost of implementing multifaceted community-based suicide prevention strategies may be more than outweighed by savings in the health sector.

Follow-up with Callers to the National Suicide Prevention Lifeline: Evaluation of Callers' Perceptions of Care

Continuity of care for suicidal individuals engaged with a variety of health and mental health care systems has become a national priority, and crisis hotlines are increasingly playing a part in the risk management and continuum of care for these individuals. The current study evaluated a national initiative to have crisis centers in the National Suicide Prevention Lifeline network provide follow-up care to suicidal callers. Data were obtained from 550 callers followed by 41 crisis counselors from 6 centers. Two main data sources provided the information for the current study: a self-report counselor questionnaire on the follow-up activities completed on each clinical follow-up call and a telephone interview with follow-up clients, providing data on their perceptions of the follow-up intervention's effectiveness. The majority of interviewed follow-up clients reported that the intervention stopped them from killing themselves (79.6%) and kept them safe (90.6%). Counselor activities, such as discussing distractors, social contacts to call for help, and reasons for dying, and individual factors, such as baseline suicide risk, were associated with callers' perceptions of the impact of the intervention on their suicide risk. Our findings provide evidence that follow-up calls to suicidal individuals can reduce the perceived risk of future suicidal behavior.

National Trends in the Prevalence of Suicidal Ideation and Behavior Among Young Adults and Receipt of Mental Health Care Among Suicidal Young Adults

OBJECTIVE

This study examined national trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults.

METHOD

We examined restricted data from 145,800 persons aged 18 to 25 years who participated in the 2009 to 2015 National Surveys on Drug Use and Health. Descriptive analyses and bivariable and multivariable logistic regressions were applied.

RESULTS

Among US young adults during 2009 to 2015, the 12-month prevalence of suicidal ideation increased from 6.1% to 8.3%, the 12-month prevalence of suicide plan increased from 2.0% to 2.7%, and 12-month prevalence of suicide attempt increased from 1.1% to 1.6%. After adjusting for personal factors and changes in residing county's population characteristics, we found upward trends in suicidal ideation among non-Hispanic whites and Hispanics, an upward trend in suicide plan among young adults overall, and an upward trend in suicide attempt among those without major depressive episodes (MDE). Among young adults with MDE, the prevalence of suicide attempt remained high and unchanged. During 2009 to 2015, trends in receipt of mental health care remained unchanged among most suicidal young adults and declined slightly among uninsured suicidal young adults. The annual average prevalence of receipt of mental health care was 36.2% among suicidal young adults.

CONCLUSION

During 2009 to 2015, suicidal ideation, suicide plan, and suicide attempt increased among young adults overall, but receipt of mental health care among suicidal young adults did not increase. Our results suggest that effective efforts are needed for suicide prevention and promotion of mental health care among young adults.

Service Use in the Month and Year Prior to Suicide Among Adults Enrolled in Ohio Medicaid

OBJECTIVES

The purpose of this study was to inform suicide prevention efforts by estimating the incidence of suicide among adult Medicaid enrollees and describing clinical profiles and service utilization patterns among decedents.

METHODS

Death certificate data for adults (N=1,338) ages 19 to 65 who died by suicide between January 1, 2008, and December 31, 2013, were linked with Ohio Medicaid data.

RESULTS

The suicide rate was 18.9 deaths per 100,000 Ohio Medicaid enrollees. Most decedents (83%) made a general medical or mental health visit within one year of suicide, with 50% doing so within 30 days and 27% within one week before death. In the year before suicide, the median number of visits was 16, indicating a subgroup with intensive service utilization. Decedents whose visits were proximal to suicide (within 30 days) rather than distal (31-365 days) were more likely to have individual and co-occurring behavioral and general medical conditions and to be Medicaid eligible through disability. In the year before suicide, most visits (79%) were outpatient general medical visits. Also in the year before suicide, decedents with serious psychiatric disorders were more likely than those without such disorders to make only mental health visits, and those with chronic general medical conditions were more likely than those without such conditions to make only general medical visits.

CONCLUSIONS

Medicaid enrollment designates a "virtual boundary" around a subpopulation of health care consumers relevant to national suicide prevention efforts. Findings highlight the potential of using Medicaid data to identify individuals at risk of suicide for screening, prevention, and intervention.

Estimating the rates of deaths by suicide among adults who attempt suicide in the United States

BACKGROUND

In 2012, over 1.3 million U.S. adults reported that they attempted suicide in the past year, and 39,426 adults died by suicide. This study estimated national suicide case fatality rates among adult suicide attempters (fatal and nonfatal cases) and examined how they varied by sociodemographic characteristics.

METHODS

We pooled data on deaths by suicide (n = 147,427, fatal cases in the U.S.) from the 2008-2011 U S. mortality files and data on suicide attempters who survived (n = 2000 nonfatal cases) from the 2008-2012 National Surveys on Drug Use and Health. Descriptive analyses and multivariable logistic regression models were applied.

RESULTS

Among adult suicide attempters in the U.S., the overall 12-month suicide case fatality rate was 3.2% (95% confidence interval (CI) = 2.9%-3.5%). It varied significantly by sociodemographic factors. For those aged 45 or older, the adjusted suicide case fatality rate was higher among men (7.6%) than among women (2.6%) (suicide case fatality rate ratio (SCFRR) = 3.0, 95% CI = 1.83-4.79), was higher among non-Hispanic whites (7.9%) than among non-white minorities (0.8-2.5%) (SCFRRs = 3.2-9.9), and was higher among those with less than high school education (16.0%) than among college graduates (1.8%) (SCFRR = 8.8, 95% CI = 3.83-20.16). Across male and female attempters, being aged 45 or older and non-Hispanic white and having less than secondary school were at a higher risk for death by suicide.

CONCLUSIONS

Focusing on these demographic characteristics can help identify suicide attempters at higher risk for death by suicide, inform clinical assessments, and improve suicide prevention and intervention efforts by increasing high-risk suicide attempters' access to mental health treatment.

Prevalence and Mental Health Treatment of Suicidal Ideation and Behavior Among College Students Aged 18-25 Years and Their Non-College-Attending Peers in the United States

OBJECTIVE

College students have been the focus of many studies on suicidal ideation with or without suicidal behavior. Little attention has been given to their non-college-attending peers on these issues. We examined the 12-month prevalence and mental health treatment of suicidal ideation with or without suicidal behavior among college students aged 18-25 years and their non-college-attending peers in the United States.

METHODS

We assessed data from 135,300 persons aged 18-25 years who participated in the 2008-2013 National Surveys on Drug Use and Health. Descriptive analyses and multivariate logistic regression models were applied.

RESULTS

Compared with full-time college students, high school students, those not enrolled in a school or college, and part-time college students were more likely to attempt suicide with a plan (model-adjusted prevalence = 0.67% vs 1.09%, 1.06%, and 1.07%, respectively). The mental health treatment rate among full-time college students with suicidal ideation with or without suicidal behavior was similar to the rates among the other 3 counterparts. The effects of race/ethnicity and serious mental illness on receipt of mental health treatment were significantly larger among those who did not perceive unmet treatment need than among those who perceived unmet treatment need (P = .019 and P = .001, respectively).

CONCLUSIONS

Compared to full-time college students, non-college-attending young adults and part-time college students were at higher risk for attempting suicide with a plan. Suicide prevention and intervention strategies should emphasize increasing access to mental health treatment among both college students with suicidal ideation with or without suicidal behavior and their non-college-attending peers (particularly among minorities and those who seem to be at low risk because they are without serious mental illness and report no need for mental health treatment).

Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: Evaluation of Caller Risk Profiles and Interventions Implemented

Crisis lines are settings where identifying individuals at imminent risk of suicidal behavior and intervening to keep them safe are critical activities. We examined clinical characteristics of crisis callers assessed by telephone crisis helpers as being at imminent risk of suicide, and the interventions implemented with these callers. Data were derived from 491 call reports completed by 132 helpers at eight crisis centers in the National Suicide Prevention Lifeline network. Helpers actively engaged the callers in collaborating to keep themselves safe on 76.4% of calls and sent emergency services without the callers' collaboration on 24.6% of calls. Four different profiles of imminent risk calls emerged. Caller profiles and some helper characteristics were associated with intervention type. Our findings provide a first step toward an empirical formulation of imminent risk warning signs and recommended interventions.

Characteristics of U.S. Mental Health Facilities That Offer Suicide Prevention Services

OBJECTIVE

This study characterized mental health facilities that offer suicide prevention services or outcome follow-up after discharge.

METHODS

The study analyzed data from 8,459 U.S. mental health facilities that participated in the 2010 National Mental Health Services Survey. Logistic regression analyses were used to compare facilities that offered neither of the prevention services with those that offered both or either service.

RESULTS

About one-fifth of mental health facilities reported offering neither suicide prevention services nor outcome follow-up. Approximately one-third offered both, 25% offered suicide prevention services only, and 21% offered only outcome follow-up after discharge. Facilities that offered neither service were less likely than facilities that offered either to offer comprehensive support services or special programs for veterans; to offer substance abuse services; and to be accredited, licensed, or certified.

CONCLUSIONS

Further examination of facilitators and barriers in implementing suicide prevention services in mental health facilities is warranted.

Effect of the Garrett Lee Smith Memorial Suicide Prevention Program on Suicide Attempts Among Youths

IMPORTANCE

Youth suicide prevention is a major public health priority. Studies documenting the effectiveness of community-based suicide prevention programs in reducing the number of nonlethal suicide attempts have been sparse.

OBJECTIVE

To determine whether a reduction in suicide attempts among youths occurs following the implementation of the Garrett Lee Smith Memorial Suicide Prevention Program (hereafter referred to as the GLS program), consistent with the reduction in mortality documented previously.

DESIGN, SETTING, AND PARTICIPANTS

We conducted an observational study of community-based suicide prevention programs for youths across 46 states and 12 tribal communities. The study compared 466 counties implementing the GLS program between 2006 and 2009 with 1161 counties that shared key preintervention characteristics but were not exposed to the GLS program. The unweighted rounded numbers of respondents used in this analysis were 84 000 in the control group and 57 000 in the intervention group. We used propensity score-based techniques to increase comparability (on background characteristics) between counties that implemented the GLS program and counties that did not. We combined information on program activities collected by the GLS national evaluation with information on county characteristics from several secondary sources. The data analysis was performed between April and August 2014. P < .05 was considered statistically significant.

EXPOSURES

Comprehensive, multifaceted suicide prevention programs, including gatekeeper training, education and mental health awareness programs, screening activities, improved community partnerships and linkages to service, programs for suicide survivors, and crisis hotlines.

MAIN OUTCOMES AND MEASURES

Suicide attempt rates for each county following implementation of the GLS program for youths 16 to 23 years of age at the time the program activities were implemented. We obtained this information from the National Survey on Drug Use and Health administered to a large national probabilistic sample between 2008 and 2011.

RESULTS

Counties implementing GLS program activities had significantly lower suicide attempt rates among youths 16 to 23 years of age in the year following implementation of the GLS program than did similar counties that did not implement GLS program activities (4.9 fewer attempts per 1000 youths [95% CI, 1.8-8.0 fewer attempts per 1000 youths]; P = .003). More than 79 000 suicide attempts may have been averted during the period studied following implementation of the GLS program. There was no significant difference in suicide attempt rates among individuals older than 23 years during that same period. There was no evidence of longer-term differences in suicide attempt rates.

CONCLUSIONS AND RELEVANCE

Comprehensive GLS program activities were associated with a reduction in suicide attempt rates. Sustained suicide prevention programming efforts may be needed to maintain the reduction in suicide attempt rates.

Identifying and Referring Youths at Risk for Suicide Following Participation in School-Based Gatekeeper Training

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

Helping callers to the National Suicide Prevention Lifeline who are at imminent risk of suicide: the importance of active engagement, active rescue, and collaboration between crisis and emergency services

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

Impact of the Garrett Lee Smith youth suicide prevention program on suicide mortality

OBJECTIVES

We examined whether a reduction in youth suicide mortality occurred between 2007 and 2010 that could reasonably be attributed to Garrett Lee Smith (GLS) program efforts.

METHODS

We compared youth mortality rates across time between counties that implemented GLS-funded gatekeeper training sessions (the most frequently implemented suicide prevention strategy among grantees) and a set of matched counties in which no GLS-funded training occurred. A rich set of background characteristics, including preintervention mortality rates, was accounted for with a combination of propensity score-based techniques. We also analyzed closely related outcomes that we did not expect to be affected by GLS as control outcomes.

RESULTS

Counties implementing GLS training had significantly lower suicide rates among the population aged 10 to 24 years the year after GLS training than similar counties that did not implement GLS training (1.33 fewer deaths per 100 000; P = .02). Simultaneously, we found no significant difference in terms of adult suicide mortality rates or nonsuicide youth mortality the year after the implementation.

CONCLUSIONS

These results support the existence of an important reduction in youth suicide rates resulting from the implementation of GLS suicide prevention programming.

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

OBJECTIVE

To examine the prevalence and correlates of attempting suicide in the past 12 months among adults with past-year suicidal ideation in the United States.

METHOD

Data were from 229,600 persons aged 18 years or older who participated in the 2008-2012 National Survey on Drug Use and Health. Among them, 12,300 reported having past-year suicidal ideation, and over 2,000 of those reported attempting suicide within the past 12 months prior to survey interview. Descriptive analyses and pooled and stratified (by suicide plan and major depressive episode [MDE]) multivariate logistic regression models were applied. Major depressive episode was based on assessments of individual diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

RESULTS

Among persons aged 18 years or older in the United States, 3.8% reported having suicidal ideation in the past 12 months. Among past-year suicidal ideators, 13.2% attempted suicide in the past 12 months. The prevalence of past 12-month suicide attempt among past-year ideators with MDE was higher than among those without MDE (14.1% vs 12.0%). Past 12-month suicide attempt was more common among ideators with a suicide plan than among ideators without a plan (37.0% vs 3.7%). However, the prevalence of suicide attempt was higher among ideators with a plan but without MDE than among ideators with a plan and MDE (42.1% vs 32.9%). Compared with ideators without a plan, ideators with a plan had a higher (adjusted odds ratio [AOR] = 2.2; 95% confidence interval [CI], 1.47-3.45) suicide attempt risk among those without MDE (AOR = 22.4; 95% CI,16.55-30.27) than among those with MDE (AOR = 10.7; 95% CI, 7.91-14.49).

CONCLUSIONS

Among adult suicidal ideators, factors associated with their progression from ideation to suicide attempt may vary by their suicide plan and major depression status. Focusing attention on high-risk subgroups may be warranted.

Mental health treatment patterns among adults with recent suicide attempts in the United States

OBJECTIVES

We examined mental health treatment patterns among adults with suicide attempts in the past 12 months in the United States.

METHODS

We examined data from 2000 persons, aged 18 years or older, who participated in the 2008 to 2012 National Survey on Drug Use and Health and who reported attempting suicide in the past 12 months. We applied descriptive analyses and multivariable logistic regression models.

RESULTS

In adults who attempted suicide in the past year, 56.3% received mental health treatment, but half of those who received treatment perceived unmet treatment needs, and of the 43.0% who did not receive mental health treatment, one fourth perceived unmet treatment needs. From 2008 to 2012, the mental health treatment rate among suicide attempters remained unchanged. Factors associated with receipt of mental health treatment varied by perceived unmet treatment need and receipt of medical attention that resulted from a suicide attempt.

CONCLUSIONS

Suicide prevention strategies that focus on suicide attempters are needed to increase their access to mental health treatments that meet their needs. To be effective, these strategies need to account for language and cultural differences and barriers to financial and treatment delivery.

The return on investment of postdischarge follow-up calls for suicidal ideation or deliberate self-harm

OBJECTIVE

Transitions of care are critical for individuals at risk of suicide. This study determined the return on investment (ROI) for providing postdischarge follow-up calls to patients at risk of suicide who are discharged from a hospital or an emergency department.

METHODS

Claims data were from the 2006-2011 Truven Health MarketScan Commercial Claims and Encounters Database and Multi-State Medicaid Database. Cost estimates were from eight call centers that provide postdischarge follow-up calls. The ROI was estimated for the 30 days after discharge and was calculated from a payer's perspective (return gained for every $1 invested). One-way and probabilistic sensitivity analyses were used to examine the influence of variations of ROI model inputs.

RESULTS

Under base case assumptions, the estimated ROI was $1.76 for commercial insurance and $2.43 for Medicaid for patients discharged from a hospital and $1.70 for commercial insurance and $2.05 for Medicaid for those discharged from an emergency department. Variation in the effect size of postdischarge contacts on reducing readmission had the largest effect on the ROI, producing a range from $0 to $4.11. The ROI would be greater than $1 for both payers and across both discharge settings as long as postdischarge contact could reduce readmission by at least 13.3%. Sensitivity analyses indicated a 77% probability (commercial) and an 88% probability (Medicaid) that the ROI would be greater than $1 among hospital discharges; the probabilities among emergency department discharges were 74% (commercial) and 82% (Medicaid).

CONCLUSIONS

The study supports the business case for payers, particularly Medicaid, to invest in postdischarge follow-up calls.

Suicidal ideation among community-dwelling adults in the United States

OBJECTIVES

We examined the prevalence and correlates of past-year suicidal ideation among US community-dwelling adults.

METHODS

We examined data from 183 100 persons aged 18 years or older (including 9800 sampled adults with past-year suicidal ideation) who participated in the 2008-2011 National Survey on Drug Use and Health. We applied descriptive analyses and pooled and stratified (by age and major depression) multivariate logistic regression models.

RESULTS

The prevalence of past-year suicidal ideation among younger adults (6.6% among those aged 18-25 years and 4.0% among those aged 26-49 years) was higher than was that among adults aged 50 years or older (2.5%). The prevalence of suicidal ideation was high among adults with major depression (26.3%), adults with both major depression and substance use disorder (37.7%), and adults who received mental health treatment but perceived unmet treatment need (33.5%).

CONCLUSIONS

Many risk and protective factors of suicidal ideation are dynamic and vary by age or major depression. These results have important implications for developing specific suicide prevention strategies that help screen, assess, and treat suicidal adults at the earliest possible time.

Suicide risk protocols: addressing the needs of high risk youths identified through suicide prevention efforts and in clinical settings

Several agencies have emphasized the importance of establishing clear protocols or procedures to address the needs of youths who are identified as suicidal through suicide prevention programs or in emergency department settings. What constitutes optimal guidelines for developing and implementing such protocols, however, is unclear. At the request of the Substance Abuse and Mental Health Services Administration, we provide an overview of recommendations, as well as steps taken in conjunction with selected prevention programs and in emergency department settings to address the needs and improve the care of these youths.

Implementation and early utilization of a Suicide Hotline for veterans

Suicide crisis lines have a respected history as a strategy for reducing deaths from suicide and suicidal behaviors. Until recently, however, evidence of the effectiveness of these crisis lines has been sparse. Studies published during the past decade suggest that crisis lines offer an alternative to populations who may not be willing to engage in treatment through traditional mental health settings. Given this promising evidence, in 2007, the Department of Veterans Affairs in collaboration with the Department of Health and Human Services' Substance Abuse and Mental Health Administration implemented a National Suicide Hotline that is staffed 24 hours a day, 7 days a week, by Veterans Affairs clinical staff. We report here on the implementation of this suicide hotline and our early observations of its utilization in a largely male population.

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

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

The Garrett Lee Smith memorial suicide prevention program

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

Establishing standards for the assessment of suicide risk among callers to the national suicide prevention lifeline

The National Suicide Prevention Lifeline was launched in January 2005. Lifeline, supported by a federal grant from the Substance Abuse and Mental Health Services Administration, consists of a network of more than 120 crisis centers located in communities across the country that are committed to suicide prevention. Lifeline's Certification and Training Subcommittee conducted an extensive review of research and field practices that yielded the Lifeline's Suicide Risk Assessment Standards. The authors of the current paper provide the background on the need for these standards; describe the process that produced them; summarize the research and rationale supporting the standards; review how these standard assessment principles and their subcomponents can be weighted in relation to one another so as to effectively guide crisis hotline workers in their everyday assessments of callers to Lifeline; and discuss the implementation process that will be provided by Lifeline.