127 Suicide prevention in the United States of America

In May 1993, the United Nations convened a meeting of fifteen experts from twelve countries (Australia, Canada, China, Estonia, Finland, Hungary, India, Japan, Netherlands, Nigeria, United Arab Emirates and the United States) to draft guidelines for the development of national strategies for the prevention of suicidal behaviours (Ramsay and Tanney 1996). These guidelines were subsequently published as Prevention of suicide: guidelines for the formulation and implementation of national strategies (United Nations 1996).

The UN Guidelines emphasized that the development of a national strategy required:

In 1997, following the United Nations Guidelines, advocates pressed for resolutions to be introduced in the 105th Congress of the United States to recognize suicide as a national problem, worthy of a national solution, and calling for the development of a national strategy. Both resolutions specifically urged the development of ‘an effective national strategy for the prevention of suicide’, and were critical steps in moving suicide prevention efforts in the United States forward.

In July 1997, the Centers for Disease Control and Prevention established two new injury control research centers, one to focus specifically on suicide. At approximately the same time, Dr David Satcher, the newly appointed Surgeon General of the United States, stated his intention to ensure that mental health and suicide prevention would be addressed during his tenure as the senior public health official in the USA. Soon thereafter, dedicated public servants and private individuals jointly organized and participated in the first National Suicide Prevention Conference held in 1998 in Reno, Nevada, to consolidate a scientific base for crafting a national suicide prevention strategy. Over 450 advocates, researchers, public servants, policy-makers, clinicians, survivors and countless others gathered and made recommendations that led to the Surgeon General's Call to action to prevent suicide, published in 1999 (USPHS 1999).

The Call to Action proposed a conceptual foundation designated as ‘AIM’:

The AIM framework included 15 recommendations derived from consensus-based and evidence-based findings intended to serve as a foundation for a more comprehensive National Strategy for Suicide Prevention.

In 2001, the National strategy for suicide prevention: goals and objectives for action, was published by the US Department of Health and Human Services (USDHHS 2001). This document, containing eleven goals and sixty-eight objectives, became the roadmap for effectively addressing the public health problem of suicide in the United States. Calling on representatives from government, business and charitable organizations to work together to prevent suicide, multiple sectors, trade associations, industries, professional groups and others were identified as having a role to play. Among some of the key organizations that were already active in suicide prevention, and supported the Strategy, was the American Association of Suicidology, American Foundation for Suicide Prevention, Suicide Prevention Action Network USA (SPAN USA), The Jed Foundation, Yellow Ribbon, and the National Council for Suicide Prevention.

While the National Strategy (NSSP) did not mandate action, it served as a model for states to follow as efforts were advanced nationally to address suicide. Today, forty-six of fifty states have developed a state strategy to prevent suicide, and many state legislatures have passed laws or resolutions to prevent suicide in their state. Many have funded the establishment of State Offices of Suicide Prevention.

One of the first tangible results of the NSSP was a federal appropriation in 2002 of $7.5 million over three years to establish a National Suicide Prevention Resource Center (SPRC), in Newton, Massachusetts. The mission of the centre would be to provide technical assistance to stakeholders, gather information on best practices, and serve as a clearing house for suicide prevention information and programmes. SPRC promotes the implementation of the NSSP and enhances the nation's mental health infrastructure by providing states, government agencies, private organizations, colleges and universities, and suicide survivor and mental health consumer groups with access to the science and experience that can support their efforts to develop programmes, implement interventions, and promote policies to prevent suicide.

In 2002, the Institute of Medicine of the National Academies of Science published Reducing suicide: A national imperative, which called for more research into the causes of suicide and interventions that work to prevent suicide (IOM 2002). In 2003 the President's New Freedom Commission on mental health report was released and the very first recommendation focused on suicide prevention as a key element of a comprehensive mental health system (PNFCMH 2003). This acknowledgement ensured that suicide prevention had carried from one presidential administration to another as a key item on the health public policy agenda.

On 21 October 2004, President Bush signed the Garrett Lee Smith Memorial Act (Public Law 108–355) providing an $82 million authorization for youth suicide prevention and early identification programmes. In addition to providing grants to states and tribal communities to advance their youth sui-cide-prevention efforts, grants would be made available to colleges and universities to enhance their behavioural health capacity to address campus suicide and its prevention. To date, 59 states and tribal communities have received federal grants up to $400,000 per year for youth suicide prevention efforts and, in addition, 64 colleges have received grants to develop campus-wide suicide prevention programmes. This law represented the first-ever federal funding for youth suicide-prevention in the United States.

In 2004 the federal government established a grant to launch a National Suicide Prevention Lifeline. This initiative supports a national network of local crisis centres that have the capacity to accept calls from those who may be in suicidal crisis. By dialling one national number callers are seamlessly connected to the crisis centre closest to where they are calling from. Once connected, crisis intervention is provided by trained staff and volunteers located in nationally certified crisis centres.

In 2006, the Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), a federal agency under the Department of Health and Human Services, designated suicide prevention as a programme and policy priority for the agency. By doing so, suicide prevention would now be incorporated into the fabric of the agency and concrete steps to advance suicide-prevention efforts would be taken. In 2007, a similar effort was taken at the Department of Health and Human Services, when the Department's five-year strategic plan was amended to include suicide prevention as one of the Department's core prevention measures, and establishing the national goal of reducing suicide deaths by six per cent by 2012. With the annual toll of deaths by suicide at approximately 31,000, this translates to a reduction of nearly 2,000 suicide deaths by 2012.

In 2007, Congress passed the Joshua Omvig Veteran Suicide Prevention Act (Public Law 110–110), directing the Department of Veterans Affairs to reduce the incidence of suicide among veterans of military service, make available 24-hour mental health care for veterans found to be at risk, and develop an outreach and education programme for veterans and their families to identify readjustment problems and promote mental health. With data suggesting 20 per cent of suicidal deaths in the United States are veterans of all ages, public policy attention has shifted to include suicide prevention efforts for this at-risk population.

Since 1996, suicide-prevention efforts in the USA have been steadily advanced. With efforts focusing on youth suicide-prevention, veterans suicide-prevention and establishing a national resource centre and a national suicide-prevention lifeline, attention needs to be directed at better suicide-prevention research, older adult suicide-prevention, and the formation of a coordinating body called for in the United Nations guidelines to oversee the implementation and advancement of the NSSP. It is expected that the National Action Alliance for Suicide Prevention will be launched in 2009, bringing together representatives from the public, private and philanthropic sectors to bring focus, resolve and national attention to advancing the objectives in the NSSP. This initiative will move the NSSP objectives from paper to practice by monitoring, guiding, coordinating and promoting suicide prevention efforts across the country.

Suicide prevention in the USA over the last decade has made significant progress. Our success is determined more by the collaborative approach we have taken, leveraging broad national investments to support local and grassroots efforts. No one sector, agency or non-governmental organization can single-handedly prevent suicide. Instead, it takes a community to prevent suicide and the work of all committed to saving lives through suicide-prevention efforts if we are to reduce the mortality and morbidity associated with the preventable public health problem of suicide. Our approach in the United States has not been to mandate or legislate action but to inspire and promote action at all levels. While our work is far from complete, the suicide-prevention movement in the United States continues to make progress.