Health Departments’ Strategies to Address Suicides

Posted on February 1, 2024 by Jocelyn Leung

This entry is part 41 of 63 in the series Wide World of Public Health Systems

In August 2023, the CDC reported that around 49,499 people died by suicide in the United States in 2022. This is 2.6% higher than the estimated 48,183 suicide deaths reported in 2021.^[1] For comparison, 48,183 deaths in 2021 translated to one death for every eleven minutes.^[2] When reflecting on this new statistic, Xavier Becerra, the United States Secretary of Health and Human Services, remarked, “Nine in ten Americans believe America is facing a mental health crisis. The new suicide death data reported by CDC illustrates why. One life lost to suicide is one too many. Yet, too many people still believe asking for help is a sign of weakness. [….] We must continue to eliminate the stigmatization of mental health and make care available to all Americans.”^[3]

All along, local and state health departments have been following Becerra’s advice by implementing strategies to reduce suicide deaths. Many of these strategies can be found in their community health improvement plans (CHIP) or state health improvement plans (SHIP), which are “long-term, systematic effort[s] to address public health problems” based on what health departments have identified as “key health needs and issues through systematic, comprehensive data collection and analysis” within their jurisdiction.^[4] These strategies for addressing suicide are so popular that I was able to find examples of them from random Google Searches in the fall of 2023 from the following states: Arizona, Connecticut, Georgia, Idaho, Illinois, Indianna, Louisiana, Maryland, Minnesota, Mississippi, Montana, North Dakota, Ohio, Oregon, Rhode Island, Tennessee, Utah, Virginia, and Wyoming.

While what I found is by no means representative of all the activities that local and state health departments are carrying out to address suicidal behaviors (“i.e., intentional self-harm with suicidal intent”); suicidal ideation (“i.e., thoughts about killing oneself with or without intent”); and deaths by suicide, there are some common strategies that came up repeatedly across different states, jurisdictions, and populations.^[5] Outside of addressing stigma around suicide, there were fewer strategies aimed at the upstream “social/environmental factors” that disproportionately put some social groups at higher risk for death by suicides than the general population.^[6] For instance, many occupations, such as mining or farming, that are associated with higher suicide rates are concentrated in rural areas, and yet there was a lack of occupation-specific strategies, like the ones that the Minnesota Department of Agriculture carry out (e.g., helplines staffed by mental health professionals equipped to understand the unique stressors, like market uncertainties and social isolation, that farmers face).^[7]

Common categories of solutions to address suicide and suicidal ideation

Most local and state health departments choose to concentrate on downstream solutions, or those targeting individual behavioral change (e.g., “beliefs and self-efficacy” associated with changing our habits) that could be informed by societal pressure, like stigma.^[8] These downstream strategies reflect popular theories on suicide that identify the risk factors for suicidal ideation or behavior. These models often emphasize screening and treatment solutions for those with severe mental illness or substance use disorders; those expressing maladaptive thinking patterns (i.e., perceiving oneself as a burden on others); expressing unmet emotional needs (e.g., ability to connect with others or feeling isolated); having exposure to prior and ongoing stress and trauma (e.g., childhood maltreatment or money problems); having biological risk factors (e.g., genetics or inflammation affecting neurotransmitter systems); and having “access to lethal means” (e.g., guns or poison).^[9] At the community or societal level, many of these downstream strategies prefer to target specific cultural silences and stigmas surrounding mental illness, substance use, and suicide rather than addressing socially constructed root causes, such as income inequities or “societal discrimination against race.”^[10]

With this framework in mind, the CHIPs and SHIPs I reviewed most frequently concentrated on helping frontline professionals better meet the needs of people who are suicidal; increasing suicidal screening within their jurisdiction; increasing access to clinical treatments and community programs for both people who are suicidal and bereaved friends or family members of a suicide victim; and reducing social stigma by increasing the general public’s understanding. For instance, one way of increasing public understanding of suicide is through enrolling people in standardized education programs, like Mental Health First Aid (MHFA), which not only counters social stigma surrounding suicide, mental illness, and substance use disorders but also helps participants on how to approach and support those who are suicidal or in distress.^[11] In Table 1 below, I have identified exemplary strategies that fit each of these categories and illustrate the detail and community partnerships that many health departments are holding themselves accountable to carrying out to address local suicide rates.

Table 1. Exemplary downstream solutions in CHIPs and SHIPs

Category	Governmental Public Health Department	Goal	Strategies	Shared characteristics within each category
Better equipping frontline professionals with evidence-based suicide prevention training	Clark County Community Health Improvement Plan 2020-2022 [Ohio]	Reduce the rate (number of cases per 100,000) of suicide deaths from 19.6 to 15.2 by December 31, 2022.	– Question. Persuade. Respond. (QPR) trainings will be offered to 3 organizations that serve the elderly (65+) population by December 31, 2022. -Question. Persuade. Respond. (QPR) trainings will be offered to 3 organizations that serve the male 45-64 population by December 31, 2022.	-Popular trainings include Mental Health First Aid and Question, Persuade, Refer (QPR) Suicide Prevention training. QPR is a 3 step process captured in its name, and more information can be found here.
	Tooele County Community Health Improvement Plan (CHIP) 2018-2022 [Utah]	Increase prevention and early intervention for mental health, suicidal ideations and substance misuse and abuse.	Offer QPR training to the public and local businesses and agencies including, but not limited to; Valley Behavioral Health, Mountain West Medical Center and ambulance, Tooele County Health Department, Tooele City, and Tooele County School District.

Suicide screening or ability to identify suicide risk by professionals	Clark County Community Health Improvement Plan 2020-2022 [Ohio]	Reduce the rate (number of cases per 100,000) of suicide deaths from 19.6 to 15.2 by December 31, 2022.	Clark County School Districts will identify and implement an evidence-based Suicide Prevention screening tool by December 31, 2022.	-CHIPs in Ohio, Illinois, Minnesota, Indiana, and Montana include screening strategies targeted at youth and in school settings.^[12]
	2018-2020 Boone County Community Health Improvement Plan (CHIP) [Indiana]	Reduce suicide rate in Boone County to 12.7 or lower by 2020 through implementation and promotion of evidence-based programs.	Collaborate with School Resource Officers in Boone County to identify at-risk persons

Easier and earlier access to clinical treatments in health care settings	Arizona Health Improvement Plan Summary Document 2021-2025	Reduce suicide-related events.	-Increase access to health management resources with a particular focus on remote options (telehealth therapy/ psychiatry/ addiction groups, mental health first aid, etc.) -Implement suicide prevention strategies in a manner that ensures cultural humility and health equity are a priority.	-Investigating how to bring treatment options to where people are (e.g., telehealth or at schools). -Increasing cross-cultural awareness of health care staff to work with patients from different racial/ethnic and socioeconomic backgrounds than them.
	Community Health Improvement Plan Pierce County 2020 [Washington]	Support wellbeing by increasing availability of and access to services.	-Pass .01% sales tax for mental health services. -Evaluate role of school-based health clinics to deliver primary care and behavioral health services for K-12 students.
	Fulton County Strategic Plan 2016-2019 [Georgia]	The rates of disease and unhealthy medical conditions are reduced ● Suicide rate	-Pro-actively promote the availability of County health care services and how to access them. -Provide welcoming, effective, and culturally-competent care by well-trained staff. -Seek appropriate reimbursement from public and private insurers and, in some cases, the patients themselves; assist County residents to enroll in health insurance for they are eligible. -Continue to adapt to changing trends such as integrated care models, tele-medicine, and mobile care delivery.

Easier and earlier access to community programs for those at risk for suicide	2020-2023 Washington County Community Health Improvement Plan [Oregon]	Decrease the overall suicide rate in Washington County by 10% between 2018 and 2023 to a rate of 9.4 per 100,000 people.	-Integrate and coordinate suicide prevention activities across multiple sectors and settings. -Promote efforts to reduce access to lethal means of suicide among individuals with identified suicide risks. -Increase knowledge and outreach resources to high risk groups including veterans and LGBTQ youth and older adults experiencing isolation.	-Solutions vary depending on who is at risk within their jurisdiction, but solutions are often proactive (e.g., programs to increase knowledge or to provide emotional support) for people as soon as they might be suicidal. -At least two health departments^[13] focused on postvention, or interventions that “reduce risk and promote healing after a suicide death,” because those who have lost a loved one to suicide face increased risk of suicide.^[14]
	Tooele County Community Health Improvement Plan (CHIP) 2018-2022 [Utah]	Increase support for survivors of suicide loss [Data from the Utah Department of Health shows Tooele County has a suicide rate of 30.5 per 100,00 population. This is well above both state (23.8) and national rates (15.3).]	-The Life’s Worth Living Foundation offers one to two grief support groups for survivors of suicide loss. Last year they had 250 participants. -The Life’s Worth Living Foundation will continue to contact families that have lost someone to suicide and provide resource referrals and connection through one on one conversations and printed materials. -The Life’s Worth Living Foundation will continue their community outreach efforts through sponsoring various events and fundraisers. Funds are used to help families in need with funeral expenses and counseling where applicable.

Reducing social stigma and increasing public awareness and understanding	Healthy Nashville Community Health Improvement Plan 2020-2022 (Tennessee)	Ensure all people have equitable access to evidenced-based mental health and substance abuse services and supports, positive early childhood development and safe, nurturing relationships and environments	“By December 2022, equip the Suicide Prevention in African American Faith Communities Coalition (SPAACC) with knowledge and tools to connect members of the faith communities to mental health and substance abuse supports and service” through the following 2 strategies: – Beginning in 2020, increase the number of faith communities participating in the SPAACC. – Beginning in 2020, align activities of SPAACC with local trauma-informed initiatives.	-Solutions to reduce stigma often included collaborating with diverse community partners, including communities of color and faith-based communities. These community partners are trusted by populations that might otherwise be hard for a public health department to reach out to, especially on a topic as sensitive as suicide.
	Tooele County Community Health Improvement Plan (CHIP) 2018-2022 [Utah]	Increase social norms supportive of help-seeking and recovery	-Partner with the faith-based community to increase awareness of suicide prevention and mental health resources. – Partner with Wendover City to offer public trainings related to mental health awareness in the Hispanic population (preferably in Spanish or with Spanish materials)
	Community Health Improvement Plan: January 2019-2024 [Hartford County, Maryland]	Reduce the rate of suicide to no more than 9.0 suicide deaths per 100,000 population	– Build an informed community that engages peers, families, faith-based communities, and others in the recovery process – Strengthen community partnerships to promote behavioral health screenings -Train and educate the community regarding mental health including Mental Health First Aid and Wellness Recovery Action Plans

The solutions outlined in the previous table are thoughtful, tangible, and compassionate towards both people feeling suicidal and those grieving over the loss of a loved one by suicide. However, these downstream public health solutions are not enough as they help people after they are in trouble instead of addressing the stressors behind why people would be desperate enough to think of suicide. Upstream public health approaches to addressing suicide would consider how existing and interconnecting social structures, the market economy, laws, norms, etc. create and reinforce systems (e.g., education system or settler colonialism’s continued harm to Native peoples) with discriminatory outcomes and unfair distribution of resources (e.g., disinvestments for communities of color and rural communities) that predispose some social groups to be at greater risk of death by suicide compared to the general population.^[15] With this approach, health departments could work with other sectors, like education or human services, to develop new or carry out existing “evidence-based programs and policy efforts” that address “structural factors (e.g., policies that improve education, income, reduce racism, and other forms of discrimination, etc.)” or the root causes behind why intergenerational trauma and disinvestment exist for some communities and not others.

From what I found, if I were just to focus on health departments explicitly mentioning suicides in either their goals or strategies (e.g., suicide prevention activities), I could not find any upstream approaches. However, by widening my focus to include social determinants of health (i.e., “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks”^[16]), many health departments are already addressing upstream factors that could lead to lower deaths by suicide, even if they are not monitoring mental health or suicide outcomes. For instance, there are health departments with strategies and programming to reduce the prevalence of adults with mental illness or substance use disorders in their criminal legal systems;^[17] reducing the prevalence of future adults with Adverse Childhood Experiences in their jurisdiction;^[18] and addressing the lack of affordable housing^[19] that could lead to lower suicide risks and deaths by suicides.

However, because none of these monitors if these interventions could lead to less severe mental illnesses, substance use disorders, suicidal ideation or behaviors, and deaths by suicides over time, it becomes difficult to show these interventions as evidence-based and upstream solutions that could help their jurisdictions tackling suicide crises. Tracking changes in participants’ mental health and suicidal thoughts for each health department intervention that could improve these mental health outcomes; understanding what percentage of the local population participated in these interventions or are impacted by an intervention (e.g., adding a survey question asking participants if they shared what they learned with family members and friends); and analyzing how these interventions could affect changes in the jurisdiction’s suicide rate is an important first step in seeing whether the timing of interventions and the percent of the jurisdiction participating in interventions could be traced to population-level changes. Collecting demographic data (e.g., race and ethnicity or income level) would also help health departments understand how interventions are affecting different social groups and inform analysis of broader population trends by social groups.

It is also worth going in-depth in one example to show that health departments could go even more upstream than how they currently define these strategies. At least two health departments and one county government include criminal diversion programs as a strategy in their CHIPs, and these programs reroute people who were arrested to resources and supports outside of the criminal legal system, such as social services or treatment options for mental illness and/or substance use.^[20] Given how experience in the criminal legal system (e.g., police, courts, prisons or jails, and community probation) can put people at a higher risk of death by suicide than the general population,^[21] these programs can save lives by preventing people who are going through severe mental illness or withdrawals from being placed in further stressful and dangerous environments. However, these solutions did not interrogate why Black and other people of color (e.g., Hispanic and Latine) have a higher likelihood of ending up in the criminal legal system due to their communities being “disproportionately policed, arrested, incarcerated, and sentenced.”^[22] By working to reduce systemic racism in public health, law enforcement, social services, and legal systems, health department staff can play an important role in showing how these strategies could reduce inequities in life expectancies for Black and other people of color in their jurisdiction as fewer people in those communities are incarcerated and subjected to risk factors that increase suicide statistics (e.g., ideation, attempts, or deaths). This in turn allows these upstream public health approaches to become evidence-based and be used to convince other health departments or policymakers to adopt similar approaches.

In the first paragraph, I included a quote from Becerra on the urgency of addressing our national suicide epidemic and through the downstream approaches of reducing stigmatization of mental illness and increasing access to care. What I hope to show is that many health departments are already carrying out Becerra’s wishes in all their hard work with screening people at risk so they can get to treatment earlier; providing treatments and programs to those who are suicidal; and reducing the shame and silence that follows mental illness and suicide in both white communities and communities of color. In addition, I believe that sometimes we all miss challenging ourselves to take on upstream public health approaches that can address root causes so that less people in specific subpopulations would reach the precipice of being suicidal in the first place. It is heartening to read that a lot of this upstream work on social determinants of health is already being carried out by health departments, and we are just missing the last step of connecting this work to mental health and suicide outcomes to learn which of these approaches make a difference on the ground. As Peter Drucker famously said, “You can’t improve what you don’t measure.”^[23]

References:

^[1] Centers for Disease Control and Prevention. (2023, August 10). Provisional Suicide Deaths in the United States, 2022. https://www.cdc.gov/media/releases/2023/s0810-US-Suicide-Deaths-2022.html#:~:text=After%20declining%20in%202019%20and,an%20increase%20of%20approximately%202.6%25.

^[2] Centers for Disease Control and Prevention. (2023, May 8). Facts About Suicide. https://www.cdc.gov/suicide/facts/index.html#:~:text=Suicide%20is%20a%20serious%20public,one%20death%20every%2011%20minutes.

^[3] Centers for Disease Control and Prevention. (2023, August 10). Provisional Suicide Deaths in the United States, 2022. https://www.cdc.gov/media/releases/2023/s0810-US-Suicide-Deaths-2022.html#:~:text=After%20declining%20in%202019%20and,an%20increase%20of%20approximately%202.6%25.

^[4] Centers for Disease Control and Prevention.(2022, November 25). Community Health Assessment & Health Improvement Plans. https://www.cdc.gov/publichealthgateway/cha/plan.html

^[5] Lamontagne, S. J., Zabala, P. K., Zarate Jr, C. A., & Ballard, E. D. (2023). Toward objective characterizations of suicide risk: A narrative review of laboratory-based cognitive and behavioral tasks. Neuroscience & Biobehavioral Reviews, 105361.

^[6] Gehlert, Sarah, Dana Sohmer, Tina Sacks, Charles Mininger, Martha McClintock, and Olufunmilayo Olopade. “Targeting health disparities: a model linking upstream determinants to downstream interventions.” Health Affairs 27, no. 2 (2008): 339-349.

^[7] Sussell A, Peterson C, Li J, Miniño A, Scott KA, Stone DM. Suicide Rates by Industry and Occupation — National Vital Statistics System, United States, 2021. MMWR Morb Mortal Wkly Rep 2023;72:1346–1350. DOI: http://dx.doi.org/10.15585/mmwr.mm7250a2; Minnesota Department of Agriculture. (n.d.). Coping with Farm & Rural Stress. https://www.mda.state.mn.us/about/mnfarmerstress

^[8] McMahon, N. E. (2022). Framing action to reduce health inequalities: what is argued for through use of the ‘upstream–downstream’metaphor?. Journal of Public Health, 44(3), 671-678.

^[9] Lamontagne, S. J., Zabala, P. K., Zarate Jr, C. A., & Ballard, E. D. (2023). Toward objective characterizations of suicide risk: A narrative review of laboratory-based cognitive and behavioral tasks. Neuroscience & Biobehavioral Reviews, 105361.

^[10] Lamontagne et. al., 2023.

^[11] Hadlaczky, Gergö, Sebastian Hökby, Anahit Mkrtchian, Vladimir Carli, and Danuta Wasserman. “Mental Health First Aid is an effective public health intervention for improving knowledge, attitudes, and behaviour: A meta-analysis.” International Review of Psychiatry 26, no. 4 (2014): 467-475.

^[12] Clark County Combined Health District. (n.d.). Clark County Community Health Improvement Plan 2020-2022. https://ccchd.com/wp-content/uploads/2022/01/Clark-County-CHIP-2020-2022-Single-Page.pdf; Cook County Department of Public Health. (n.d.). We Plan 2025: Community Health Assessment & Community Health Improvement Plan for Suburban Cook County, Illinois. https://cookcountypublichealth.org/wp-content/uploads/2022/06/WePlan-2025_with-assessments_final_110321_514PM.pdf; Saint Paul-Ramsey County Public Health. (2022, August). Community Health Improvement Plan (CHIP) 2019-2023. https://www.ramseycounty.us/sites/default/files/Departments/Public%20Health/CHIP%202019-2023%20%2022_0927.pdf; Boone County Health Department. (n.d.). 2018-2020 Boone County Community Health Improvement Plan (CHIP). https://boonecounty.in.gov/wp-content/uploads/2021/06/Community-Health-Improvement-Plan.pdf; Lewis and Clark Public Health. (n.d.). 2022 Lewis and Clark County Community Health Improvement Plan. https://www.lccountymt.gov/files/assets/county/v/1/health/documents/chip_2022_final_updated.pdf

^[13] Lewis and Clark Public Health. (n.d.). 2022 Lewis and Clark County Community Health Improvement Plan. https://www.lccountymt.gov/files/assets/county/v/1/health/documents/chip_2022_final_updated.pdf; Tooele County Health Department. (n.d.). Toole County Community Health Improvement Plan (CHIP) 2018-2022. https://tooelehealth.org/wp-content/uploads/2018/07/Final-CHIP-2018…2022.pdf

^[14] Norton, K. Alliance of Hope for suicide loss survivors. What is Suicide Postvention?https://allianceofhope.org/for-professionals/what-is-suicide-postvention/

^[15] Dopp, Alex. R., and Paula M. Lantz. “Moving upstream to improve children’s mental health through community and policy change.” Administration and Policy in Mental Health and Mental Health Services Research 47 (2020): 779-787.

^[16] United States Department of Health and Human Services and Office of Disease Prevention and Health Promotion. (n.d.). Social Determinants of Health. Healthy People 2030. https://health.gov/healthypeople/priority-areas/social-determinants-health

^[17] Jefferson County Public Health. (2019, January). 2019-2021 Jefferson County Community Health Improvement Plan. https://www.jeffco.us/DocumentCenter/View/16041/2019-2021-Community-Health-Improvement-Plan?bidId; New Orleans Health Department. (n.d.). https://nola.gov/getattachment/Health/Community-Health-Improvement/Reports/NOHD_New-Orleans-CHIP-2022-2025_FINAL.pdf/?lang=en-US; Fulton County. (n.d.). Fulton County Strategic Plan: 2016-2019. https://performance.fultoncountyga.gov/download/8efk-4cpy/application%2Fpdf

^[18] Greater Mercer Public Health Partnership. (2021, November 18). 2021 Community Health Improvement Plan. https://www.hamiltonnj.com/DocumentCenter/View/1172/2021-Mercer-County-Community-Health-Improvement-Plan-PDF

^[19] Tacoma-Pierce County Health Department. (n.d.). Community Health Improvement Plan Pierce County 2020. https://tpchd.org/wp-content/uploads/2023/12/2020-Pierce-County-CHIP.pdf

^[20] Jefferson County Public Health. (2019, January). 2019-2021 Jefferson County Community Health Improvement Plan. https://www.jeffco.us/DocumentCenter/View/16041/2019-2021-Community-Health-Improvement-Plan?bidId; New Orleans Health Department. (n.d.). https://nola.gov/getattachment/Health/Community-Health-Improvement/Reports/NOHD_New-Orleans-CHIP-2022-2025_FINAL.pdf/?lang=en-US; Fulton County. (n.d.). Fulton County Strategic Plan: 2016-2019. https://performance.fultoncountyga.gov/download/8efk-4cpy/application%2Fpdf

^[21] Lawson, Spencer G., Evan M. Lowder, and Bradley Ray. “Correlates of suicide risk among Black and White adults with behavioral health disorders in criminal-legal systems.” BMC psychiatry 22, no. 1 (2022): 1-13.

^[22] Lawson et al., 2022.

^[23] Drucker, J. (2018, December 4). You Are What You Measure. Forbes. https://www.forbes.com/sites/theyec/2018/12/04/you-are-what-you-measure/?sh=308476792075

About the Author

Jocelyn Leung: Jocelyn Leung is a researcher at the Center for Public Health Systems with over four years of experience practicing community-based participatory research, qualitative research, and evaluation with BIPOC and Greater Minnesota communities. She has facilitated decision-making processes and planning efforts involving communities most impacted by inequities, philanthropy, county governments, and state agencies on social determinants of health, including affordable housing and keeping drinking water safe from contamination. Ms. Leung holds an MPH in Community Health Promotion from the University of Minnesota, a MA in Political Science from the University of Minnesota, and a MSc in Modern Chinese Studies from the University of Oxford.

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